Factors that contribute to physician variability in decisions to limit life support in the ICU: a qualitative study

A window of opportunity for ICU end-of-life care-A retrospective multicenter cohort study

BACKGROUND

The "window of opportunity" for intensive care staff to deliver end-of-life (EOL) care lies in the timeframe from "documenting the diagnosis of dying" to death. Diagnosing the dying can be a challenging task in the ICU. We aimed to describe the trajectories for dying patients in Danish intensive care units (ICUs) and to examine whether physicians document that patients are dying in time to perform EOL care and, if so, when a window of opportunity for EOL care exists.

METHODS

From the Danish Intensive Care Database, we identified patients ≥18 years old admitted to Danish ICUs between January and December 2020 with an ICU stay of >96 h (four days) and who died during the ICU stay or within 7 days after ICU discharge. A chart review was performed on 250 consecutive patients admitted from January 1, 2020, to ICUs in the Central Denmark Region.

RESULTS

In most charts (223 [89%]), it was documented that the patient was dying. Of those patients who received mechanical ventilation, 171 (68%) died after abrupt discontinuation of mechanical ventilation, and 63 (25%) died after gradual withdrawal. Patients whose mechanical ventilation was discontinued abruptly died after a median of 1 h (interquartile range [IQR]: 0-15) and 5 h (IQR: 2-15) after a diagnosis of dying was recorded. In contrast, patients with a gradual withdrawal died after a median of 108 h (IQR: 71-189) and 22 h (IQR: 5-67) after a diagnosis of dying was recorded.

CONCLUSIONS

EOL care hinges on the ability to diagnose the dying. This study shows that there is a window of opportunity for EOL care, particularly for patients who are weaned from mechanical ventilation. This highlights the importance of intensifying efforts to address EOL care requirements for ICU patients and those discharged from ICUs who are not eligible for readmission.

Psychological Determinants of Physician Variation in End-of-Life Treatment Intensity: A Systematic Review and Meta-Synthesis

BACKGROUND

Physicians treating similar patients in similar care-delivery contexts vary in the intensity of life-extending care provided to their patients at the end-of-life. Physician psychological propensities are an important potential determinant of this variability, but the pertinent literature has yet to be synthesized.

OBJECTIVE

Conduct a review of qualitative studies to explicate whether and how psychological propensities could result in some physicians providing more intensive treatment than others.

METHODS

Systematic searches were conducted in five major electronic databases-MEDLINE ALL (Ovid), Embase (Elsevier), CINAHL (EBSCO), PsycINFO (Ovid), and Cochrane CENTRAL (Wiley)-to identify eligible studies (earliest available date to August 2021). Eligibility criteria included examination of a physician psychological factor as relating to end-of-life care intensity in advanced life-limiting illness. Findings from individual studies were pooled and synthesized using thematic analysis, which identified common, prevalent themes across findings.

RESULTS

The search identified 5623 references, of which 28 were included in the final synthesis. Seven psychological propensities were identified as influencing physician judgments regarding whether and when to withhold or de-escalate life-extending treatments resulting in higher treatment intensity: (1) professional identity as someone who extends lifespan, (2) mortality aversion, (3) communication avoidance, (4) conflict avoidance, (5) personal values favoring life extension, (6) decisional avoidance, and (7) over-optimism.

CONCLUSIONS

Psychological propensities could influence physician judgments regarding whether and when to de-escalate life-extending treatments. Future work should examine how individual and environmental factors combine to create such propensities, and how addressing these propensities could reduce physician-attributed variation in end-of-life care intensity.

Variability of Prognostic Communication in Critically Ill Neurologic Patients: A Pilot Multicenter Mixed-Methods Study

IMPORTANCE

Withdrawal-of-life-sustaining treatments (WOLST) rates vary widely among critically ill neurologic patients (CINPs) and cannot be solely attributed to patient and family characteristics. Research in general critical care has shown that clinicians prognosticate to families with high variability. Little is known about how clinicians disclose prognosis to families of CINPs, and whether any associations exist with WOLST.

OBJECTIVES

Primary: to demonstrate feasibility of audio-recording clinician-family meetings for CINPs at multiple centers and characterize how clinicians communicate prognosis during these meetings. Secondary: to explore associations of 1) clinician, family, or patient characteristics with clinicians' prognostication approaches and 2) prognostication approach and WOLST.

DESIGN SETTING AND PARTICIPANTS

Forty-three audio-recorded clinician-family meetings during which prognosis was discussed from seven U.S. centers for 39 CINPs with 88 family members and 27 clinicians.

MAIN OUTCOMES AND MEASURES

Two investigators qualitatively coded transcripts using inductive methods (inter-rater reliability > 80%) to characterize how clinicians prognosticate. We then applied univariate and multivariable multinomial and binomial logistic regression.

RESULTS

Clinicians used four distinct prognostication approaches: Authoritative (21%; recommending treatments without discussing values and preferences); Informational (23%; disclosing just the prognosis without further discussions); advisory (42%; disclosing prognosis followed by discussion of values and preferences); and responsive (14%; eliciting values and preferences, then disclosing prognosis). Before adjustment, prognostication approach was associated with center (p < 0.001), clinician specialty (neurointensivists vs non-neurointensivists; p = 0.001), patient age (p = 0.08), diagnosis (p = 0.059), and meeting length (p = 0.03). After adjustment, only clinician specialty independently predicted prognostication approach (p = 0.027). WOLST decisions occurred in 41% of patients and were most common under the advisory approach (56%). WOLST was more likely in older patients (p = 0.059) and with more experienced clinicians (p = 0.07). Prognostication approach was not independently associated with WOLST (p = 0.198).

CONCLUSIONS AND RELEVANCE

It is feasible to audio-record sensitive clinician-family meetings about CINPs in multiple ICUs. We found that clinicians prognosticate with high variability. Our data suggest that larger studies are warranted in CINPs to examine the role of clinicians' variable prognostication in WOLST decisions.

Ignorance is Not Bliss: The Case for Comprehensive Reproductive Counseling for Women with Chronic Kidney Disease

The bioethics literature has paid little attention to matters of informed reproductive decision-making among women of childbearing age who have chronic kidney disease (CKD), including women who are on dialysis or women who have had a kidney transplant. Women with CKD receive inconsistent and, sometimes, inadequate reproductive counseling, particularly with respect to information about pursuing pregnancy. We identify four factors that might contribute to inadequate and inconsistent reproductive counseling. We argue that women with CKD should receive comprehensive reproductive counseling, including information about the possibility of pursuing pregnancy, and that more rigorous research on pregnancy in women with CKD, including women on dialysis or who have received a kidney transplant, is warranted to improve informed reproductive decision making in this population.

Reasons for physician-related variability in end-of-life decision-making in intensive care

BACKGROUND

There is increasing evidence that the individual physician is the main factor influencing variability in end-of-life decision-making in intensive care units. End-of-life decisions are complex and should be adapted to each patient. Physician-related variability is problematic as it may result in unequal assessments that affect patient outcomes. The primary aim of this study was to investigate factors contributing to physician-related variability in end-of-life decision-making.

METHOD

This is a qualitative substudy of a previously conducted study. In-depth thematic analysis of semistructured interviews with 19 critical care specialists from five different Swedish intensive care units was performed. Interviews took place between 1 February 2017 and 31 May 2017.

RESULTS

Factors influencing physician-related variability consisted of different assessment of patient preferences, as well as intensivists' personality and values. Personality was expressed mainly through pace and determination in the decision-making process. Personal prejudices appeared in decisions, but few respondents had personally witnessed this. Avoidance of criticism and conflicts as well as individual strategies for emotional coping were other factors that influenced physician-related variability. Many respondents feared criticism for making their assessments, and the challenging nature of end-of-life decision-making lead to avoidance as well as emotional stress.

CONCLUSION

Variability in end-of-life decision-making is an important topic that needs further investigation. It is imperative that such variability be acknowledged and addressed in a more formal and transparent manner. The ethical issues faced by intensivists have recently been compounded by the devastating impact of the COVID-19 pandemic, demonstrating in profound terms the importance of the topic.

Predictors and Direct Cost Estimation of Long Stays in Pediatric Intensive Care Units in Saudi Arabia: A Mixed Methods Study

Background

Several factors influence patients’ length of stay (LOS) in pediatric intensive care units (PICUs). This study explored the factors and cost associated with long LOS among pediatric patient population across various PICUs and pediatric surgical cardiac intensive care units (SCICUs).

Methods

This is a multi-center concurrent mixed-methods study that was conducted in different PICUs and SCICUs in Riyadh, Saudi Arabia. The units’ leaders were qualitatively interviewed to explore the potential factors contributing to long LOSs in PICUs and SCICUs, and deductive content analysis was used. Microcosting was utilized to estimate the inpatient costs for a sample of long-stay patients (LSPs) and the potential cost savings if those patients were transferred to step-down care units (SDUs) for those who stayed ≥60 days.

Results

Ten (90%) leaders of PICUs and SCICUs who were invited had participated. Changing the admission criteria, patient transfer to SDUs, family engagement in the decision-making process, and adopting a national do-not-resuscitate (DNR) policy were factors contributing to short LOSs. On the other hand, administrative constraints, staff avoidance of code status decisions, lack of palliative care resources, and complex patient characteristics were factors associated with long LOSs. The mean inpatient cost per patient was SAR 3.63 million (USD 0.97 million), and the total cost for the 48 patients was SAR 172.95 million (USD 46.12 million).

Conclusion

If the recommendation to transfer LSPs after a 60-day PICU stay to SDUs is taken, the estimated cost savings among this sample of patients alone can be as high as SAR 109.47 million (USD 29.19 million). Therefore, future studies should examine the factors contributing to long LOSs in PICUs and SCICUs as well as the effectiveness of different policies aimed at improving the resource allocation and management using more robust study designs and diverse patient population.

Framework to Support the Process of Decision-Making on Life-Sustaining Treatments in the ICU: Results of a Delphi Study

Supplemental Digital Content is available in the text.

To develop a consensus framework that can guide the process of decision-making on continuing or limiting life-sustaining treatments in ICU patients, using evidence-based items, supported by caregivers, patients, and surrogate decision makers from multiple countries.

Barriers to Evidence-Based Treatment of Serious Burns: The Impact of Implicit Bias on Clinician Perceptions of Patient Adherence

The underlying assumption of modern evidence-based practice is that treatment decisions made by healthcare providers are based solely on the best available scientific data. However, the connection between evidence informed care guidelines and the provision of care remains ambiguous. In reality, a number of contextual and nonclinical factors can also play a role, among which is the implicit bias that affects the way in which we approach or treat others based on irrelevant, individual characteristics despite conscious efforts to treat everyone equally. Influenced by the social and demographic characteristics of patients, this bias and its associated perceptions have been shown to affect clinical decision making and access to care across multiple conditions and settings. This summary article offers an introduction to how the phenomenon of implicit bias can impact on treatment compliance in multiple care contexts, its potential presence and impact in burns care and describes some of the strategies which offer possible solutions to reducing the disconnect between the conscious attempts to deliver equitable care and the discrepancies in care delivery that remain.

From Awareness to Prognosis: Ethical Implications of Uncovering Hidden Awareness in Behaviorally Nonresponsive Patients

Long-term patient outcomes after severe brain injury are highly variable, and reliable prognostic indicators are urgently needed to guide treatment decisions. Functional neuroimaging is a highly sensitive method of uncovering covert cognition and awareness in patients with prolonged disorders of consciousness, and there has been increased interest in using it as a research tool in acutely brain injured patients. When covert awareness is detected in a research context, this may impact surrogate decisionmaking-including decisions about life-sustaining treatment-even though the prognostic value of covert consciousness is currently unknown. This paper provides guidance to clinicians and families in incorporating individual research results of unknown prognostic value into surrogate decisionmaking, focusing on three potential issues: (1) Surrogate decisionmakers may misinterpret results; (2) Results may create false hope about the prospects of recovery; (3) There may be disagreement about the meaningfulness or relevance of results, and appropriateness of continued care.

Withholding/Withdrawing Life-Sustaining Treatment in a Multiethnic Critical Care Setting: An Ethnographic Study

Background: Critical care physicians often have to make challenging decisions to withhold/withdraw life-sustaining treatments. As a result of society's increasingly cultural diversity such decision making often involves patients from ethnic minority groups, which might pose extra challenges. Objective: To investigate withholding/withdrawing life-sustaining treatments with patients from ethnic minority groups and their families during critical care. Design: Ethnographic fieldwork (observations, in-depth interviews and reading patients' medical files). Setting/Subjects: Eighteen patients from ethnic minority groups, their relatives, physicians and nurses were studied in one intensive care unit of a multi-ethnic urban hospital (Belgium). Results: During decision making physicians had a very central role. The contribution of patients and nurses was limited, while families' input was more noticeable. Decision making was hampered by communication difficulties between: (1) staff and relative(s), (2) relatives, and (3) patient and relative(s). Different approaches were used by physicians to overcome difficulties, which often reflected their tendency to control decision making, for example, stressing their central role. At times their approaches reflected their inability to align families' wishes with their own, for example, when making decisions without explicitly informing relatives. Conclusions: Withholding/withdrawing life-sustaining treatments in a multi-ethnic critic care context has a number of alarming difficulties, such as how to take families' input correctly into account. It is important that decision making happens in a cultural sensitive way and with involvement tailored to patients' and relatives' needs and in close consultation with interprofessional health care workers/other services.

Do-not-intubate orders in patients with acute respiratory failure: a systematic review and meta-analysis

PURPOSE

To assess the rates and variability of do-not-intubate orders in patients with acute respiratory failure.

METHODS

We conducted a systematic review of observational studies that enrolled adult patients with acute respiratory failure requiring noninvasive ventilation or high-flow nasal cannula oxygen from inception to 2019.

RESULTS

Twenty-six studies evaluating 10,755 patients were included. The overall pooled rate of do-not-intubate orders was 27%. The pooled rate of do-not-intubate orders in studies from North America was 14% (range 9-22%), from Europe was 28% (range 13-58%), and from Asia was 38% (range 9-83%), p = 0.001. Do-not-intubate rates were higher in studies with higher patient age and in studies where do-not-intubate decisions were made without reported patient/family input. There were no significant differences in do-not-intubate orders according to illness severity, observed mortality, malignancy comorbidity, or methodological quality. Rates of do-not-intubate orders increased over time from 9% in 2000-2004 to 32% in 2015-2019. Only 12 studies (46%) reported information about do-not-intubate decision-making processes. Only 4 studies (15%) also reported rates of do-not-resuscitate.

CONCLUSIONS

One in four patients with acute respiratory failure (who receive noninvasive ventilation or high-flow nasal cannula oxygen) has a do-not-intubate order. The rate of do-not-intubate orders has increased over time. There is high inter-study variability in do-not-intubate rates-even when accounting for age and illness severity. There is high variability in patient/family involvement in do-not-intubate decision making processes. Few studies reported differences in rates of do-not-resuscitate and do-not-intubate-even though recovery is very different for acute respiratory failure and cardiac arrest.

Neurocritical care physicians' doubt about whether to withdraw life-sustaining treatment the first days after devastating brain injury: an interview study

Background

Multilevel uncertainty exists in the treatment of devastating brain injury and variation in end-of-life decision-making is a concern. Cognitive and emotional doubt linked to making challenging decisions have not received much attention. The aim of this study was to explore physicians´ doubt related to decisions to withhold or withdraw life-sustaining treatment within the first 72 h after devastating brain injury and to identify the strategies used to address doubt.

Method

Semi-structured interviews were conducted with 18 neurocritical care physicians in a Norwegian trauma centre (neurosurgeons, intensivists and rehabilitation specialists) followed by a qualitative thematic analysis.

Result

All physicians described feelings of doubt. The degree of doubt and how they dealt with it varied. Institutional culture, ethics climate and individual physicians´ values, experiences and emotions seemed to impact judgements and decisions. Common strategies applied by physicians across specialities when dealing with uncertainty and doubt were: 1. Provision of treatment trials 2. Using time as a coping strategy 3. Collegial counselling and interdisciplinary consensus seeking 4. Framing decisions as purely medical.

Conclusion

Decisions regarding life-sustaining treatment after devastating brain injury are crafted in a stepwise manner. Feelings of doubt are frequent and seem to be linked to the recognition of fallibility. Doubt can be seen as positive and can foster open-mindedness towards the view of others, which is one of the prerequisites for a good ethical climate. Doubt in this context tends to be mitigated by open interdisciplinary discussions acknowledging doubt as rational and a normal feature of complex decision-making.

Influence of nurse's involvement on practices during end-of-life decisions within stroke units

OBJECTIVES

Decision-making processes concerning end-of-life decisions are not well understood for patients admitted into stroke units with severe stroke. To assess the influence of nurses on the medical perspectives and approaches that lead to withholding and/or withdrawing treatments related to end-of-life (EOL) decisions.

PATIENTS AND METHODS

This secondary analysis nested within the TELOS French national survey was based on a physicians' self-report questionnaire and on a I-Score which was linked to nurses' involvement. Physician's responses were evaluated to assess the potential influence of nurse's involvement on physician's choices during an end-of-life decision.

RESULTS

Among the 120 questionnaires analyzed, end-of-life decisions were more often made during a round-table discussion (58% vs. 35%, p = 0.004) when physicians declare to involve nurses in the decision process. Neurologists involved with nurses in decision making were more likely to withhold a treatment (98% vs. 88%, p = 0.04), to withdraw artificial feeding and hydration (59% vs. 39%, p = 0.04), and more frequently prescribed analgesics and hypnotics at a potentially lethal dose (70% vs. 48%, p = 0.03).

CONCLUSION

The involvement of nurses during end-of-life decisions for patients with acute stroke in stroke units seemed to influence neurologists' intensivist practices and behaviors. Nurses supported the physicians' decisions related to forgoing life sustaining treatment for patients with acute stroke and may positively impact on the family's choice to participate in end-of-life decisions.

Clinical Requirements of Future Patient Monitoring in the Intensive Care Unit: Qualitative Study

Background

In the intensive care unit (ICU), continuous patient monitoring is essential to detect critical changes in patients’ health statuses and to guide therapy. The implementation of digital health technologies for patient monitoring may further improve patient safety. However, most monitoring devices today are still based on technologies from the 1970s.

Objective

The aim of this study was to evaluate statements by ICU staff on the current patient monitoring systems and their expectations for future technological developments in order to investigate clinical requirements and barriers to the implementation of future patient monitoring.

Methods

This prospective study was conducted at three intensive care units of a German university hospital. Guideline-based interviews with ICU staff—5 physicians, 6 nurses, and 4 respiratory therapists—were recorded, transcribed, and analyzed using the grounded theory approach.

Results

Evaluating the current monitoring system, ICU staff put high emphasis on usability factors such as intuitiveness and visualization. Trend analysis was rarely used; inadequate alarm management as well as the entanglement of monitoring cables were rated as potential patient safety issues. For a future system, the importance of high usability was again emphasized; wireless, noninvasive, and interoperable monitoring sensors were desired; mobile phones for remote patient monitoring and alarm management optimization were needed; and clinical decision support systems based on artificial intelligence were considered useful. Among perceived barriers to implementation of novel technology were lack of trust, fear of losing clinical skills, fear of increasing workload, and lack of awareness of available digital technologies.

Conclusions

This qualitative study on patient monitoring involves core statements from ICU staff. To promote a rapid and sustainable implementation of digital health solutions in the ICU, all health care stakeholders must focus more on user-derived findings. Results on alarm management or mobile devices may be used to prepare ICU staff to use novel technology, to reduce alarm fatigue, to improve medical device usability, and to advance interoperability standards in intensive care medicine. For digital transformation in health care, increasing the trust and awareness of ICU staff in digital health technology may be an essential prerequisite.

Trial Registration

ClinicalTrials.gov NCT03514173; https://clinicaltrials.gov/ct2/show/NCT03514173 (Archived by WebCite at http://www.webcitation.org/77T1HwOzk)

Differences in Code Status and End-of-Life Decision Making in Patients With Limited English Proficiency in the Intensive Care Unit

OBJECTIVE

To determine whether code status, advance directives, and decisions to limit life support were different for patients with limited English proficiency (LEP) in the intensive care unit (ICU) as compared with patients whose primary language was English.

PATIENTS AND METHODS

We conducted a retrospective cohort study in adult patients admitted to 7 ICUs in a single tertiary academic medical center from May 31, 2011, through June 1, 2014.

RESULTS

Of the 27,523 patients admitted to the ICU, 779 (2.8%) had LEP. When adjusted for severity of illness, sex, education level, and insurance status, patients with LEP were less likely to change their code status from full code to do not resuscitate during ICU admission (odds ratio [OR], 0.62; 95% CI, 0.46-0.82; P<.001) and took 3.8 days (95% CI, 1.9-5.6 days; P<.001) longer to change to do not resuscitate. Patients with LEP who died in the ICU were less likely to receive a comfort measures order set (OR, 0.38; 95% CI, 0.16-0.91; P=.03) and took 19.1 days (95% CI, 13.2-25.1 days; P<.001) longer to transition to comfort measures only. Patients with LEP were less likely to have an advance directive (OR, 0.23; 95% CI, 0.18-0.29; P<.001), more likely to receive mechanical ventilation (OR, 1.26; 95% CI, 1.07-1.48; P=.005), and more likely to have restraints used (OR, 1.36; 95% CI, 1.11-1.65; P=.003). The hospital length of stay was 2.7 days longer for patients with LEP. Additional adjustment for religion, race, and age yielded similar results.

CONCLUSION

There are important differences in end-of-life care and decision making for patients with LEP.

Practice variation and practice guidelines: Attitudes of generalist and specialist physicians, nurse practitioners, and physician assistants

Objective

To understand clinicians' beliefs about practice variation and how variation might be reduced.

Methods

We surveyed board-certified physicians (N = 178), nurse practitioners (N = 60), and physician assistants (N = 12) at an academic medical center and two community clinics, representing family medicine, general internal medicine, and cardiology, from February—April 2016. The Internet-based questionnaire ascertained clinicians' beliefs regarding practice variation, clinical practice guidelines, and costs.

Results

Respondents agreed that practice variation should be reduced (mean [SD] 4.5 [1.1]; 1 = strongly disagree, 6 = strongly agree), but agreed less strongly (4.1 [1.0]) that it can realistically be reduced. They moderately agreed that variation is justified by situational differences (3.9 [1.2]). They strongly agreed (5.2 [0.8]) that clinicians should help reduce healthcare costs, but agreed less strongly (4.4 [1.1]) that reducing practice variation would reduce costs. Nearly all respondents (234/249 [94%]) currently depend on practice guidelines. Clinicians rated differences in clinician style and experience as most influencing practice variation, and inaccessibility of guidelines as least influential. Time to apply standards, and patient decision aids, were rated most likely to help standardize practice. Nurse practitioners and physicians assistants (vs physicians) and less experienced (vs senior) clinicians rated more favorably several factors that might help to standardize practice. Differences by specialty and academic vs community practice were small.

Conclusions

Clinicians believe that practice variation should be reduced, but are less certain that this can be achieved. Accessibility of guidelines is not a significant barrier to practice standardization, whereas more time to apply standards is viewed as potentially helpful.

A qualitative exploration of the discharge process and factors predisposing to readmissions to the intensive care unit

Background

Quantitative studies have demonstrated several factors predictive of readmissions to intensive care. Clinical decision tools, derived from these factors have failed to reduce readmission rates. The purpose of this study was to qualitatively explore the experiences and perceptions of physicians and nurses to gain more insight into intensive care readmissions.

Methods

Semi-structured interviews of intensive care unit (ICU) and general medicine care providers explored work routines, understanding and perceptions of the discharge process, and readmissions to intensive care. Participants included ten providers from the ICU setting, including nurses (n = 5), consultant intensivists (n = 2), critical care fellows (n = 3) and 9 providers from the general medical setting, nurses (n = 4), consulting physicians (n = 2) and senior resident physicians (n = 3). Principles of grounded theory were used to analyze the interview transcripts.

Results

Nine factors within four broad themes were identified: (1) patient factors – severity-of-illness and undefined goals of care; (2) process factors – communication, transitions of care; (3) provider factors – discharge decision-making, provider experience and comfort level; (4) organizational factors – resource constraints, institutional policies.

Conclusions

Severe illness predisposes ICU patients to readmission, especially when goals of care were not adequately addressed. Communication, premature discharge, and other factors, mostly unrelated to the patient were also perceived by physicians and nurses to be associated with readmissions to intensive care. Quality improvement efforts that focus on modifying or improving aspects of non-patient factors may improve outcomes for patients at risk of ICU readmission.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2821-z) contains supplementary material, which is available to authorized users.

Early Withdrawal Decision-Making in Patients with Coma After Cardiac Arrest: A Qualitative Study of Intensive Care Clinicians

INTRODUCTION

Neurologists are often asked to define prognosis in comatose patients. However, comatose patients following cardiac arrest are usually cared for by cardiologists or intensivists, and it is their approach that will influence decisions regarding withdrawal of life-sustaining interventions (WLSI). We observed that factors leading to these decisions vary across specialties and considered whether they could result in self-fulfilling prophecies and early WLSI. We conducted a hypothesis-generating qualitative study to identify factors used by non-neurologists to define prognosis in these patients and construct an explanatory model for how early WLSI might occur.

METHODS

This was a single-center qualitative study of intensivists caring for cardiac arrest patients with hypoxic-ischemic coma. Thirty attending physicians (n = 16) and fellows (n = 14) from cardiac (n = 8), medical (n = 6), surgical (n = 10), and neuro (n = 6) intensive care units underwent semi-structured interviews. Interview transcripts were analyzed using grounded theory techniques.

RESULTS

We found three components of early WLSI among non-neurointensivists: (1) development of fixed negative opinions; (2) early framing of poor clinical pictures to families; and (3) shortened windows for judging recovery potential. In contrast to neurointensivists, non-neurointensivists' negative opinions were frequently driven by patients' lack of consciousness and cardiopulmonary resuscitation circumstances. Both groups were influenced by age and comorbidities.

CONCLUSIONS

The results demonstrate that factors influencing prognostication differ across specialties. Some differ from those recommended by published guidelines and may lead to self-fulfilling prophecies and early WLSI. Better understanding of this framework would facilitate educational interventions to mitigate this phenomenon and its implications on patient care.

Limitation of therapeutic effort experienced by intensive care nurses

Background:

Nurses who practice limitation of therapeutic effort become fully involved in emotionally charged situations, which can affect them significantly on an emotional and professional level.

Objectives:

To describe the experience of intensive care nurses practicing limitation of therapeutic effort.

Method:

A qualitative, phenomenological study was performed within the intensive care units of the Madrid Hospitals Health Service. Purposeful and snowball sampling methods were used, and data collection methods included semi-structured and unstructured interviews, researcher field notes, and participants’ personal letters. The Giorgi proposal for data analysis was used on the data.

Ethical considerations:

This study was approved by the Ethical Research Committee of the relevant hospital and by the Ethics Committee of the Rey Juan Carlos University and was guided by the ethical principles of voluntary enrollment, anonymity, privacy, and confidentiality.

Results:

In total, 22 nurses participated and 3 themes were identified regarding the nurses’ experiences when faced with limitation of therapeutic effort: (a) experiencing relief, (b) accepting the medical decision, and (c) implementing limitation of therapeutic effort.

Conclusion:

Nurses felt that, although they were burdened with the responsibility of implementing limitation of therapeutic effort, they were being left out of the final decision-making process regarding the same.

Decision Aids and Shared Decision-Making in Neurocritical Care: An Unmet Need in Our NeuroICUs

Improved resuscitation methods and advances in critical care have significantly increased the survival of patients presenting with devastating brain injuries compared to prior decades. After the patient's stabilization phase, families and patients are faced with "goals-of-care" decisions about continuation of aggressive intensive care unit care or comfort care only (CMO). Highly varying rates of CMO between centers raise the question of "self-fulfilling prophecies." Disease severity, the physician's communication and the family's understanding of projected outcomes, their uncertainties, complication risks with continued care, physician bias, and the patient's and surrogate's wishes and values all influence a CMO decision. Disease-specific decision support interventions, decision aids (DAs), may remedy these issues in the neurocritical care unit, potentially leading to better-informed and less-biased goals-of-care decisions in neurocritically ill patients, while increasing decision knowledge, confidence, and realistic expectations and decreasing decisional conflict and regret. Shared decision-making (SDM) is a collaborative process that enhances patients' and proxies' understanding about prognosis, encourages them to actively weigh the risks and benefits of a treatment, and considers the patient's preferences and values to make better decisions. DAs are SDM tools, which have been successfully implemented for many other conditions to assist difficult decision-making. In this article, we summarize the purposes of SDM, the derivation of DAs, and their potential application in neurocritical care.

Who Am I to Decide Whether This Person Is to Die Today? Physicians' Life-or-Death Decisions for Elderly Critically Ill Patients at the Emergency Department-ICU Interface: A Qualitative Study

STUDY OBJECTIVE

We explored physicians' perceptions of and attitudes toward triage and end-of-life decisions for elderly critically ill patients at the emergency department (ED)-ICU interface.

METHODS

This was a qualitative study with thematic analysis of data collected through semistructured interviews (15 emergency physicians and 9 ICU physicians) and nonparticipant observations (324 hours, 8 units, in 2 hospitals in France).

RESULTS

Six themes emerged: (1) Physicians revealed a representation of elderly patients that comprised both negative and positive stereotypes, and expressed the concept of physiologic age. (2) These age-related factors influenced physicians' decisionmaking in resuscitate/not resuscitate situations. (3) Three main communication patterns framed the decisions: interdisciplinary decisions, decisions by 2 physicians on their own, and unilateral decisions by 1 physician; however, some physicians avoided decisions, facing uncertainty and conflicts. (4) Conflicts and communication gaps occurred at the ED-ICU interface and upstream of the ED-ICU interface. (5) End-of-life decisions were perceived as more complex in the ED, in the absence of family or of information about elderly patients' end-of-life preferences, and when there was conflict with relatives, time pressure, and a lack of training in end-of-life decisionmaking. (6) During decisionmaking, patients' safety and quality of care were potentially compromised by delayed or denied intensive care and lack of palliative care.

CONCLUSION

These qualitative findings highlight the cognitive heuristics and biases, interphysician conflicts, and communication gaps influencing physicians' triage and end-of-life decisions for elderly critically ill patients at the ED-ICU interface and suggest strategies to improve these decisions.

Qualitative research in critical care: Has its time finally come?

As clinicians, we are well acquainted with using randomised controlled trials, case-control studies and cohort studies together with p-values, odds ratios and confidence intervals to understand and improve the way in which we care for our patients. We have a degree of familiarity, trust and confidence with well-performed scientific quantitative studies in critical care and we make a judgment about our practice based on their recommendations. The same cannot be said of qualitative research, and its use accounts for only a small proportion of published studies in critical care. There are many research questions in our environment that lend themselves to a qualitative research design. Our positivistic education as doctors potentially incites distrust towards such studies and, as such, they are seldom undertaken in our units. We aim to describe and discuss the differences between quantitative and qualitative research with focus being given to common misunderstandings and misconceptions. An overview of the methods of data collection and analysis is provided with references towards published qualitative studies in critical care. Finally, we provide pragmatic and practical instruction and guidance for those wishing to undertake their own qualitative study in critical care.

Important clinician information needs about family members in the intensive care unit

PURPOSE

Clinicians often lack key information regarding intensive care unit (ICU) families. Our objective was to identify (1) important information for clinicians to know about ICU families when making decisions and (2) important information for families to know about patients from clinicians.

MATERIALS AND METHODS

We identified important information items through a literature review and semistructured interviews. A separate cohort of family members, nurses, and physicians from 2 ICUs in a single institution were asked to prioritize the identified information as necessary for decision making.

RESULTS

We identified 21 items important for clinicians to know about families and 32 items important for families to know about patients from clinicians. Themes important for clinicians to know about family members included family background, questions, understanding, goals, concerns, well-being, and requests for additional help. Themes important for families to know about the patient included diagnosis, treatments, prognosis, clinical status, schedule, comfort, goals of care, medical team, and family participation.

CONCLUSIONS

Through qualitative and quantitative analysis, we identified important information for ICU clinicians to know about family members and for family members to know about patients. The identified information can be used to guide strategies and tools to improve assessment of and communication with families.

Withholding or withdrawal of treatment under French rules: a study performed in 43 intensive care units

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.

The Ethics of Chronic Dialysis for the Older Patient: Time to Reevaluate the Norms

Recent research highlights the potential burdens of hemodialysis for older patients with significant comorbidities, for whom there is clinical equipoise regarding the net benefits. With the advent of accountable care and bundled payment, previous incentives to offer hemodialysis to as many patients as possible are being replaced with a disincentive to dialyze high-risk patients. While this may offset the harm of overtreatment for some elderly patients, some voice concerns that the pendulum will swing too far back, with a return to ageist rationing of hemodialysis. Nephrologists should ensure that the patient's rights to be informed about the potential benefits and burdens of hemodialysis are respected, particularly because age, functional status, nutritional status, and comorbidities affect the net balance between benefits and burdens. Nephrologists are also called on to help patients make a decision, for which the patient's goals of care guide determination of potential benefit from hemodialysis. This article addresses concerns about present overtreatment and future risk of undertreatment of older adults with ESRD. It also discusses ways in which providers can ethically approach the question of initiation of hemodialysis in the elderly patient by including patient-specific estimates of prognosis, shared decision-making, and the use of specialist palliative care clinicians or ethics consultants for complex cases.

ICU physician-based determinants of life-sustaining therapy during nights and weekends: French multicenter study from the Outcomerea Research Group

OBJECTIVE

Patient- and organization-related factors are the most common influences affecting the ICU decision-making process. Few studies have investigated ICU physician-related factors and life-sustaining treatment use during nights and weekends, when staffing ratios are low. Here, we described patients admitted during nights/weekends and looked for physician-related determinants of life-sustaining treatment use in these patients after adjustment for patient- and center-related factors.

DESIGN

Multicenter observational cohort study of admission procedures during nights/weekends shifts.

SUBJECTS

ICU physicians working nights/weekends in 6 French ICUs.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patient characteristics and intensity of care were extracted from the prospective Outcomerea database. Physician characteristics were age, gender, religion and religiosity, ICU experience, specialty, being a permanent ICU staff member, degree in ethics, and degree in intensive care. We used hierarchical mixed models to adjust on center, physician random effects, and admission patient characteristics. Of 156 physicians contacted, 119 (77%) participated. Patients admitted during nights/weekends were younger and had fewer comorbidities and lower treatment intensity during the shift. ICU physicians who are younger than 35 years used more renal replacement therapy (odds ratio, 1.04; 95% CI, 1-1.07; p = 0.04), invasive mechanical ventilation (odds ratio, 1.09; 95% CI, 1.1-1.19; p = 0.04), and vasopressors (odds ratio, 1.16; 95% CI, 1.09-1.23; p < 0.0001). Internal or emergency medicine as the primary specialty was associated with invasive mechanical ventilation (odds ratio, 1.14; 95% CI, 1.04-1.24; p = 0.004) and vasopressor use (odds ratio, 1.09; 95% CI, 1.02-1.17; p = 0.01). Noninvasive ventilation was used less often by physicians with more than 10 years of night/weekend shifts and more often by those with religious beliefs (odds ratio, 1.05; 95% CI, 1.01-1.08; p = 0.008).

CONCLUSIONS

Patients admitted during nights/weekends were younger and had fewer comorbidities. Age, specialty, ICU experience, and religious beliefs of the physicians were significantly associated life-sustaining treatments used.

Self-fulfilling prophecies through withdrawal of care: do they exist in traumatic brain injury, too?

OBJECTIVE

We examined factors associated with withdrawal of care (WOC) in moderate-severe traumatic brain injury (msTBI) patients, and how WOC may affect short-term mortality and receipt of neurosurgery. Variability in msTBI-related outcome prognostication by clinicians from different specialties was also assessed.

METHODS

Rates of WOC, factors associated with WOC, and the relation between WOC and in-hospital case-fatality rate (CFR) and neurosurgery were determined in 232 prospectively enrolled msTBI patients in the ongoing OPTIMISM Study at a level-1 trauma center. In a concomitant web-based survey with clinical vignettes, outcome prognostication comfort, treatment aggressiveness, and WOC recommendations were examined among 106 respondents from neurology, neurocritical care, neurosurgery, trauma and anesthesia/critical care.

RESULTS

The average age of the study sample was 53 years, with a median Glasgow Coma Scale of 6. The in-hospital CFR was 36 and 68 % of patients had WOC. Factors independently associated with WOC were advanced age, pupillary reactivity, lower intensive care unit-length-of-stay, pre- and in-hospital cardiac arrest, herniation, intracranial pressure crisis, and pre-existing endocrine disease. Inclusion of WOC in our multivariable regression model predicting in-hospital CFRs negated all other variables. Survey results suggested that in younger patients, some clinicians prognosticated overly pessimistically based upon data available at the time of presentation.

CONCLUSION

In our msTBI cohort, WOC was the most important predictor of in-hospital mortality. We identified several important independent predictors of WOC. Large within-center variability in msTBI outcome prognostication with varying levels of possible clinical nihilism exists, which may form the basis of self-fulfilling prophecies.

The Durban World Congress Ethics Round Table Conference Report: I. Differences between withholding and withdrawing life-sustaining treatments

INTRODUCTION

Withholding life-sustaining treatments (WHLST) and withdrawing life-sustaining treatments (WDLST) occur in most intensive care units (ICUs) around the world to varying degrees.

METHODS

Speakers from invited faculty of the World Federation of Societies of Intensive and Critical Care Medicine Congress in 2013 with an interest in ethics were approached to participate in an ethics round table. Participants were asked if they agreed with the statement "There is no moral difference between withholding and withdrawing a mechanical ventilator." Differences between WHLST and WDLST were discussed. Official statements relating to WHLST and WDLST from intensive care societies, professional bodies, and government statements were sourced, documented, and compared.

RESULTS

Sixteen respondents stated that there was no moral difference between withholding or withdrawing a mechanical ventilator, 2 were neutral, and 4 stated that there was a difference. Most ethicists and medical organizations state that there is no moral difference between WHLST and WDLST. A review of guidelines noted that all but 1 of 29 considered WHLST and WDLST as ethically or legally equivalent.

CONCLUSIONS

Most respondents, practicing intensivists, stated that there is no difference between WHLST and WDLST, supporting most ethicists and professional organizations. A minority of physicians still do not accept their equivalency.