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Mathey L, Jacquier M, Meunier-Beillard N, Andreu P, Roudaut JB, Labruyère M, Rigaud JP, Quenot JP, Ecarnot F. ICU stays that are judged to be non-beneficial: A qualitative study of the perception of nursing staff. PLoS One 2023; 18:e0289954. [PMID: 37561766 PMCID: PMC10414562 DOI: 10.1371/journal.pone.0289954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 07/20/2023] [Indexed: 08/12/2023] Open
Abstract
INTRODUCTION Non-beneficial stays in the intensive care unit (ICU) may have repercussions for patients and their families, but can also cause suffering among the nursing staff. We aimed explore the perceptions of nursing staff in the ICU about patient stays that are deemed to be "non-beneficial" for the patient, to identify areas amenable to intervention, with a view to improving how the nursing staff perceive the patient pathway before, during and after intensive care. METHODS Multicentre, qualitative study using individual, semi-structured interviews. All qualified nurses and nurses' aides who were full-time employees in the ICU of three participating centres were invited to participate. Interviews were recorded, transcribed and analyzed using textual content analysis. RESULTS A total of 21 interviews were performed from February 2020 to October 2021, at which point saturation was reached in the data. Average age of participants was 38.5±7.5 years, and they had an average of 10.7±7.4 years of experience working in the ICU. Four major themes emerged from the interviews, namely: (1) the work is oriented towards life-threatening emergencies, technical procedures and burdensome care; (2) a range of specific criteria and circumstances influence the decisions to admit patients to ICU; (3) there are significant organisational, physical and psychological repercussions associated with a non-beneficial stay in the ICU; (4) respondents made some proposals for improvements to the patient care pathway. CONCLUSION Nursing staff have a similar perception to physicians regarding admission decisions and non-beneficial ICU stays. The possibility of future ICU admission needs to be anticipated, discussed systematically with patients and integrated into healthcare goals that are consistent with the patient's wishes and preferences, in multi-professional collaboration including nursing and medical staff.
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Affiliation(s)
- Lucas Mathey
- Service de Médecine Intensive-Réanimation, CHU Dijon-Bourgogne, Dijon, France
| | - Marine Jacquier
- Service de Médecine Intensive-Réanimation, CHU Dijon-Bourgogne, Dijon, France
- Equipe Lipness, Centre de Recherche INSERM UMR1231 et LabEx LipSTIC, Université de Bourgogne-Franche Comté, Dijon, France
| | - Nicolas Meunier-Beillard
- INSERM, CIC 1432, Module Épidémiologie Clinique, Université de Bourgogne-Franche Comté, Dijon, France
- DRCI, USMR, CHU Dijon Bourgogne, Dijon, France
| | - Pascal Andreu
- Service de Médecine Intensive-Réanimation, CHU Dijon-Bourgogne, Dijon, France
| | | | - Marie Labruyère
- Service de Médecine Intensive-Réanimation, CHU Dijon-Bourgogne, Dijon, France
- INSERM, CIC 1432, Module Épidémiologie Clinique, Université de Bourgogne-Franche Comté, Dijon, France
| | - Jean-Philippe Rigaud
- Department of Intensive Care, Centre Hospitalier de Dieppe, Dieppe, France
- Espace de Réflexion Éthique de Normandie, University Hospital Caen, Caen, France
| | - Jean-Pierre Quenot
- Service de Médecine Intensive-Réanimation, CHU Dijon-Bourgogne, Dijon, France
- Equipe Lipness, Centre de Recherche INSERM UMR1231 et LabEx LipSTIC, Université de Bourgogne-Franche Comté, Dijon, France
- INSERM, CIC 1432, Module Épidémiologie Clinique, Université de Bourgogne-Franche Comté, Dijon, France
- Espace de Réflexion Éthique Bourgogne Franche-Comté (EREBFC), Dijon, France
| | - Fiona Ecarnot
- EA3920, Department of Cardiology, University Hospital Besancon, Besancon, France
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Rigaud JP, Ecarnot F, Quenot JP. Patient Information and Consent for Care in the Intensive Care Unit. Healthcare (Basel) 2023; 11:healthcare11050707. [PMID: 36900711 PMCID: PMC10001104 DOI: 10.3390/healthcare11050707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 02/22/2023] [Accepted: 02/23/2023] [Indexed: 03/04/2023] Open
Abstract
In this paper, we review the ethical issues involved in providing information to, and obtaining consent (for treatment and/or research) from patients in the intensive care unit. We first review the ethical obligations of the physician in treating patients, who are by definition, vulnerable, and often unable to assert their autonomy during situations of critical illness. Providing clear and transparent information to the patient about treatment options or research opportunities is an ethical and, in some cases, legal obligation for the physicians, but may be rendered difficult, not to say impossible in the intensive care unit by the patient's health state. In this context, we review the specificities of intensive care with respect to information and consent. We discuss who the right contact person is in the ICU setting, with possible choices including a surrogate decision maker, or a member of the family, in the absence of an officially designated surrogate. We further review the specific considerations relating to the family of critically ill patients, and the amount and type of information that may be given to them without breaching the tenets of medical confidentiality. Finally, we discuss the specific cases of consent to research, and patients who refuse care.
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Affiliation(s)
- Jean-Philippe Rigaud
- Department of Intensive Care, Centre Hospitalier, 76202 Dieppe, France
- Espace de Réflexion Éthique de Normandie, University Hospital Caen, 14000 Caen, France
| | - Fiona Ecarnot
- Department of Cardiology, University Hospital Besançon, 25000 Besançon, France
- EA3920, University of Franche-Comté, 25000 Besançon, France
| | - Jean-Pierre Quenot
- Department of Intensive Care, Burgundy University Hospital, 21079 Dijon, France
- Lipness Team, INSERM Research Center LNC-UMR1231 and LabEx LipSTIC, University of Burgundy, 21078 Dijon, France
- INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, 21078 Dijon, France
- Correspondence:
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Giabicani M, Arditty L, Mamzer MF, Fournel I, Ecarnot F, Meunier-Beillard N, Bruneel F, Weiss E, Spranzi M, Rigaud JP, Quenot JP. Team-family conflicts over end-of-life decisions in ICU: A survey of French physicians' beliefs. PLoS One 2023; 18:e0284756. [PMID: 37098023 PMCID: PMC10128920 DOI: 10.1371/journal.pone.0284756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/08/2023] [Indexed: 04/26/2023] Open
Abstract
INTRODUCTION Conflicts between relatives and physicians may arise when decisions are being made about limiting life-sustaining therapies (LST). The aim of this study was to describe the motives for, and management of team-family conflicts surrounding LST limitation decisions in French adult ICUs. METHODS Between June and October 2021, French ICU physicians were invited to answer a questionnaire. The development of the questionnaire followed a validated methodology with the collaboration of consultants in clinical ethics, a sociologist, a statistician and ICU clinicians. RESULTS Among 186 physicians contacted, 160 (86%) answered all the questions. Conflicts over LST limitation decisions were mainly related to requests by relatives to continue treatments considered to be unreasonably obstinate by ICU physicians. The absence of advance directives, a lack of communication, a multitude of relatives, and religious or cultural issues were frequently mentioned as factors contributing to conflicts. Iterative interviews with relatives and proposal of psychological support were the most widely used tools in attempting to resolve conflict, while the intervention of a palliative care team, a local ethics resource or the hospital mediator were rarely solicited. In most cases, the decision was suspended at least temporarily. Possible consequences include stress and psychological exhaustion among caregivers. Improving communication and anticipation by knowing the patient's wishes would help avoid these conflicts. CONCLUSION Team-family conflicts during LST limitation decisions are mainly related to requests from relatives to continue treatments deemed unreasonable by physicians. Reflection on the role of relatives in the decision-making process seems essential for the future.
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Affiliation(s)
- Mikhael Giabicani
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, and Université Paris Cité, Paris, France
- Centre de Recherche des Cordeliers, Sorbonne Université, Université Paris Cité, Inserm, Laboratoire ETREs, Paris, France
| | - Laure Arditty
- Service de Réanimation, Centre Hospitalier Intercommunal des Alpes du Sud, Gap, France
| | - Marie-France Mamzer
- Centre de Recherche des Cordeliers, Sorbonne Université, Université Paris Cité, Inserm, Laboratoire ETREs, Paris, France
- Unité Fonctionnelle d'Ethique Médicale, Hôpital Necker-Enfants Malades, AP-HP, Paris, France
| | - Isabelle Fournel
- CHU Dijon Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
| | - Fiona Ecarnot
- Department of Cardiology, University Hospital Besançon, Besançon, France
- EA3920, Université de Bourgogne-Franche Comté, Besançon, France
| | - Nicolas Meunier-Beillard
- CHU Dijon Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
- DRCI, USMR, CHU Dijon Bourgogne, Dijon, France
| | - Fabrice Bruneel
- Intensive Care Unit, Versailles Hospital Center, Le Chesnay, France
| | - Emmanuel Weiss
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, and Université Paris Cité, Paris, France
| | - Marta Spranzi
- Center for Clinical Ethics, AP-HP, Paris and Université de Versailles Saint-Quentin en Yvelines, Versailles, France
| | - Jean-Philippe Rigaud
- Service de Médecine Intensive Réanimation, CH de Dieppe, Dieppe, France
- Espace de Réflexion Éthique de Normandie, CHU de Caen, Caen, France
| | - Jean-Pierre Quenot
- CHU Dijon Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
- Service de Médecine Intensive-Réanimation, CHU Dijon-Bourgogne, Dijon, France
- Equipe Lipness, Centre de Recherche INSERM UMR1231 et LabEx LipSTIC, Université de Bourgogne-Franche Comté, Dijon, France
- Espace de Réflexion Éthique Bourgogne Franche-Comté (EREBFC), Dijon, France
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Taha A, Jacquier M, Meunier-Beillard N, Ecarnot F, Andreu P, Roudaut JB, Labruyère M, Rigaud JP, Quenot JP. Anticipating need for intensive care in the healthcare trajectory of patients with chronic disease: A qualitative study among specialists. PLoS One 2022; 17:e0274936. [PMID: 36121869 PMCID: PMC9484637 DOI: 10.1371/journal.pone.0274936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 09/08/2022] [Indexed: 12/16/2022] Open
Abstract
Introduction We investigated the reflections and perceptions of non-ICU physicians about anticipating the need for ICU admission in case of acute decompensation in patients with chronic disease. Methods We performed a qualitative multicentre study using semi-structured interviews among non-ICU specialist physicians. The interview guide, developed in advance, focused on 3 questions: (1) What is your perception of ICU care? (2) How do you think advance directives can be integrated into the patient’s healthcare goals? and (3) How can the possibility of a need for ICU admission be integrated into the patient’s healthcare goals? Interviews were recorded, transcribed and analysed by thematic analysis. Interviews were performed until theoretical saturation was reached. Results In total, 16 physicians (8 women, 8 men) were interviewed. The main themes related to intensive care being viewed as a distinct specialty, dispensing very technical care, and with major human and ethical challenges, especially regarding end-of-life issues. The participants also mentioned the difficulty in anticipating an acute decompensation, and the choices that might have to be made in such situations. The timing of discussions about potential decompensation of the patient, the medical culture and the presence of advance directives are issues that arise when attempting to anticipate the question of ICU admission in the patient’s healthcare goals or wishes. Conclusion This study describes the perceptions that physicians treating patients with chronic disease have of intensive care, notably that it is a distinct and technical specialty that presents challenging medical and ethical situations. Our study also opens perspectives for actions that could promote a pluridisciplinary approach to anticipating acute decompensation and ICU requirements in patients with chronic disease.
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Affiliation(s)
- Alicia Taha
- Service de Médecine Intensive-Réanimation, CHU Dijon-Bourgogne, Dijon, France
| | - Marine Jacquier
- Service de Médecine Intensive-Réanimation, CHU Dijon-Bourgogne, Dijon, France
- Equipe Lipness, Centre de Recherche INSERM UMR1231 et LabEx LipSTIC, Université de Bourgogne-Franche Comté, Dijon, France
| | - Nicolas Meunier-Beillard
- INSERM, CIC 1432, Module Épidémiologie Clinique, Université de Bourgogne-Franche Comté, Dijon, France
- DRCI, USMR, CHU Dijon Bourgogne, Dijon, France
| | - Fiona Ecarnot
- EA3920, Department of Cardiology, University Hospital Besancon, Besançon, France
| | - Pascal Andreu
- Service de Médecine Intensive-Réanimation, CHU Dijon-Bourgogne, Dijon, France
| | | | - Marie Labruyère
- Service de Médecine Intensive-Réanimation, CHU Dijon-Bourgogne, Dijon, France
- INSERM, CIC 1432, Module Épidémiologie Clinique, Université de Bourgogne-Franche Comté, Dijon, France
| | - Jean-Philippe Rigaud
- Department of Intensive Care, Centre Hospitalier de Dieppe, Dieppe, France
- Espace de Réflexion Éthique de Normandie, University Hospital Caen, Caen, France
| | - Jean-Pierre Quenot
- Service de Médecine Intensive-Réanimation, CHU Dijon-Bourgogne, Dijon, France
- Equipe Lipness, Centre de Recherche INSERM UMR1231 et LabEx LipSTIC, Université de Bourgogne-Franche Comté, Dijon, France
- INSERM, CIC 1432, Module Épidémiologie Clinique, Université de Bourgogne-Franche Comté, Dijon, France
- Espace de Réflexion Éthique Bourgogne Franche-Comté (EREBFC), Dijon, France
- * E-mail:
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Ito K, George N, Wilson J, Bowman J, Aaronson E, Ouchi K. Primary palliative care recommendations for critical care clinicians. J Intensive Care 2022; 10:20. [PMID: 35428371 PMCID: PMC9013119 DOI: 10.1186/s40560-022-00612-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 04/06/2022] [Indexed: 11/19/2022] Open
Abstract
Palliative care is an interdisciplinary care to optimize physical, psychosocial, and spiritual symptoms of patients and their families whose quality of life is impaired by serious, life-limiting illness. In 2021, the importance of providing palliative care in the intensive care unit (ICU) is well recognized by various studies to alleviate physical symptoms due to invasive treatments, to set patient-centered goals of care, and to provide end-of-life care. This paper summarizes the evidence known to date on primary palliative care delivered in the ICU settings. We will then discuss the potential benefits and harms of primary palliative care so that critical care clinicians are better equipped to decide what services might best improve the palliative care needs in their ICUs.
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Perraud F, Ecarnot F, Loiseau M, Laurent A, Fournier A, Lheureux F, Binquet C, Rigaud JP, Meunier-Beillard N, Quenot JP. A qualitative study of reinforcement workers' perceptions and experiences of working in intensive care during the COVID-19 pandemic: A PsyCOVID-ICU substudy. PLoS One 2022; 17:e0264287. [PMID: 35245297 PMCID: PMC8896724 DOI: 10.1371/journal.pone.0264287] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 02/07/2022] [Indexed: 01/15/2023] Open
Abstract
PURPOSE During the COVID pandemic, many hospitals had to mobilize reinforcement healthcare workers, especially in intensive care (ICUs). We investigated the perceptions and experiences of reinforcement workers deployed to ICUs, and the impact of deployment on their personal and professional lives. METHODS For this qualitative study, a random sample of 30 reinforcement workers was drawn from 4 centres participating in the larger PsyCOVID-ICU study. Individual semi-structured interviews were held, recorded, transcribed and analyzed by thematic analysis. RESULTS Thirty interviews were performed from April to May 2021 (22 nurses, 2 anesthesiology nurses, 6 nurses' aides). Average age was 36.8±9.5 years; 7 participants had no ICU experience. Four major themes emerged, namely: (1) Difficulties with integration, especially for those with no ICU experience; (2) lack of training; (3) difficulties with management, notably a feeling of insufficient communication; (4) Mental distress relating to the unusual work and fear of contaminating their entourage. CONCLUSION Healthcare workers deployed as reinforcements to ICUs at the height of the pandemic had a unique experience of the crisis, and identified important gaps in organisation and preparation. They also suffered from a marked lack of training, given the stakes in the management of critically ill patients in the ICU.
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Affiliation(s)
- Florian Perraud
- Service d’Accueil des Urgences, University Hospital Dijon, and Université de Bourgogne Franche-Comté, Dijon, France
| | - Fiona Ecarnot
- Department of Cardiology, University Hospital Besançon, 25000 Besançon, France
- EA3920, University of Burgundy-Franche-Comté, 25000 Besançon, France
| | - Mélanie Loiseau
- Service de Médecine Légale, Cellule d’Urgence Médico-Psychologique de Bourgogne Franche-Comté, University Hospital Dijon, Dijon, France
| | - Alexandra Laurent
- Laboratoire de Psychologie: Dynamiques Relationnelles Et Processus Identitaires (PsyDREPI), Université Bourgogne Franche-Comté, Dijon, France
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Dijon, Dijon, France
| | - Alicia Fournier
- Laboratoire de Psychologie: Dynamiques Relationnelles Et Processus Identitaires (PsyDREPI), Université Bourgogne Franche-Comté, Dijon, France
| | - Florent Lheureux
- Laboratoire de Psychologie, University of Burgundy-Franche-Comté, 25000 Besançon, France
| | - Christine Binquet
- Inserm CIC1432, module Épidémiologie Clinique (CIC-EC)- CHU Dijon-Bourgogne, UFR des Sciences de Santé, Dijon, France
| | - Jean-Philippe Rigaud
- Service de Médecine Intensive-Réanimation, Hospital Centre of Dieppe, Dieppe, France
- Espace de Réflexion Éthique de Normandie, Université de Caen, Caen, France
| | - Nicolas Meunier-Beillard
- CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
- Direction de la Recherche Clinique et de l’Innovation, University Hospital Dijon, Dijon, France
| | - Jean-Pierre Quenot
- Inserm CIC1432, module Épidémiologie Clinique (CIC-EC)- CHU Dijon-Bourgogne, UFR des Sciences de Santé, Dijon, France
- Service de Médecine Intensive-Réanimation, University Hospital Dijon, Dijon, France
- Equipe Lipness, centre de recherche INSERM UMR1231 et LabEx LipSTIC, université de Bourgogne-Franche Comté, Dijon, France
- Espace de Réflexion Éthique Bourgogne Franche-Comté (EREBFC), Dijon, France
- * E-mail:
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Blythe JA, Kentish-Barnes N, Debue AS, Dohan D, Azoulay E, Covinsky K, Matthews T, Curtis JR, Dzeng E. An Interprofessional Process for the Limitation of Life-Sustaining Treatments at the End of Life in France. J Pain Symptom Manage 2022; 63:160-170. [PMID: 34157398 DOI: 10.1016/j.jpainsymman.2021.06.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 06/15/2021] [Accepted: 06/16/2021] [Indexed: 11/25/2022]
Abstract
CONTEXT The provision of potentially non-beneficial life-sustaining treatments (LSTs) remains a challenging problem. In 2005, legislation in France established an interprofessional process by which non-beneficial LSTs could be withheld or withdrawn, permitting exploration of the effects of such a legally-protected process and its implementation. OBJECTIVES To characterize intensive care unit (ICU) interprofessional team decision-making and consensus-building practices regarding withholding and withdrawing of LSTs in two Parisian hospitals and to explore physician and nurse perceptions of and experiences with these practices. METHODS This was an exploratory qualitative study utilizing thematic analysis of semi-structured, in-depth interviews of physicians and nurses purposively sampled based on level of training and experience from two hospitals in Paris, France. RESULTS A total of 25 participants were interviewed. Participants reported that the two Parisian hospitals in this study have each created an interprofessional process for withholding or withdrawing non-beneficial LSTs, providing insight into how norms of decision-making respond to systems-level legal changes. Participants reported that these processes tended to be consistent across several domains: maintaining unified messaging with patients, empowering nurses to participate in end-of-life decision-making, reducing moral distress provoked by end-of-life decisions, and shaping the ethical milieu within which end-of-life decision-making takes place. CONCLUSIONS The architecture of the interprofessional process created at two Parisian hospitals and its perceived benefits may be useful to clinicians and policy-makers attempting to establish processes, policies, or legislation directed at withholding or withdrawing potentially non-beneficial LSTs in the United States and elsewhere.
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Affiliation(s)
- Jacob A Blythe
- Stanford University School of Medicine (J.A.B.), Stanford, California, USA
| | - Nancy Kentish-Barnes
- Assistance Publique Hôpitaux de Paris (APHP) (N.K.-B.), Hôpital Saint Louis, Famiréa Research Group, Paris, France
| | - Anne-Sophie Debue
- Assistance Publique Hôpitaux de Paris (APHP) (A.-S.D.), Hôpitaux Universitaires Paris Centre (HUPC), Hôpital Cochin, Medical Intensive Care Unit, Paris, France; UVSQ, INSERM, Équipe Recherches en éthique et épistémologie (A.-S.D.), CESP, Université Paris-Saclay, Paris, France
| | - Daniel Dohan
- Philip R. Lee Institute of Health Policy Studies (D.D., T.M., E.D.), University of California, San Francisco, California, USA
| | - Elie Azoulay
- Médecine Intensive et Réanimation (E.A.), Hôpital Saint-Louis, APHP, Paris, France; Université de Paris (E.A), Paris, France
| | - Ken Covinsky
- University of California (K.C.), San Francisco, California, USA
| | - Thea Matthews
- Philip R. Lee Institute of Health Policy Studies (D.D., T.M., E.D.), University of California, San Francisco, California, USA
| | - J Randall Curtis
- Division of Pulmonary (R.C.), Department of Medicine, Division of Geriatrics, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA; Cambia Palliative Care Center of Excellence (R.C.), University of Washington, Seattle, Washington, USA
| | - Elizabeth Dzeng
- Philip R. Lee Institute of Health Policy Studies (D.D., T.M., E.D.), University of California, San Francisco, California, USA; Division of Hospital Medicine (E.D.), Department of Medicine, University of California, San Francisco, California, USA.
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Palliative care interventions in intensive care unit patients. Intensive Care Med 2021; 47:1415-1425. [PMID: 34652465 DOI: 10.1007/s00134-021-06544-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/21/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The integration of palliative care into intensive care units (ICUs) is advocated to mitigate physical and psychological burdens for patients and their families, and to improve end-of-life care. The most efficacious palliative care interventions, the optimal model of their delivery and the most appropriate outcome measures in ICU are not clear. METHODS We conducted a systematic review of randomised clinical trials and observational studies to evaluate the number and types of palliative care interventions implemented within the ICU setting, to assess their impact on ICU practice and to evaluate differences in palliative care approaches across different countries. RESULTS Fifty-eight full articles were identified, including 9 randomised trials and 49 cohort studies; all but 4 were conducted within North America. Interventions were categorised into five themes: communication (14, 24.6%), ethics consultations (5, 8.8%), educational (18, 31.6%), involvement of a palliative care team (28, 49.1%) and advance care planning or goals-of-care discussions (7, 12.3%). Thirty studies (51.7%) proposed an integrative model, whilst 28 (48.3%) reported a consultative one. The most frequently reported outcomes were ICU or hospital length of stay (33/55, 60%), limitation of life-sustaining treatment decisions (22/55, 40%) and mortality (15/55, 27.2%). Quantitative assessment of pooled data was not performed due to heterogeneity in interventions and outcomes between studies. CONCLUSION Beneficial effects on the most common outcomes were associated with strategies to enhance palliative care involvement, either with an integrative or a consultative approach. Few studies reported functional outcomes for ICU patients. Almost all studies were from North America, limiting the generalisability to other healthcare systems.
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Jacquier M, Meunier-Beillard N, Ecarnot F, Large A, Aptel F, Labruyère M, Dargent A, Andreu P, Roudaut JB, Rigaud JP, Quenot JP. Non-readmission decisions in the intensive care unit: A qualitative study of physicians' experience in a multicentre French study. PLoS One 2021; 16:e0244919. [PMID: 33444323 PMCID: PMC7808577 DOI: 10.1371/journal.pone.0244919] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 12/21/2020] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Deciding not to re-admit a patient to the intensive care unit (ICU) poses an ethical dilemma for ICU physicians. We aimed to describe and understand the attitudes and perceptions of ICU physicians regarding non-readmission of patients to the ICU. MATERIALS AND METHODS Multicenter, qualitative study using semi-directed interviews between January and May 2019. All medical staff working full-time in the ICU of five participating centres (two academic and three general, non-academic hospitals) were invited to participate. Participants were asked to describe how they experienced non-readmission decisions in the ICU, and to expand on the manner in which the decision was made, but also on the traceability and timing of the decision. Interviews were recorded, transcribed and analyzed using textual content analysis. RESULTS In total, 22 physicians participated. Interviews lasted on average 26±7 minutes. There were 14 men and 8 women, average age was 35±9 years, and average length of ICU experience was 7±5 years. The majority of respondents said that they regretted that the question of non-readmission was not addressed before the initial ICU admission. They acknowledged that the ICU stay did lead to more thorough contemplation of the overall goals of care. Multidisciplinary team meetings could help to anticipate the question of readmission within the patient's care pathway. Participants reported that there is a culture of collegial decision-making in the ICU, although the involvement of patients, families and other healthcare professionals in this process is not systematic. The timing and traceability of non-readmission decisions are heterogeneous. CONCLUSIONS Non-readmission decisions are a major issue that raises ethical questions surrounding the fact that there is no discussion of the patient's goals of care in advance. Better anticipation, and better communication with the patients, families and other healthcare providers are suggested as areas that could be targeted for improvement.
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Affiliation(s)
- Marine Jacquier
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
- Lipness Team, INSERM Research Centre LNC-UMR1231 and LabEx LipSTIC, University of Burgundy, Dijon, France
| | - Nicolas Meunier-Beillard
- INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
- DRCI, USMR, Francois Mitterrand University Hospital, Dijon, France
| | - Fiona Ecarnot
- EA3920, Department of Cardiology, University Hospital Besancon, Besancon, France
| | - Audrey Large
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
| | - François Aptel
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
| | - Marie Labruyère
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
| | - Auguste Dargent
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
- Lipness Team, INSERM Research Centre LNC-UMR1231 and LabEx LipSTIC, University of Burgundy, Dijon, France
| | - Pascal Andreu
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
| | - Jean-Baptiste Roudaut
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
| | - Jean-Philippe Rigaud
- Department of Intensive Care, Dieppe General Hospital, Dieppe, France
- Espace de Réflexion Éthique de Normandie, University Hospital Caen, Caen, France
| | - Jean-Pierre Quenot
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
- Lipness Team, INSERM Research Centre LNC-UMR1231 and LabEx LipSTIC, University of Burgundy, Dijon, France
- INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
- Espace de Réflexion Éthique de Bourgogne Franche-Comté, Dijon, France
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10
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Morales A, Murphy A, Fanning JB, Gao S, Schultz K, Hall DE, Barnato A. Key Physician Behaviors that Predict Prudent, Preference Concordant Decisions at the End of Life. AJOB Empir Bioeth 2020; 12:215-226. [PMID: 33382633 DOI: 10.1080/23294515.2020.1865476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND This study introduces an empirical approach for studying the role of prudence in physician treatment of end-of-life (EOL) decision making. METHODS A mixed-methods analysis of transcripts from 88 simulated patient encounters in a multicenter study on EOL decision making. Physicians in internal medicine, emergency medicine, and critical care medicine were asked to evaluate a decompensating, end-stage cancer patient. Transcripts of the encounters were coded for actor, action, and content to capture the concept of Aristotelian prudence, and then quantitatively and qualitatively analyzed to identify actions associated with preference-concordant treatment. RESULTS Focusing on codes that describe characteristics of physician-patient interaction, the code for physicians restating patient preferences was associated with avoiding intubation. Multiple codes were associated with secondary measures of preference-concordant treatment. CONCLUSIONS Prudent actions can be identified empirically, and research focused on the virtue of prudence may provide a new avenue for assessment and training in EOL care.
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Affiliation(s)
- Andre Morales
- Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Joseph B Fanning
- Center for Biomedical Ethics and Society, Vanderbilt University, Nashville, Tennessee, USA
| | - Shasha Gao
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Kevan Schultz
- Center for Social and Urban Research, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Daniel E Hall
- General Surgery, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,General Surgery, UPMC Presbyterian, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Amber Barnato
- Dartmouth College, Dartmouth Institute for Health Policy & Clinical Practice, Hanover, New Hampshire, USA
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11
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Eltaybani S, Igarashi A, Yamamoto-Mitani N. Assessing the Palliative and End-of-Life Care Education-Practice-Competence Triad in Intensive Care Units: Content Validity, Feasibility, and Reliability of a New Tool. J Palliat Care 2020; 36:234-242. [PMID: 32779529 DOI: 10.1177/0825859720948972] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND To date, a comprehensive, psychometrically robust instrument to assess palliative and end-of-life (PEOL) care education, practice, and perceived competence among intensive care unit (ICU) nurses does not exist. OBJECTIVE To examine content validity and reliability of a proposed instrument to assess the PEOL care education-practice- competence triad among ICU nurses. METHODS An international modified e-Delphi and a cross-sectional pilot questionnaire survey. The Delphi involved 23 panelists from 11 countries. The pilot study involved 40 staff nurses and 3 nurse managers from 3 adult ICUs in a randomly selected hospital in Egypt. An instrument was developed and judged for content validity by international panelists, and then pretested in a pilot study, where data were collected at 2 time points using self-administered questionnaires, followed by cognitive interviews. Test-retest reliability was examined using intraclass correlation (ICC), standard error of measurement (SEM), and repeatability coefficient (RC). RESULTS The panelists confirmed content validity of the proposed instrument, and staff nurses confirmed its comprehensibility. At the level of the instrument's total scores, the lowest ICC was .9 (95% confidence interval: .8-.9); and the highest SEM and RC were 4.8 and 13.3, respectively. CONCLUSIONS The PEOL Care Index is a comprehensive, comprehensible, content valid, and reliable instrument to assess the PEOL care education-practice-competence triad among ICU nurses. Construct and criterion validities need to be confirmed in future studies. Applicability of the PEOL Care Index in different settings and cultures needs to be examined.
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Affiliation(s)
- Sameh Eltaybani
- Department of Gerontological Home Care and Long-Term Care Nursing/Palliative Care Nursing, The University of Tokyo, Tokyo, Japan.,Department of Critical Care and Emergency Nursing, Faculty of Nursing, Alexandria University, Alexandria Governorate, Egypt
| | - Ayumi Igarashi
- Department of Gerontological Home Care and Long-Term Care Nursing/Palliative Care Nursing, The University of Tokyo, Tokyo, Japan
| | - Noriko Yamamoto-Mitani
- Department of Gerontological Home Care and Long-Term Care Nursing/Palliative Care Nursing, The University of Tokyo, Tokyo, Japan
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12
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Orr S. The Acceptability and Feasibility of Using Mortality Prediction Scores for Initiating End-of-Life Goals-of-Care Communication in the Adult Intensive Care Unit. J Pain Symptom Manage 2020; 59:121-129. [PMID: 31546001 DOI: 10.1016/j.jpainsymman.2019.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/10/2019] [Accepted: 09/12/2019] [Indexed: 01/31/2023]
Abstract
CONTEXT Uncertainties in prognosis remain a barrier to end-of-life (EOL) communication in the intensive care unit (ICU), thus strategies are needed for increasing the precision of prognosis and timeliness of EOL goals-of-care communication. Use of mortality prediction scores offers one approach to this issue. OBJECTIVES This study evaluated the acceptability and feasibility of providers' use of patient mortality prediction scores as part of routine practice to increase prognosis precision and timeliness of EOL communication as well as providers' intentions to change practice related to EOL goals-of-care communication based on awareness of the scores. METHODS An explanatory mixed-methods approach was used to provide Sequential Organ Failure Assessment (SOFA) patient mortality prediction scores to ICU providers, who then completed an acceptability and feasibility questionnaire and participated in follow-up interviews conducted to further understand questionnaire responses and gain insight into their perceptions based on having SOFA scores. RESULTS Providers reported that using SOFA scores was acceptable and feasible, although there was some disagreement about effectiveness of SOFA scores for determining mortality risk. Providers with limited ICU experience were eager, and accepting of the scores while those with more experience found the scores to be an adjunct to their own intuition, although all acknowledged the benefit of looking at score trends. An important finding was the need to consider SOFA scores in relation to patient clinical context. CONCLUSION Use of SOFA scores as a means to potentially increase EOL goals-of-care communication emerged as most beneficial and acceptable to providers with limited ICU experience.
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Affiliation(s)
- Shelly Orr
- Virginia Commonwealth University School of Nursing, Richmond, Virginia, USA.
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13
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Selecting and evaluating decision-making strategies in the intensive care unit: A systematic review. J Crit Care 2019; 51:39-45. [DOI: 10.1016/j.jcrc.2019.01.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 01/28/2019] [Accepted: 01/29/2019] [Indexed: 11/22/2022]
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14
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Schwarzkopf D. [Nonbeneficial care-a burden for clinicians and relatives]. Med Klin Intensivmed Notfmed 2019; 114:222-228. [PMID: 30918982 DOI: 10.1007/s00063-019-0531-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 12/14/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Ethically demanding decisions in intensive care as well as the perception of nonbeneficial care can be a burden for clinicians and patients' relatives. OBJECTIVES An overview of prevalence, causes, and consequences of perceived nonbeneficial care and possible interventions is provided. MATERIALS AND METHODS Narrative review. RESULTS AND CONCLUSIONS The perception of nonbeneficial care is a subjective moral judgement. Almost every ICU clinician regularly perceives nonbeneficial care. There is clear evidence that perceived nonbeneficial care is associated with burnout of clinicians and intention to leave the job. For relatives being involved in end-of-life decisions is of particular burden. Clinicians often state that relatives' whishes are the reason for nonbeneficial life-sustaining treatment. A good ethical climate as well as good nurse-physician collaboration are associated with less perception of nonbeneficial care and shorter time to therapy limitations. Structured communication to plan therapy involving relatives might reduce nonbeneficial care and together with supporting interventions reduce staff burnout. Improving communication by consultants in charge has been shown to reduce the burden of relatives. In future, co-treating surgeons must be more strongly involved in interventions.
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Affiliation(s)
- D Schwarzkopf
- Klinik für Anästhesiologie und Intensivmedizin, Center for Sepsis Control and Care, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland.
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15
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Rigaud JP, Giabicani M, Meunier-Beillard N, Ecarnot F, Beuzelin M, Marchalot A, Dargent A, Quenot JP. Non-readmission decisions in the intensive care unit under French rules: A nationwide survey of practices. PLoS One 2018; 13:e0205689. [PMID: 30335804 PMCID: PMC6193659 DOI: 10.1371/journal.pone.0205689] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 09/28/2018] [Indexed: 11/18/2022] Open
Abstract
PURPOSE We investigated, using a multicentre survey of practices in France, the practices of ICU physicians concerning the decision not to readmit to the ICU, in light of current legislation. MATERIALS AND METHODS Multicentre survey of practices among French ICU physicians via electronic questionnaire in January 2016. Questions related to respondents' practices regarding re-admission of patients to the ICU and how these decisions were made. Criteria were evaluated by the health care professionals as regards importance for non-readmission. RESULTS In total, 167 physicians agreed to participate, of whom 165 (99%) actually returned a completed questionnaire from 58 ICUs. Forty-five percent were aged <35 years, 74% were full-time physicians. The findings show that decisions for non-readmission are taken at the end of the patient's stay (87%), using a collegial decision-making procedure (89% of cases); 93% reported that this decision was noted in the patient's medical file. While 73% indicated that the family/relatives were informed of non-readmission decisions, only 29% reported informing the patient, and 91% considered that non-readmission decisions are an integral part of the French legislative framework. CONCLUSION This study shows that decisions not to re-admit a patient to the ICU need to be formally materialized, and anticipated by involving the patient and family in the discussions, as well as the other healthcare providers that usually care for the patient. The optimal time to undertake these conversations is likely best decided on a case-by-case basis according to each patient's individual characteristics.
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Affiliation(s)
- Jean-Philippe Rigaud
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Dieppe, Dieppe, France
- * E-mail:
| | - Mikhael Giabicani
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Dieppe, Dieppe, France
| | - Nicolas Meunier-Beillard
- Service de Médecine Intensive Réanimation, Université de Bourgogne Franche Comté, CHU de Dijon, Dijon, France
- UMR 7366 CNRS, Université de Bourgogne Franche Comté, Centre Georges Chevrier, Dijon, France
| | - Fiona Ecarnot
- EA3920, Department of Cardiology, University Hospital Besancon, and University of Burgundy Franche Comté, Besançon, France
| | - Marion Beuzelin
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Dieppe, Dieppe, France
| | - Antoine Marchalot
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Dieppe, Dieppe, France
| | - Auguste Dargent
- Service de Médecine Intensive Réanimation, Université de Bourgogne Franche Comté, CHU de Dijon, Dijon, France
- Lipness Team, INSERM, UMR 1231, Université de Bourgogne Franche Comté, Dijon, France
| | - Jean-Pierre Quenot
- Service de Médecine Intensive Réanimation, Université de Bourgogne Franche Comté, CHU de Dijon, Dijon, France
- Lipness Team, INSERM, UMR 1231, Université de Bourgogne Franche Comté, Dijon, France
- INSERM CIC 1432, Faculté de médecine de Dijon, Université de Bourgogne Franche Comté, Dijon, France
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16
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Lesieur O, Herbland A, Cabasson S, Hoppe MA, Guillaume F, Leloup M. Changes in limitations of life-sustaining treatments over time in a French intensive care unit: A prospective observational study. J Crit Care 2018; 47:21-29. [DOI: 10.1016/j.jcrc.2018.05.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 05/29/2018] [Accepted: 05/30/2018] [Indexed: 01/31/2023]
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17
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Abstract
Management of limited health-care resources has been of growing concern. Stewardship of health-care dollars and avoidance of low-value care is being increasingly recognized as a matter that affects all practitioners. This review aims to examine a particular pathological state with multifactorial origins: chronic critical illness (CCI). This condition exerts a large toll on society as well as individual patients and their families. Here, we offer a brief review as to the incidence/prevalence of CCI and suggestions for prevention. Emphasis should be placed on the importance of early, open communication among physicians and patients about their end-of-life decisions and advanced directives, so that decisions can be made wisely and with the patient's best interests in mind.
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Affiliation(s)
| | - William McGee
- 1 Baystate Medical Center, Springfield, MA, USA.,2 University of Massachusetts Medical School, Worcester, MA, USA
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18
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Quenot JP, Meunier-Beillard N, Ecarnot F, Dargent A, Rigaud JP. How can we best organise communication with patients' families? Anaesth Crit Care Pain Med 2018; 37:187-189. [PMID: 29578077 DOI: 10.1016/j.accpm.2018.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Jean-Pierre Quenot
- Department of intensive care, François-Mitterrand University Hospital, 14, rue Paul Gaffarel, 21000 Dijon, France; Lipness Team, Inserm Research Center LNC-UMR1231 and LabExLipSTIC, University of Burgundy, 21000 Dijon, France; Inserm CIC 1432, Clinical Epidemiology, University of Burgundy, 21000 Dijon, France.
| | - Nicolas Meunier-Beillard
- Department of intensive care, François-Mitterrand University Hospital, 14, rue Paul Gaffarel, 21000 Dijon, France; Départment of sociology,centre Georges Chevrier UMR 7366 CNRS-University of Burgundy, 21000 Dijon, France
| | - Fiona Ecarnot
- EA3920, department of cardiology, University Hospital Besançon, 25000 Besançon, France
| | - Auguste Dargent
- Department of intensive care, François-Mitterrand University Hospital, 14, rue Paul Gaffarel, 21000 Dijon, France; Lipness Team, Inserm Research Center LNC-UMR1231 and LabExLipSTIC, University of Burgundy, 21000 Dijon, France
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19
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Quenot JP, Ecarnot F, Meunier-Beillard N, Dargent A, Large A, Andreu P, Rigaud JP. What are the ethical aspects surrounding the collegial decisional process in limiting and withdrawing treatment in intensive care? ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:S43. [PMID: 29302599 DOI: 10.21037/atm.2017.04.15] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The decision to limit or withdraw life-support treatment is an integral part of the job of a physician working in the intensive care unit, and of the approach to care. However, this decision is influenced by a number of factors. It is widely accepted that a medical decision that will ultimate lead to end-of-life in the intensive care unit (ICU) must be shared between all those involved in the care process, and should give precedence to the patient's wishes (either directly expressed by the patient or in written form, such as advance directives), and taking into account the opinion of the patient's family, including the surrogate if the patient is no longer capable of expressing themselves. A number of questions still remain unanswered regarding how decisions to limit or withdraw treatment are taken in daily practice, especially when this decision can be anticipated. We discuss here the collegial procedure for decision-making, in particular in the context of recent French legislation on end-of-life issues. We describe how collegial decision-making procedures should be carried out, and what points are covered in shared discussions regarding decisions to limit or withdraw life-sustaining therapies.
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Affiliation(s)
- Jean-Pierre Quenot
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France.,Lipness Team, INSERM Research Center LNC-UMR1231 and LabEx LipSTIC, University of Burgundy, Dijon, France.,INSERM Besancon, CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
| | - Fiona Ecarnot
- EA3920, Department of Cardiology, University Hospital Besancon, Besancon, France
| | - Nicolas Meunier-Beillard
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France.,Department of Sociology, Centre Georges Chevrier UMR 7366 CNRSUniversity of Burgundy, Dijon, France
| | - Auguste Dargent
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France.,Lipness Team, INSERM Research Center LNC-UMR1231 and LabEx LipSTIC, University of Burgundy, Dijon, France
| | - Audrey Large
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
| | - Pascal Andreu
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
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20
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Quenot JP, Ecarnot F, Meunier-Beillard N, Dargent A, Large A, Andreu P, Rigaud JP. What are the ethical questions raised by the integration of intensive care into advance care planning? ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:S46. [PMID: 29302602 DOI: 10.21037/atm.2017.08.08] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A major goal of intensive care units (ICUs) is to offer optimal management, but for many patients admitted to the ICU, they are unlikely to yield any lasting benefit. In this context, the ICU physician remains a key intermediary, particularly when a decision regarding possible limitation or withdrawal of life-sustaining therapy becomes necessary. The possibility of admission to the ICU, and the type of care the patient would like to receive there, should be integrated into the healthcare project in agreement with the patient, regardless of the stage of disease that the patient suffers from. These dispositions should be recorded in the patient's file, and should respect the progressive nature of both the disease itself, and the discussions necessary in such complex situations. The ICU physician can serve as a valuable consultant for the treating physician, in particular to guide patient choices when formalizing their healthcare preferences in the form of advance care planning (ACP) or advance directives (AD). Ideally, the best time to address this issue is before the patient's clinical situation deteriorates towards an acute emergency, and providing complete and transparent information to inform the patient's choices.
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Affiliation(s)
- Jean-Pierre Quenot
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France.,Lipness Team, INSERM Research Center LNC-UMR1231 and LabExLipSTIC, University of Burgundy, Dijon, France.,INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
| | - Fiona Ecarnot
- EA3920, Department of Cardiology, University Hospital Besancon, Besancon, France
| | | | - Auguste Dargent
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
| | - Audrey Large
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
| | - Pascal Andreu
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
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21
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Quenot JP, Ecarnot F, Meunier-Beillard N, Dargent A, Eraldi JP, Bougerol F, Large A, Andreu P, Rigaud JP. What are the ethical dimensions in the profession of intensive care specialist? ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:S47. [PMID: 29302603 DOI: 10.21037/atm.2017.09.34] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Two essential components of the profession of a medical doctor are the constant review of the patient's therapeutic project, and collaboration between healthcare professionals. The profession of intensive care unit (ICU) physician goes further in terms of responsibility, vis-à-vis the intensive treatments dispensed to the patients, and the physician's responsibilities towards the patient's family and the caregiving team, also bearing in mind that ICU care is costly in terms of human and financial resources. In this review, we address the profession of ICU physician from the perspective of the ethical questions that arise constantly, focusing on the timeframe of the reflection process. Firstly, admission to the ICU must be anticipated. The concept of advance care planning is a suitable tool for this, and in case of non-admission to the ICU, does not by any means constitute an abandonment of the patient, because palliative care can also be anticipated, with a view to avoiding suffering for the patient and their family. Next, during an ICU stay, while the technical aspects undoubtedly characterise the ICU best at the start of the patient's stay, the process of reflection rapidly becomes preponderant, and involves the analysis of often complex situations with a view to defining the level of therapeutic engagement and optimizing the care dispensed to the patient. Last, a further ethical issue concerns the decision to re-admit (or not) a patient to the ICU. This decision can be made, for example, in the framework of a systematic, formalised, structured, multidisciplinary meeting at the end of an ICU stay, using a similar procedure to that implemented for decisions relating to withholding or withdrawal of life-sustaining therapies. The profession of ICU physician is not simply a question of prolonging or sustaining life, but is also fraught with ethical questions about how best to employ their competences. In this regard, it is essential to foster interdisciplinary collaboration, and emphasise the need for ICU physicians to be involved in the development of therapeutic projects, particularly when the disease in question is likely to be complicated by acute situations that may require admission of the patient to the ICU.
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Affiliation(s)
- Jean-Pierre Quenot
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France.,Lipness Team, INSERM Research Center LNC-UMR1231 and LabExLipSTIC, University of Burgundy, Dijon, France.,INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
| | - Fiona Ecarnot
- EA3920, Department of Cardiology, University Hospital Besancon, Besancon, France
| | - Nicolas Meunier-Beillard
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France.,Département de sociologie, Centre Georges Chevrier UMR 7366 CNRS-Université de Bourgogne, Dijon, France
| | - Auguste Dargent
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France.,Lipness Team, INSERM Research Center LNC-UMR1231 and LabExLipSTIC, University of Burgundy, Dijon, France
| | | | - François Bougerol
- Department of Intensive Care, Dieppe General Hospital, Dieppe, France
| | - Audrey Large
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
| | - Pascal Andreu
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
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22
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Impact of a stay in the intensive care unit on the preparation of Advance Directives: Descriptive, exploratory, qualitative study. Anaesth Crit Care Pain Med 2017; 37:113-119. [PMID: 28826983 DOI: 10.1016/j.accpm.2017.05.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 05/29/2017] [Accepted: 05/29/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Our objective was to assess, through a qualitative, exploratory study, the thought processes of patients regarding the formulation of advance directives (AD) after a stay in the ICU. METHODS The study was conducted from May to July 2016 using telephone interviews performed by four senior ICU physicians. Inclusion criteria were: patients discharged from ICU to home>3 months earlier. Semi-directive interviews with patients focused on 5 main points surrounding AD. RESULTS In total, among 159 eligible patients, data from 94 (59%) were available for analysis. Among all those interviewed, 83.5% had never heard of "advance directives". Only 2% had executed AD before ICU admission, and 7% expressed a desire to prepare AD further to their ICU stay. Among the barriers to preparation of AD, lack of information was the main reason cited for not executing AD. Patients noted the following in their AD: withdrawal of life-support in case of vegetative/minimally conscious state or when there is no longer any hope, in case of uncontrollable pain, and if impossible to wean from mechanical ventilation. CONCLUSION The ideal time to engage patients in these discussions is most likely well before an acute health event occurs, although this warrants further investigation both before and after ICU admissions.
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23
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Abstract
Although 80% of the deaths worldwide occur in middle- and low-income countries such as India, there is less awareness of end-of-life care (EOLC) for people with chronic, serious, progressive, or advanced life-limiting illnesses, including dementia. EOLC involves good communication, clinical decision-making, liaison with medical teams and families, comprehensive assessment of and specialized interventions for physical, psychological, spiritual, and social needs of patients and their caregivers. The psychiatrist can play a significant role in each of the above domains in EOLC. The current trends in India are examined, including ambiguities between EOLC and euthanasia. Future directions include formulating a national EOLC policy, providing appropriate services and training. The psychiatrist should get involved in this process, with major responsibilities in providing good quality EOLC for patients with both life-limiting physical illnesses and severe mental disorders, supporting their caregivers, and ensuring dignity in death.
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Affiliation(s)
- Jayita K Deodhar
- MD (Psych), DPM, DNB (Psych), MRCPsych. Associate Professor, Tata Memorial Hospital, Parel, Mumbai, Maharashtra, India
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24
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Quenot JP, Ecarnot F, Meunier-Beillard N, Dargent A, Large A, Andreu P, Rigaud JP. Intensive care unit strain should not rush physicians into making inappropriate decisions, but merely reduce the time to the right decisions being made. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:316. [PMID: 27668236 DOI: 10.21037/atm.2016.07.27] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Jean-Pierre Quenot
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France; ; Lipness Team, INSERM Research Center UMR 866 and LabExLipSTIC, University of Burgundy, Dijon, France; ; INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
| | - Fiona Ecarnot
- EA3920, Department of Cardiology, University Hospital Besancon, Besancon, France
| | - Nicolas Meunier-Beillard
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France; ; Department of Sociology, UMR 7366 CNRS, University of Burgundy - Franche-Comté, Dijon, France
| | - Auguste Dargent
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
| | - Audrey Large
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
| | - Pascal Andreu
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
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Palliative Care and Intensive Care Units. J Hosp Palliat Nurs 2016. [DOI: 10.1097/njh.0000000000000218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Hua M, Halpern SD, Gabler NB, Wunsch H. Effect of ICU strain on timing of limitations in life-sustaining therapy and on death. Intensive Care Med 2016; 42:987-94. [PMID: 26862018 PMCID: PMC4846491 DOI: 10.1007/s00134-016-4240-8] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 01/21/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE The effect of capacity strain in an ICU on the timing of end-of-life decision-making is unknown. We sought to determine how changes in strain impact timing of new do-not-resuscitate (DNR) orders and of death. METHODS Retrospective cohort study of 9891 patients dying in the hospital following an ICU stay ≥72 h in Project IMPACT, 2001-2008. We examined the effect of ICU capacity strain (measured by standardized census, proportion of new admissions, and average patient acuity) on time to initiation of DNR orders and time to death for all ICU decedents using fixed-effects linear regression. RESULTS Increases in strain were associated with shorter time to DNR for patients with limitations in therapy (predicted time to DNR 6.11 days for highest versus 7.70 days for lowest quintile of acuity, p = 0.02; 6.50 days for highest versus 7.77 days for lowest quintile of admissions, p < 0.001), and shorter time to death (predicted time to death 7.64 days for highest versus 9.05 days for lowest quintile of admissions, p < 0.001; 8.28 days for highest versus 9.06 days for lowest quintile of census, only in closed ICUs, p = 0.006). Time to DNR order significantly mediated relationships between acuity and admissions and time to death, explaining the entire effect of acuity, and 65 % of the effect of admissions. There was no association between strain and time to death for decedents without a limitation in therapy. CONCLUSIONS Strains in ICU capacity are associated with end-of-life decision-making, with shorter times to placement of DNR orders and death for patients admitted during high-strain days.
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Affiliation(s)
- May Hua
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, 622 West 168th Street PH5, Room 527D, New York, NY, 10032, USA.
| | - Scott D Halpern
- Division of Pulmonary, Allergy and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
- Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, University of Pennsylvania, Philadelphia, USA
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Nicole B Gabler
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
- Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, University of Pennsylvania, Philadelphia, USA
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Center, Toronto, Canada
- Department of Anesthesia and Interdisciplinary Department of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, USA
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Noome M, Dijkstra BM, van Leeuwen E, Vloet LCM. The Perspectives of Intensive Care Unit Nurses About the Current and Ideal Nursing End-of-Life Care. J Hosp Palliat Nurs 2016. [DOI: 10.1097/njh.0000000000000221] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Oczkowski SJW, Chung HO, Hanvey L, Mbuagbaw L, You JJ. Communication tools for end-of-life decision-making in the intensive care unit: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:97. [PMID: 27059989 PMCID: PMC4826553 DOI: 10.1186/s13054-016-1264-y] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 03/11/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND For many patients admitted to the intensive care unit (ICU), preferences for end-of-life care are unknown, and clinicians and substitute decision-makers are required to make decisions about the goals of care on their behalf. We conducted a systematic review to determine the effect of structured communication tools for end-of-life decision-making, compared to usual care, upon the number of documented goals of care discussions, documented code status, and decisions to withdraw life-sustaining treatments, in adult patients admitted to the ICU. METHODS We searched multiple databases including MEDLINE, Embase, CINAHL, ERIC, and Cochrane from database inception until July 2014. Two reviewers independently screened articles, assessed eligibility, verified data extraction, and assessed risk of bias using the tool described by the Cochrane Collaboration and the Newcastle Ottawa Scale. Pooled estimates of effect (relative risk, standardized mean difference, or mean difference), were calculated where sufficient data existed. GRADE was used to evaluate the overall quality of evidence for each outcome. RESULTS We screened 5785 abstracts and reviewed the full text of 424 articles, finding 168 eligible articles, including 19 studies in the ICU setting. The use of communication tools increased documentation of goals-of-care discussions (RR 3.47, 95% CI 1.55, 7.75, p = 0.020, very low-quality evidence), but did not have an effect on code status documentation (RR 1.03, 95% CI 0.96, 1.10, p = 0.540, low-quality evidence) or decisions to withdraw or withhold life-sustaining treatments (RR 0.98, 95% CI 0.89, 1.08, p = 0.70, low-quality evidence). The use of such tools was associated with a decrease in multiple measures of health care resource utilization, including duration of mechanical ventilation (MD -1.9 days, 95% CI -3.26, -0.54, p = 0.006, very low-quality evidence), length of ICU stay (MD -1.11 days, 95% CI -2.18, -0.03, p = 0.04, very low-quality evidence), and health care costs (SMD -0.32, 95% CI -0.5, -0.15, p < 0.001, very low-quality evidence). CONCLUSIONS Structured communication tools may improve documentation of EOL decision making and may result in lower resource use. The supporting evidence is low to very low in quality. Further high-quality randomized studies of simple communication interventions are needed to determine whether structured, rather than ad hoc, approaches to end-of-life decision-making improve patient-level, family-level, and system-level outcomes. TRIAL REGISTRATION PROSPERO CRD42014012913.
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Affiliation(s)
| | - Han-Oh Chung
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Louise Hanvey
- Canadian Hospice Palliative Care Association, Ottawa, Canada
| | - Lawrence Mbuagbaw
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada.,Biostatistics Unit, Father Sean O'Sullivan Research Centre, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - John J You
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada
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Rigaud JP, Meunier-Beillard N, Aubry R, Dion M, Ecarnot F, Quenot JP. Le médecin réanimateur : un consultant extérieur pour un choix éclairé du patient et de ses proches ? MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-016-1189-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Noome M, Dijkstra BM, van Leeuwen E, Vloet LCM. Exploring family experiences of nursing aspects of end-of-life care in the ICU: A qualitative study. Intensive Crit Care Nurs 2016; 33:56-64. [PMID: 26899128 DOI: 10.1016/j.iccn.2015.12.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 12/09/2015] [Accepted: 12/21/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES The aim of this study was to examine the experience(s) of family with the nursing aspects of End-of-life care in the intensive care unit after a decision to end life-sustaining treatment, and to describe what nursing care was most appreciated and what was lacking. METHOD A phenomenological approach including inductive thematic analysis was used. Twenty-six family members of deceased critically ill-patients were interviewed within two months after the patient's death about their experiences with nursing aspects of end-of-life care in the intensive care unit. FINDINGS Most family members experienced nursing contribution to end-of-life care of the patient and themselves, especially supportive care. Families mentioned the following topics: Communication between intensive care nurses, critically ill patients and family; Nursing care for critically ill patients; Nursing care for families of critically ill patients; Pre-conditions. Families appreciated that intensive care nurses were available at any time and willing to answer questions. But care was lacking because families had for example, a sense of responsibility for obtaining information, they had problems to understand their role in the decision-making process, and were not invited by nurses to participate in the care. CONCLUSIONS Most family appreciated the nursing EOLC they received, specifically the nursing care given to the patient and themselves. Some topics needed more attention, like information and support for the family.
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Affiliation(s)
- Marijke Noome
- Research Department of Emergency and Critical Care, HAN University of Applied Sciences, Nijmegen, The Netherlands; Bachelor of Nursing, The Hague University of Applied Sciences, The Hague, The Netherlands.
| | - Boukje M Dijkstra
- Research Department of Emergency and Critical Care, HAN University of Applied Sciences, Nijmegen, The Netherlands; Intensive Care Unit, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands.
| | - Evert van Leeuwen
- Scientific Institute for Quality of Healthcare, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands.
| | - Lilian C M Vloet
- Research Department of Emergency and Critical Care, HAN University of Applied Sciences, Nijmegen, The Netherlands; Scientific Institute for Quality of Healthcare, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands; Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands.
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Walczak A, Butow PN, Bu S, Clayton JM. A systematic review of evidence for end-of-life communication interventions: Who do they target, how are they structured and do they work? PATIENT EDUCATION AND COUNSELING 2016; 99:3-16. [PMID: 26404055 DOI: 10.1016/j.pec.2015.08.017] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 08/09/2015] [Accepted: 08/11/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To identify and synthesise evidence for interventions targeting end-of-life communication. METHODS Database, reference list and author searches were conducted to identify evaluations of end-of-life communication-focussed interventions. Data were extracted, synthesised and QUALSYST quality analyses were performed. RESULTS Forty-five studies met inclusion criteria. Interventions targeted patients (n=6), caregivers (n=3), healthcare professionals (HCPs n=24) and multiple stakeholders (n=12). Interventions took various forms including communication skills training, education, advance care planning and structured practice changes. Substantial heterogeneity in study designs, outcomes, settings and measures was apparent and study quality was variable. CONCLUSION A substantial number of end-of-life communication interventions have been evaluated. Interventions have particularly targeted HCPs in cancer settings, though patient, caregiver and multi-focal interventions have also been evaluated. While some interventions were efficacious in well-designed RCTs, most evidence was from less robust studies. While additional interventions targeting patients and caregivers are needed, multi-focal interventions may more effectively remove barriers to end-of-life communication. PRACTICE IMPLICATIONS Despite the limitations evident in the existing literature, healthcare professionals may still derive useful insights into effective approaches to end-of-life communication if appropriate caution is exercised. However, additional RCTs, implementation studies and cost-benefit analyses are required to bolster arguments for implementing and resourcing communication interventions.
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Affiliation(s)
- Adam Walczak
- Centre for Medical Psychology and Evidence-based Decision- making (CeMPED), The University of Sydney, Sydney, Australia.
| | - Phyllis N Butow
- Centre for Medical Psychology and Evidence-based Decision- making (CeMPED), The University of Sydney, Sydney, Australia
| | - Stella Bu
- Centre for Medical Psychology and Evidence-based Decision- making (CeMPED), The University of Sydney, Sydney, Australia
| | - Josephine M Clayton
- Centre for Medical Psychology and Evidence-based Decision- making (CeMPED), The University of Sydney, Sydney, Australia; HammondCare Palliative and Supportive Care Service, Greenwich Hospital, Greenwich, NSW 2065, Australia
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Bodí M, Pont T, Oliver E, Sandiumenge A. Respuesta de los autores. Med Intensiva 2016; 40:70. [DOI: 10.1016/j.medin.2015.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 09/08/2015] [Indexed: 10/22/2022]
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Lesieur O, Leloup M, Gonzalez F, Mamzer MF. Withholding or withdrawal of treatment under French rules: a study performed in 43 intensive care units. Ann Intensive Care 2015; 5:56. [PMID: 26092498 PMCID: PMC4486647 DOI: 10.1186/s13613-015-0056-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 05/28/2015] [Indexed: 01/24/2023] Open
Abstract
Background In France, decisions to limit treatment fall under the Leonetti law adopted in 2005. Leading figures from the French world of politics, science, and justice recently claimed for amendments to the law, considering it incomplete. This study, conducted before any legislative change, aimed to investigate the procedural aspects of withholding/withdrawing treatment in French ICUs and their adequacy with the existing law. Methods The characteristics of patients qualified for a withholding/withdrawal procedure were prospectively collected in 43 French ICUs. The study period (60 or 90 days under normal operating conditions) took place in the first half of 2013. Results During the study period, 777 (14 %) of 5589 admitted patients and 584 (52 %) of 1132 patients dying in the ICU had their treatment withheld or withdrawn. Whereas 344 patients had treatment(s) withheld (i.e., not started or not increased if already engaged), 433 had one or more treatment(s) withdrawn. Withdrawal of treatment was applied in 156 of 223 (70 %) brain-injured patients, compared to 277 of 554 (50 %) patients with other reasons for admission (p < 0.01). At the time of the decision-making, the patient’s wishes were known in 181 (23 %) of the 777 cases in one or more different way(s): 73 (9.4 %) from the patient, 10 (1.3 %) by advance directives, 10 (1.3 %) through a designated trusted person, and 108 (13.9 %) reported by the family or close relatives. An external consultant was involved in less than half of all decisions (356 of 777, 46 %). Of the 777 patients qualified for a withholding/withdrawal procedure, 133 (17 %) were discharged alive from the hospital (126 after withholding, 7 after withdrawal). Conclusions More than half of deaths in the study population occurred after a decision to withhold or withdraw treatment. Among patients under withholding/withdrawal procedures, brain-injured subjects were more likely to undergo a withdrawal procedure. The prevalence of advance directives and designated trusted persons was low. Because patients’ preferences were unknown in more than three quarters of cases, decisions remained primarily based on medical judgment. Limitations, especially withholding of treatment, did not preclude survival and hospital discharge.
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Mark NM, Rayner SG, Lee NJ, Curtis JR. Global variability in withholding and withdrawal of life-sustaining treatment in the intensive care unit: a systematic review. Intensive Care Med 2015; 41:1572-85. [DOI: 10.1007/s00134-015-3810-5] [Citation(s) in RCA: 166] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 04/07/2015] [Indexed: 12/01/2022]
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Baidoobonso S. Patient Care Planning Discussions for Patients at the End of Life: An Evidence-Based Analysis. ONTARIO HEALTH TECHNOLOGY ASSESSMENT SERIES 2014; 14:1-72. [PMID: 26357528 PMCID: PMC4561366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND Ontario spends about 9% of its health budget on care for people at the end of life (EoL), most of whom die from chronic, prolonged conditions. For many people, patient care planning discussions (PCPDs) can improve the quality and reduce the cost of care. OBJECTIVES This evidence-based analysis aimed to examine the effectiveness of PCPDs in achieving better patient-centred outcomes for people at the EoL. DATA SOURCES A systematic literature search was conducted in MEDLINE, Embase, CINAHL, and EBM Reviews to identify relevant literature published between January 1, 2004, and October 9, 2013. REVIEW METHODS Peer-reviewed reports from randomized controlled trials (RCTs) and observational studies were examined. Outcomes included quality of life (QoL), satisfaction, concordance, advance care planning (ACP), and health care use. Quality of evidence was assessed using GRADE. RESULTS While the effects of PCPDs on QoL are unclear, single-provider PCPDs were associated with family members being very satisfied with EoL care (odds ratio [OR]: 5.17 [95% CI: 1.52, 17.58]), improved concordance between patients' and families' wishes (OR: 4.32, P < 0.001), fewer episodes of hospital care (mean difference [MD]: -0.21, P = 0.04), spending fewer days in hospital (MD: -1.8, P = 0.03), and receiving hospice care (OR: 5.17 [95% CI: 2.03, 13.17]). Team-based PCPDs were associated with greater patient satisfaction (standardized mean difference [SMD]: 0.39 [95% CI: 0.17, 0.60]) and fewer outpatient visits (MD: -5.20 [95% CI: -9.70, -0.70]). Overall, PCPDs were associated with more ACP and more optimal health care use. LIMITATIONS Most of the RCTs were unblinded, intervention was measured or described inadequately in some studies, and the term "usual care" was often undefined. CONCLUSIONS Patients at the EoL and their families benefited from PCPDs. Furthermore, PCPDs occurring earlier in the course of illness were associated with better outcomes than those occurring later.
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Tell me where the patient comes from. Intensive Care Med 2014; 40:1775-7. [DOI: 10.1007/s00134-014-3462-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 08/20/2014] [Indexed: 10/24/2022]
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Affiliation(s)
- Raj Kumar Mani
- Department of Pulmonology, Critical Care and Sleep Medicine, Saket City Hospital, Mandir Marg, Saket, New Delhi, India
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An MS, Lee KJ. Awareness of Good Death and Attitudes toward Terminal Care among Geriatric Hospital Nurses. ACTA ACUST UNITED AC 2014. [DOI: 10.14475/kjhpc.2014.17.3.122] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Mi Sook An
- Department of Nursing, Graduate School of Public Administration, Gachon University, Seongnam, Korea
| | - Keum Jae Lee
- Department of Nursing, Gachon University, Seongnam, Korea
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Long AC, Kross EK, Engelberg RA, Downey L, Nielsen EL, Back AL, Curtis JR. Quality of dying in the ICU: is it worse for patients admitted from the hospital ward compared to those admitted from the emergency department? Intensive Care Med 2014; 40:1688-97. [PMID: 25116294 DOI: 10.1007/s00134-014-3425-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 07/24/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Although most intensive care unit (ICU) admissions originate in the emergency department (ED), a substantial number of admissions arrive from hospital wards. Patients transferred from the hospital ward often share clinical characteristics with those admitted from the ED, but family expectations may differ. An understanding of the impact of ICU admission source on family perceptions of end-of-life care may help improve patient and family outcomes by identifying those at risk for poor outcomes. DESIGN AND SETTING This was a cohort study of patients with chronic illness and acute respiratory failure requiring mechanical ventilation who died after admission to an ICU in any of the 14 participating hospitals in the Seattle-Tacoma area between 2003 and 2008 (n = 1,500). MEASUREMENTS Using regression models adjusted for hospital site and patient-, nurse- and family-level characteristics, we examined associations between ICU admission source (hospital ward vs. ED) and (1) family ratings of satisfaction with ICU care; (2) family and nurse ratings of quality of dying; (3) chart-based indicators of palliative care. MAIN RESULTS Admission from the hospital ward was associated with lower family ratings of quality of dying [β -0.90, 95% confidence interval (CI) -1.54, -0.26, p = 0.006] and satisfaction (total score β -3.97, 95% CI -7.89, -0.05, p = 0.047; satisfaction with care domain score β -5.40, 95% CI -9.44, -1.36, p = 0.009). Nurses did not report differences in quality of dying. Patients from hospital wards were less likely to have family conferences [odds ratio (OR) 0.68, 95% CI 0.52, 0.88, p = 0.004] or discussion of prognosis in the first 72 h after ICU admission (OR 0.72, 95% CI 0.56, 0.91, p = 0.007) but were more likely to receive spiritual care (OR 1.48, 95% CI 1.14, 1.93, p = 0.003) or have life support withdrawn (OR 1.38, 95% CI 1.04, 1.82, p = 0.025). CONCLUSION Admission from the hospital ward is associated with family perceptions of a lower quality of dying and less satisfaction with ICU care. Differences in receipt of palliative care suggest that family of patients from the hospital ward receive less communication. Nurse ratings of quality of dying did not significantly differ by ICU admission source, suggesting dissimilarities between family and nurse perspectives. This study identifies a patient population at risk for poor quality palliative and end-of-life care. Future studies are needed to identify interventions to improve care for patients who deteriorate on the wards following hospital admission.
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Affiliation(s)
- Ann C Long
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Box 359762, Seattle, WA, 98104, USA
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Abstract
PURPOSE OF REVIEW Decisions to limit life-sustaining therapy (DLLST) in the ICU are used to uphold patients' autonomy, protect them from non-beneficial treatment and fairly distribute resources. The institution of these decisions is complex, with a variety of qualitative and quantitative data published. This review aims to summarize the main issues and review the contemporary research findings on this subject. RECENT FINDINGS DLLST are used in a variety of clinical and non-clinical situations, before and after ICU admission, and are not always part of end-of-life management. There are many dilemmas and barriers that beset their institution. Many ICU physicians feel inadequately trained to carry them out and they are frequently a source of conflict. A variety of strategies have been examined to improve their institution, including advanced directives, intensive communication strategies and family information leaflets, many of which have improved patient and family-centred outcomes. SUMMARY There are a number of uncertainties that beset the institution of DLLST in the ICU; however, a variety of research has improved our ability to understand and implement them. This review frames some of the dilemmas and discusses some of the procedural strategies that have been used to improve outcomes.
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Guidet B, Hodgson E, Feldman C, Paruk F, Lipman J, Koh Y, Vincent JL, Azoulay E, Sprung CL. The Durban World Congress Ethics Round Table Conference Report: II. Withholding or withdrawing of treatment in elderly patients admitted to the intensive care unit. J Crit Care 2014; 29:896-901. [PMID: 25216948 DOI: 10.1016/j.jcrc.2014.08.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 07/31/2014] [Accepted: 08/02/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Life-sustaining treatment (LST) limitation for elderly patients is highly controversial. In that context, it is useful to evaluate the attitudes to LST in the elderly among experienced intensive care unit (ICU) physicians with different backgrounds and cultures. METHODS A panel of 22 international ICU physicians from 13 countries responded to a questionnaire related to withholding (WH) and withdrawing (WD) LST in elderly patients using a semi-Likert scale. RESULTS Most experts disagree or strongly disagree (77%) that age should be used as the sole criterion for WH or WD LST, and almost all disagree (91%) that there should be a specific age for such decision making. However, the vast majority (91%) acknowledge that age should be an important consideration in conjunction with other factors. Disagreement for consideration of prioritizing the young over the old in normal ICU operations was reported in 68%, whereas in an emergency triage situation, disagreement dropped to 18%. CONCLUSIONS There is a consensus among ICU physicians that age cannot be the sole criterion on which health care decisions should be made. In that perspective, it is important to provide data showing that outcome differences between elderly and nonelderly patients are partly related to decisions to forgo LSTs.
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Affiliation(s)
- Bertrand Guidet
- Assistance Publique, Hôpitaux de Paris, Hôpital Saint-Antoine, service de réanimation médicale, Paris, F-75012, France; Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, F-75013, Paris, France; INSERM, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, F-75013, Paris, France.
| | - Eric Hodgson
- Department of Anaesthesia & Critical Care, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, eThekwini-Durban, South Africa
| | - Charles Feldman
- Division of Pulmonology, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Fathima Paruk
- Department of Anaesthesiology, University of the Witwatersrand, Johannesburg, South Africa
| | - Jeffrey Lipman
- Department of Anaesthesiology and Critical Care, The University of Queensland School of Medicine: Department of Intensive Care Medicine l Royal Brisbane and Women's Hospital, Herston, QLD 4029
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, Univ. of Ulsan College of Medicine, 388-1 Pungnap Dong Songpa Ku, Seoul, 138-736, Korea
| | - Jean Louis Vincent
- Dept of Intensive Care, Université Libre de Bruxelles, Erasme Univ Hospital
| | - Elie Azoulay
- AP-HP, Hôpital Saint-Louis, Medical ICU, University Paris-7 Paris-Diderot, UFR de Médecine, 1 avenue Claude Vellefaux, 75010 Paris, France
| | - Charles L Sprung
- General Intensive Care Unit, Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, PO Box 12000, Jerusalem, Israel 91120
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A prospective determination of the incidence of perceived inappropriate care in critically ill patients. Can Respir J 2013; 21:165-70. [PMID: 24367791 DOI: 10.1155/2014/429789] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Health care providers' perceptions regarding appropriateness in end-of-life treatments have been widely studied. While nurses and physicians believe that rationing and other cost-related practices sometimes occur in the intensive care unit (ICU), they allege that treatment is often excessive. OBJECTIVE To prospectively determine the incidence and causes of health care providers' perceptions regarding appropriateness of end-of-life treatments. METHODS The present prospective study collected data from patients admitted to the medical-surgical trauma ICU of a 30-bed, Canadian teaching hospital over a three-month period. Daily surveys were completed independently by bedside nurses, charge nurses and attending physician. RESULTS In total, 5224 of 6558 expected surveys (representing 294 patients) were analyzed, yielding a response rate of 79.7%. The incidence of perceived inappropriate care in the present study was 6.5% (19 of 294 patients), with ongoing treatment for >2 days after this determination occurring in 1% (three of 294 patients). However, at least one caregiver perceived inappropriate care at some point in 110 of 294 (37.5%) patients. In these cases, in which processes to address care were not already underway, respondents believed that important issues resulting in provision of inappropriate treatments included patient-family issues and communication before or in the ICU. Caregivers did not know their patients' wishes 22% (1129 of 5224) of the time. CONCLUSIONS Although ongoing inappropriate care appeared to be a rare occurrence, the issue was a concern to at least one caregiver in one-third of cases. Public awareness for end-of-life issues, adequate communication, and up-to-date knowledge and practice in determining the wishes of critically ill patients are potential target areas to improve end-of-life care and reduce inappropriate care in the ICU. A daily, prospective survey of multidisciplinary caregivers, such as the survey used in the present study, is a viable and valuable means of determining the scope and causes of inappropriate care in the ICU.
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Shah RD, Rasinski KA, Alexander GC. The Influence of Surrogate Decision Makers on Clinical Decision Making for Critically Ill Adults. J Intensive Care Med 2013; 30:278-85. [PMID: 24362444 DOI: 10.1177/0885066613516597] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 10/22/2013] [Indexed: 11/15/2022]
Abstract
PURPOSE Intensive care unit patients rarely have decisional capacity and often surrogates make clinical decisions on their behalf. Little is known about how surrogate characteristics may influence end-of-life decision making for these patients. This study sought to determine how surrogate characteristics impact physicians' approach to end-of-life decision making. METHODS From March 2011 to August 2011, a survey was fielded to 1000 randomly sampled critical care physicians using a modified Dillman approach. The survey included a hypothetical vignette to examine how physicians' approach varied based on patient age, patient-surrogate relationship, surrogate-staff relationship, basis for surrogate's stated preferences, and surrogate's understanding of patient's condition. Outcomes included physicians' beliefs regarding (1) appropriateness of cardiopulmonary resuscitation (CPR); (2) appropriate locus of decision making for the patient; (3) degree to which a physician would try to influence a surrogate if disagreement was present; and (4) physician strategies to discussing end-of-life with surrogates. RESULTS Of 922 eligible physicians, 608 (66%) participated. Across all vignettes, CPR was felt to be less appropriate and surrogates less likely to be given priority with an older rather than younger patient (15% vs 63% and 50% vs 65%, both P values <.001). Cardiopulmonary resuscitation was considered less appropriate when the surrogate-patient relationship was not close (34% vs 44%, P = .03) and the surrogate's understanding was poor (34% vs 43%, P = .05). No other surrogate characteristics examined yielded statistically significant associations. CONCLUSION Some surrogate characteristics may modify clinicians' beliefs and practices regarding end-of-life care, suggesting the nuances of the surrogate-physician relationship and clinical decision making for critically ill patients.
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Affiliation(s)
- Raj D Shah
- Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, USA
| | - Kenneth A Rasinski
- Chicago Consortium for School Research, University of Chicago, Chicago, IL, USA
| | - G Caleb Alexander
- MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago, IL, USA Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA Department of Medicine, Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD, USA Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA Department of Pharmacy Practice, University of Illinois at Chicago School of Pharmacy, Chicago, IL, USA
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Reineck LA, Wallace DJ, Barnato AE, Kahn JM. Nighttime intensivist staffing and the timing of death among ICU decedents: a retrospective cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R216. [PMID: 24090194 PMCID: PMC4057319 DOI: 10.1186/cc13033] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 07/23/2013] [Indexed: 11/12/2022]
Abstract
Introduction Intensive care units (ICUs) are increasingly adopting 24-hour intensivist physician staffing. Although nighttime intensivist staffing does not consistently reduce mortality, it may affect other outcomes such as the quality of end-of-life care. Methods We conducted a retrospective cohort study of ICU decedents using the 2009–2010 Acute Physiology and Chronic Health Evaluation clinical information system linked to a survey of ICU staffing practices. We restricted the analysis to ICUs with high-intensity daytime staffing, in which the addition of nighttime staffing does not influence mortality. We used multivariable regression to assess the relationship between nighttime intensivist staffing and two separate outcomes potentially related to the quality of end-of-life care: time from ICU admission to death and death at night. Results Of 30,456 patients admitted to 27 high-intensity daytime staffed ICUs, 3,553 died in the hospital within 30 days. After adjustment for potential confounders, admission to an ICU with nighttime intensivist staffing was associated with a shorter duration between ICU admission and death (adjusted difference: –2.5 days, 95% CI -3.5 to -1.5, p-value < 0.001) and a decreased odds of nighttime death (adjusted odds ratio: 0.75, 95% CI 0.60 to 0.94, p-value 0.011) compared to admission to an ICU without nighttime intensivist staffing. Conclusions Among ICU decedents, nighttime intensivist staffing is associated with reduced time between ICU admission and death and reduced odds of nighttime death.
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Human Becoming. J Hosp Palliat Nurs 2013. [DOI: 10.1097/njh.0b013e31829bcca2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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McLeod-Sordjan R. Death preparedness: a concept analysis. J Adv Nurs 2013; 70:1008-19. [DOI: 10.1111/jan.12252] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Renee McLeod-Sordjan
- Pace University; College of Health Professions; New York New York USA
- Attending Division of Medical Ethics, North Shore-Long Island Jewish, University Hospital System; Great Neck, New York USA
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Wilson ME, Samirat R, Yilmaz M, Gajic O, Iyer VN. Physician staffing models impact the timing of decisions to limit life support in the ICU. Chest 2013. [PMID: 23187703 DOI: 10.1378/chest.12-1173] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND A growing trend is the implementation of 24-h attending physician coverage in the ICU. Our aim was to measure the impact of 24-h, in-house, attending intensivist coverage on the quality of end-of-life care and the timing of end-of-life decision-making. METHODS A retrospective cohort study was conducted of all ICU deaths 6 months before and 6 months after the implementation of mandatory 24-h attending intensivist coverage in a medical ICU. Data relevant to end-of-life care per established consensus recommendations were abstracted from the medical record. RESULTS The following changes were observed after implementation of 24-h intensivist coverage: Time from ICU admission to decision to withdraw mechanical ventilation and time to decision to change to do-not-resuscitate code status both were shortened by 2 days (both P = .03). Quality measures, such as increased family presence around time of death ( P = .01) also improved. Other findings, which did not reach statistical significance, included the following: Time to family conference was shortened by 2 days ( P = .09), time to decision to limit any life support was shortened by 1 day ( P = .08), time to death was shortened by 2 days ( P = .08), and intubations against patient wishes decreased (from three to none; P = .12). CONCLUSIONS The implementation of mandatory 24-h, in-house, attending intensivist coverage was associated with earlier decision-making across a number of domains related to end-of-life care. Positive trends were noted in quality of end-of-life care as reflected in the presence of family at the time of death.
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Affiliation(s)
| | - Ramez Samirat
- Department of Internal Medicine, University of Miami Jackson Memorial Hospital, Miami, FL
| | - Murat Yilmaz
- Department of Anesthesiology and Intensive Care, Akdeniz University, Antalya, Turkey
| | - Ognjen Gajic
- Divisions of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Vivek N Iyer
- Divisions of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN.
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Year in review in Intensive Care Medicine 2012. II: Pneumonia and infection, sepsis, coagulation, hemodynamics, cardiovascular and microcirculation, critical care organization, imaging, ethics and legal issues. Intensive Care Med 2013; 39:345-64. [PMID: 23291735 PMCID: PMC3578723 DOI: 10.1007/s00134-012-2804-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 12/13/2012] [Indexed: 12/16/2022]
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Guidelines for withholding and withdrawing therapy in the ICU: impact on decision-making process and interdisciplinary collaboration. HEART, LUNG AND VESSELS 2013; 5:158-67. [PMID: 24364007 PMCID: PMC3848674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Interdisciplinary collaboration in end-of-life decision-making is challenging. Guidelines developed within the interdisciplinary team may help to clarify, describe, and obtain consensus on standards for end-of-life decision-making and care. The aim of the study was to develop, implement, and evaluate guidelines for withholding and withdrawing therapy in the intensive care unit. METHODS An intervention study in two Danish intensive care units, evaluated in a pre-post design by a retrospective hospital record review and a questionnaire survey. The hospital record review included 1,665 patients at baseline (12-month review) and 897 patients after the intervention (6-month review). The questionnaire survey included 273 nurses, intensivists, and primary physicians at baseline and 229 post-intervention. RESULTS For patients with therapy withdrawn, the median time from admission to first consideration on level of therapy decreased from 1.1 to 0.4 days (p=0.03), and the median time from admission to a withdrawal decision decreased from 3.1 to 1.1 days (p=0.02). Sixty-five percent of the participants who used the guidelines concerning end-of-life decision-making considered them helpful to high or very high extent. No significant changes were found in satisfaction with interdisciplinary collaboration or in withholding or withdrawing decisions being changed or unnecessarily postponed. The healthcare professionals' perception of the care following withdrawal of therapy increased significantly after implementation of the guidelines. CONCLUSIONS The study indicates that working with guidelines for withholding and withdrawing therapy in the intensive care unit may facilitate improvements in end-of-life decision-making and patient care, but further studies are needed to provide robust evidence.
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Current World Literature. Curr Opin Support Palliat Care 2012; 6:402-16. [DOI: 10.1097/spc.0b013e3283573126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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