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Feldman C, Joynt GM, Mentzelopoulos SD, Sprung CL, Avidan A, Richards GA. Limitations of life-sustaining therapies in South Africa. J Crit Care 2024; 82:154797. [PMID: 38554544 DOI: 10.1016/j.jcrc.2024.154797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/18/2024] [Accepted: 03/19/2024] [Indexed: 04/01/2024]
Abstract
PURPOSE Limitations of life sustaining therapies (LLST) are frequent in intensive care units (ICUs), but no previous studies have examined end-of-life (EOL) care and LLST in South Africa (SA). MATERIALS AND METHODS This study evaluated LLST in SA from the data of a prospective, international, multicentre, observational study (Ethicus-2) and compared practices with countries in the rest of the world. RESULTS LLST was relatively common in SA, and withholding was more frequent than withdrawing therapy. However, withdrawing and withholding therapy were less common, while failed CPR was more common, than in many other countries. No patients had an advance directive. Primary reasons for LLST in SA were poor quality of life, multisystem organ failure and patients' unresponsiveness to maximal therapy. Primary considerations for EOL decision-making were good medical practice and patients' best-interest, with the need for an ICU bed only rarely considered. CONCLUSIONS Withholding was more common than withdrawing treatment both in SA and worldwide, although both were significantly less frequent in SA compared with the world average.
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Affiliation(s)
- Charles Feldman
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Gavin M Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, China
| | - Spyros D Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelsimos General Hospital, Athens, Greece
| | - Charles L Sprung
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Alexander Avidan
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Guy A Richards
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Lissak IA, Young MJ. Limitation of life sustaining therapy in disorders of consciousness: ethics and practice. Brain 2024; 147:2274-2288. [PMID: 38387081 PMCID: PMC11224617 DOI: 10.1093/brain/awae060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 02/01/2024] [Accepted: 02/08/2024] [Indexed: 02/24/2024] Open
Abstract
Clinical conversations surrounding the continuation or limitation of life-sustaining therapies (LLST) are both challenging and tragically necessary for patients with disorders of consciousness (DoC) following severe brain injury. Divergent cultural, philosophical and religious perspectives contribute to vast heterogeneity in clinical approaches to LLST-as reflected in regional differences and inter-clinician variability. Here we provide an ethical analysis of factors that inform LLST decisions among patients with DoC. We begin by introducing the clinical and ethical challenge and clarifying the distinction between withdrawing and withholding life-sustaining therapy. We then describe relevant factors that influence LLST decision-making including diagnostic and prognostic uncertainty, perception of pain, defining a 'good' outcome, and the role of clinicians. In concluding sections, we explore global variation in LLST practices as they pertain to patients with DoC and examine the impact of cultural and religious perspectives on approaches to LLST. Understanding and respecting the cultural and religious perspectives of patients and surrogates is essential to protecting patient autonomy and advancing goal-concordant care during critical moments of medical decision-making involving patients with DoC.
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Affiliation(s)
- India A Lissak
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Michael J Young
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
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3
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Iyer S, Sonawane RN, Shah J, Salins N. Semiotics of ICU Physicians' Views on End-of-life Care and Quality of Dying in a Critical Care Setting: A Qualitative Study. Indian J Crit Care Med 2024; 28:424-435. [PMID: 38738199 PMCID: PMC11080105 DOI: 10.5005/jp-journals-10071-24696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 03/22/2024] [Indexed: 05/14/2024] Open
Abstract
Background and aim While intensive care unit (ICU) mortality rates in India are higher when compared to countries with more resources, fewer patients with clinically futile conditions are subjected to limitation of life-sustaining treatments or given access to palliative care. Although a few surveys and audits have been conducted exploring this phenomenon, the qualitative perspectives of ICU physicians regarding end-of-life care (EOLC) and the quality of dying are yet to be explored. Methods There are 22 eligible consultant-level ICU physicians working in multidisciplinary ICUs were purposively recruited and interviewed. The study data was analyzed using reflexive thematic analysis (RTA) with a critical realist perspective, and the study findings were interpreted using the lens of the semiotic theory that facilitated the development of themes. Results About four themes were generated. Intensive care unit physicians perceived the quality of dying as respecting patients' and families' choices, fulfilling their needs, providing continued care beyond death, and ensuring family satisfaction. To achieve this, the EOLC process must encompass timely decision-making, communication, treatment guidelines, visitation rights, and trust-building. The contextual challenges were legal concerns, decision-making complexities, cost-related issues, and managing expectations. To improve care, ICU physicians suggested amplifying patient and family voices, building therapeutic relationships, mitigating conflicts, enhancing palliative care services, and training ICU providers in EOLC. Conclusion Effective management of critically ill patients with life-limiting illnesses in ICUs requires a holistic approach that considers the complex interplay between the EOLC process, its desired outcome, the quality of dying, care context, and the process of meaning-making by ICU physicians. How to cite this article Iyer S, Sonawane RN, Shah J, Salins N. Semiotics of ICU Physicians' Views on End-of-life Care and Quality of Dying in a Critical Care Setting: A Qualitative Study. Indian J Crit Care Med 2024;28(5):424-435.
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Affiliation(s)
- Shivakumar Iyer
- Department of Critical Care Medicine, Bharati Vidyapeeth Deemed University Medical College, Pune, Maharashtra, India
| | - Rutula N Sonawane
- Department of Critical Care Medicine, Bharati Vidyapeeth Deemed University Medical College, Pune, Maharashtra, India
| | - Jignesh Shah
- Department of Critical Care Medicine, Bharati Vidyapeeth Deemed University Medical College, Pune, Maharashtra, India
| | - Naveen Salins
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Fong C, Kueh WL, Lew SJW, Ho BCH, Wong YL, Lau YH, Chia YW, Tan HL, Seet YHC, Siow WT, MacLaren G, Agrawal R, Lim TJ, Lim SL, Lim TW, Ho VK, Soh CR, Sewa DW, Loo CM, Khan FA, Tan CK, Gokhale RS, Siau C, Lim NLSH, Yim CF, Venkatachalam J, Venkatesan K, Chia NCH, Liew MF, Li G, Li L, Myat SM, Zena Z, Zhuo S, Yueh LL, Tan CSF, Ma J, Yeo SL, Chan YH, Phua J. Predictors and outcomes of withholding and withdrawal of life-sustaining treatments in intensive care units in Singapore: a multicentre observational study. J Intensive Care 2024; 12:13. [PMID: 38528556 DOI: 10.1186/s40560-024-00725-3] [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: 01/14/2024] [Accepted: 03/13/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Clinical practice guidelines on limitation of life-sustaining treatments (LST) in the intensive care unit (ICU), in the form of withholding or withdrawal of LST, state that there is no ethical difference between the two. Such statements are not uniformly accepted worldwide, and there are few studies on LST limitation in Asia. This study aimed to evaluate the predictors and outcomes of withholding and withdrawal of LST in Singapore, focusing on the similarities and differences between the two approaches. METHODS This was a multicentre observational study of patients admitted to 21 adult ICUs across 9 public hospitals in Singapore over an average of three months per year from 2014 to 2019. The primary outcome measures were withholding and withdrawal of LST (cardiopulmonary resuscitation, invasive mechanical ventilation, and vasopressors/inotropes). The secondary outcome measure was hospital mortality. Multivariable generalised mixed model analysis was used to identify independent predictors for withdrawal and withholding of LST and if LST limitation predicts hospital mortality. RESULTS There were 8907 patients and 9723 admissions. Of the former, 80.8% had no limitation of LST, 13.0% had LST withheld, and 6.2% had LST withdrawn. Common independent predictors for withholding and withdrawal were increasing age, absence of chronic kidney dialysis, greater dependence in activities of daily living, cardiopulmonary resuscitation before ICU admission, higher Acute Physiology and Chronic Health Evaluation (APACHE) II score, and higher level of care in the first 24 h of ICU admission. Additional predictors for withholding included being of Chinese race, the religions of Hinduism and Islam, malignancy, and chronic liver failure. The additional predictor for withdrawal was lower hospital paying class (with greater government subsidy for hospital bills). Hospital mortality in patients without LST limitation, with LST withholding, and with LST withdrawal was 10.6%, 82.1%, and 91.8%, respectively (p < 0.001). Withholding (odds ratio 13.822, 95% confidence interval 9.987-19.132) and withdrawal (odds ratio 38.319, 95% confidence interval 24.351-60.298) were both found to be independent predictors of hospital mortality on multivariable analysis. CONCLUSIONS Differences in the independent predictors of withholding and withdrawal of LST exist. Even after accounting for baseline characteristics, both withholding and withdrawal of LST independently predict hospital mortality. Later mortality in patients who had LST withdrawn compared to withholding suggests that the decision to withdraw may be at the point when medical futility is recognised.
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Affiliation(s)
- Clare Fong
- FAST and Chronic Programmes, Alexandra Hospital, 378 Alexandra Road, Singapore, 159964, Singapore.
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore.
| | - Wern Lunn Kueh
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Sennen Jin Wen Lew
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Benjamin Choon Heng Ho
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Yu-Lin Wong
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Yie Hui Lau
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Yew Woon Chia
- Cardiac Intensive Care Unit, Department of Cardiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Hui Ling Tan
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Ying Hao Christopher Seet
- Department of Neurology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Wen Ting Siow
- FAST and Chronic Programmes, Alexandra Hospital, 378 Alexandra Road, Singapore, 159964, Singapore
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Graeme MacLaren
- Cardiothoracic ICU, Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Rohit Agrawal
- Department of Anaesthesia, National University Hospital, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| | - Tian Jin Lim
- Department of Anaesthesia, National University Hospital, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| | - Shir Lynn Lim
- Department of Cardiology, National University Heart Centre, 1E Kent Ridge Road, Singapore, 119228, Singapore
- Department of Medicine, National University of Singapore, 1E Kent Ridge Road, Singapore, 119228, Singapore
- Pre-Hospital and Emergency Research Center, Duke-NUS Medical School, 8 College Rd, Singapore, 16985, Singapore
| | - Toon Wei Lim
- Department of Cardiology, National University Heart Centre, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Vui Kian Ho
- Department of Intensive Care Medicine, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
- Department of Surgical Intensive Care, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Chai Rick Soh
- Department of Anaesthesiology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Duu Wen Sewa
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Chian Min Loo
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Faheem Ahmed Khan
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - Chee Keat Tan
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - Roshni Sadashiv Gokhale
- Department of Intensive Care, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore
| | - Chuin Siau
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore
| | - Noelle Louise Siew Hua Lim
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore
| | - Chik-Foo Yim
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Jonathen Venkatachalam
- Department of Respiratory and Critical Care Medicine, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore
| | - Kumaresh Venkatesan
- Department of Anaesthesia, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore
| | - Naville Chi Hock Chia
- Department of Anaesthesia, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore
- Yong Loo Lin School of Medicine, 10 Medical Dr, Singapore, 117597, Singapore
- Lee Kong Chian School of Medicine, 11 Mandalay Rd, Singapore, 308232, Singapore
| | - Mei Fong Liew
- FAST and Chronic Programmes, Alexandra Hospital, 378 Alexandra Road, Singapore, 159964, Singapore
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Guihong Li
- Department of Intensive Care Unit Operations, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Li Li
- Department of Intensive Care Unit Operations, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Su Mon Myat
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Zena Zena
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Shuling Zhuo
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - Ling Ling Yueh
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - Caroline Shu Fang Tan
- Department of Intensive Care Medicine, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Jing Ma
- Division of Nursing, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Siew Lian Yeo
- Division of Nursing, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Jason Phua
- FAST and Chronic Programmes, Alexandra Hospital, 378 Alexandra Road, Singapore, 159964, Singapore
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
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Mani RK, Bhatnagar S, Butola S, Gursahani R, Mehta D, Simha S, Divatia JV, Kumar A, Iyer SK, Deodhar J, Bhat RS, Salins N, Thota RS, Mathur R, Iyer RK, Gupta S, Kulkarni P, Murugan S, Nasa P, Myatra SN. Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit. Indian J Crit Care Med 2024; 28:200-250. [PMID: 38477011 PMCID: PMC10926026 DOI: 10.5005/jp-journals-10071-24661] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 02/28/2024] [Indexed: 03/14/2024] Open
Abstract
End-of-life care (EOLC) exemplifies the joint mission of intensive and palliative care (PC) in their human-centeredness. The explosion of technological advances in medicine must be balanced with the culture of holistic care. Inevitably, it brings together the science and the art of medicine in their full expression. High-quality EOLC in the ICU is grounded in evidence, ethical principles, and professionalism within the framework of the Law. Expert professional statements over the last two decades in India were developed while the law was evolving. Recent landmark Supreme Court judgments have necessitated a review of the clinical pathway for EOLC outlined in the previous statements. Much empirical and interventional evidence has accumulated since the position statement in 2014. This iteration of the joint Indian Society of Critical Care Medicine-Indian Association of Palliative Care (ISCCM-IAPC) Position Statement for EOLC combines contemporary evidence, ethics, and law for decision support by the bedside in Indian ICUs. How to cite this article Mani RK, Bhatnagar S, Butola S, Gursahani R, Mehta D, Simha S, et al. Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit. Indian J Crit Care Med 2024;28(3):200-250.
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Affiliation(s)
- Raj K Mani
- Department of Critical Care and Pulmonology, Yashoda Super Specialty Hospital, Ghaziabad, Kaushambi, Uttar Pradesh, India
| | - Sushma Bhatnagar
- Department of Onco-Anaesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Savita Butola
- Department of Palliative Care, Border Security Force Sector Hospital, Panisagar, Tripura, India
| | - Roop Gursahani
- Department of Neurology, P. D. Hinduja National Hospital & Medical Research Centre, Mumbai, Maharashtra, India
| | - Dhvani Mehta
- Division of Health, Vidhi Centre for Legal Policy, New Delhi, India
| | - Srinagesh Simha
- Department of Palliative Care, Karunashraya, Bengaluru, Karnataka, India
| | - Jigeeshu V Divatia
- Department of Anaesthesia, Critical Care, and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Arun Kumar
- Department of Intensive Care, Medical Intensive Care Unit, Fortis Healthcare Ltd, Mohali, Punjab, India
| | - Shiva K Iyer
- Department of Critical Care, Bharati Vidyapeeth (Deemed to be University) Medical College, Pune, Maharashtra, India
| | - Jayita Deodhar
- Department Palliative Care, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Rajani S Bhat
- Department of Interventional Pulmonology and Palliative Medicine, SPARSH Hospitals, Bengaluru, Karnataka, India
| | - Naveen Salins
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Raghu S Thota
- Department Palliative Care, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Roli Mathur
- Department of Bioethics, Indian Council of Medical Research, Bengaluru, Karnataka, India
| | - Rajam K Iyer
- Department of Palliative Care, Bhatia Hospital; P. D. Hinduja National Hospital & Medical Research Centre, Mumbai, Maharashtra, India
| | - Sudeep Gupta
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | | | - Sangeetha Murugan
- Department of Education and Research, Karunashraya, Bengaluru, Karnataka, India
| | - Prashant Nasa
- Department of Critical Care Medicine, NMC Specialty Hospital, Dubai, United Arab Emirates
| | - Sheila N Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
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Schembs L, Racine E, Shevell M, Jox RJ. Physicians' attitudes towards ethical issues and end-of-life decision-making for pediatric patients with unresponsive wakefulness syndrome: An international survey. Dev Med Child Neurol 2023; 65:1646-1655. [PMID: 36758014 DOI: 10.1111/dmcn.15540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 01/06/2023] [Accepted: 01/11/2023] [Indexed: 02/10/2023]
Abstract
AIM We examined physicians' perspectives on the mental capabilities of pediatric patients with unresponsive wakefulness syndrome (UWS) and their attitudes towards limiting life-sustaining treatment (LST) in an international context. METHOD A questionnaire survey was conducted among 267 neuropediatricians, practicing in 65 countries. Comparisons were made according to the Human Development Index (HDI) of the countries. The Idler Index of Religiosity was applied to determine religiosity. RESULTS Participants from countries with a very high HDI were generally more favorable to limiting LST (p < 0.001), specifically cardiopulmonary resuscitation (p = 0.021), intubation/ventilation (p = 0.014), hemodialysis/hemofiltration (p < 0.001), and antibiotic therapy (p < 0.001). Treatment costs that were too high had a weaker influence on their decisions (p < 0.001). Participants who found it never ethically justifiable to limit LST had a higher mean Idler Index of private (p = 0.001) and general (p = 0.020) religiosity and were less satisfied with treatment decisions (p < 0.001) and the communication during the process (p = 0.016). INTERPRETATION The perspectives towards limiting LST for pediatric patients with UWS are markedly different between physicians from countries with very high and lower HDIs.
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Affiliation(s)
- Leah Schembs
- Institute of Ethics, History and Theory of Medicine, LMU Munich, Munich, Germany
| | - Eric Racine
- Pragmatic Health Ethics Research Unit, Institut de recherches cliniques de Montréal, Montréal, QC, Canada
- Division of Experimental Medicine, McGill University, Montréal, QC, Canada
- Department of Neurology and Neurosurgery, McGill University, Montréal, QC, Canada
- Department of Medicine and Department of Social and Preventive Medicine, Université de Montréal, Montréal, QC, Canada
| | - Michael Shevell
- Department of Neurology and Neurosurgery, McGill University, Montréal, QC, Canada
- Department of Pediatrics, McGill University, Montréal, QC, Canada
| | - Ralf J Jox
- Institute of Humanities in Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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7
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Burns KEA, Cook DJ, Xu K, Dodek P, Villar J, Jones A, Kapadia FN, Gattas DJ, Epstein SK, Pelosi P, Kefala K, Meade MO, Rizvi L. Differences in directives to limit treatment and discontinue mechanical ventilation between elderly and very elderly patients: a substudy of a multinational observational study. Intensive Care Med 2023; 49:1181-1190. [PMID: 37736783 DOI: 10.1007/s00134-023-07188-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 08/01/2023] [Indexed: 09/23/2023]
Abstract
PURPOSE The aim of this study was to characterize differences in directives to limit treatments and discontinue invasive mechanical ventilation (IMV) in elderly (65-80 years) and very elderly (> 80 years) intensive care unit (ICU) patients. METHODS We prospectively described new written orders to limit treatments, IMV discontinuation strategies [direct extubation, direct tracheostomy, spontaneous breathing trial (SBT), noninvasive ventilation (NIV) use], and associations between initial failed SBT and outcomes in 142 ICUs from 6 regions (Canada, India, United Kingdom, Europe, Australia/New Zealand, United States). RESULTS We evaluated 788 (586 elderly; 202 very elderly) patients. Very elderly (vs. elderly) patients had similar withdrawal orders but significantly more withholding orders, especially cardiopulmonary resuscitation and dialysis, after ICU admission [67 (33.2%) vs. 128 (21.9%); p = 0.002]. Orders to withhold reintubation were written sooner in very elderly (vs. elderly) patients [4 (2-8) vs. 7 (4-13) days, p = 0.02]. Very elderly and elderly patients had similar rates of direct extubation [39 (19.3%) vs. 113 (19.3%)], direct tracheostomy [10 (5%) vs. 40 (6.8%)], initial SBT [105 (52%) vs. 302 (51.5%)] and initial successful SBT [84 (80%) vs. 245 (81.1%)]. Very elderly patients experienced similar ICU outcomes (mortality, length of stay, duration of ventilation) but higher hospital mortality [26 (12.9%) vs. 38 (6.5%)]. Direct tracheostomy and initial failed SBT were associated with worse outcomes. Regional differences existed in withholding orders at ICU admission and in withholding and withdrawal orders after ICU admission. CONCLUSIONS Very elderly (vs. elderly) patients had more orders to withhold treatments after ICU admission and higher hospital mortality, but similar ICU outcomes and IMV discontinuation. Significant regional differences existed in withholding and withdrawal practices.
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Affiliation(s)
- Karen E A Burns
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada.
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Unity Health Toronto, St Michael's Hospital, 30 Bond St, Office 4-045 Donnelly Wing, Toronto, ON, M5B 1W8, Canada.
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada.
- Departments of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.
| | - Deborah J Cook
- Departments of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
- Division of Critical Care Medicine, St Joseph's Hospital, Hamilton, Canada
| | - Keying Xu
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- Applied Health Research Centre, St Michael's Hospital, Toronto, Canada
| | - Peter Dodek
- Division of Critical Care Medicine, Centre for Health Evaluation and Outcome Sciences, St Paul's Hospital, Vancouver, BC, Canada
- University of British Columbia, Vancouver, BC, Canada
| | - Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Multidisciplinary Organ Dysfunction Evaluation Research Network, Research Unit, Hospital Universitario Dr Negrin, Las Palmas de Gran Canaria, Spain
| | - Andrew Jones
- Department of Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Farhad N Kapadia
- Department of Intensive Care, Hinduja National Hospital, Bombay, India
| | - David J Gattas
- Intensive Care Unit, Royal Prince Alfred Hospital, University of Sydney, Camperdown, NSW, Australia
- The George Institute for Global Health, Sydney, Australia
| | | | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Kallirroi Kefala
- Anaesthesia, Critical Care and Pain Medicine, Edinburgh Royal Infirmary, Edinburgh, Scotland, UK
| | - Maureen O Meade
- Departments of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Leena Rizvi
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Unity Health Toronto, St Michael's Hospital, 30 Bond St, Office 4-045 Donnelly Wing, Toronto, ON, M5B 1W8, Canada
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Myatra SN, Divatia JV, Salins N. Evaluating Determinants of End-of-life Care Provision in Indian Intensive Care Units. Indian J Crit Care Med 2023; 27:299-300. [PMID: 37214113 PMCID: PMC10196653 DOI: 10.5005/jp-journals-10071-24467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 04/25/2023] [Indexed: 05/24/2023] Open
Abstract
How to cite this article: Myatra SN, Divatia JV, Salins N. Evaluating Determinants of End-of-life Care Provision in Indian Intensive Care Units. Indian J Crit Care Med 2023;27(5):299-300.
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Affiliation(s)
- Sheila Nainan Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Jigeeshu Vasishtha Divatia
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Naveen Salins
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Mohanty S, Venkateshan M, Das PK, Pandey A, Gehlot M, Gomathi B, Shetty A, Mishra P, Das D. Socioeconomic Burden of Critically Ill Patients: A Descriptive Study. Cureus 2023; 15:e35598. [PMID: 37007309 PMCID: PMC10063161 DOI: 10.7759/cureus.35598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2023] [Indexed: 03/04/2023] Open
Abstract
Background The cost of critical illness treatment is generally recognized as expensive and increasing in India. Critical illness of the individual will affect the socioeconomic status of the individual and the family. The direct and indirect costs of intensive care and its impact on the socioeconomic status of critically ill patients and their families need to be estimated. The present study was carried out to evaluate the socioeconomic burden of critically ill patients admitted to ICUs in Eastern India. Methods A descriptive survey was conducted to measure the socioeconomic burden. One hundred fifteen critically ill patients and their family members were conveniently selected for the study. Critically ill patients admitted to ICUs and those who were bedridden for more than seven days along with anyone the family member, i.e., spouse, father, or mother, were included in the study to estimate the impact of long-term illness on the care providers in the family. Socio-demographic and socioeconomic burdens were analyzed through the interview method. Results Half (49.6%) of the critically ill patients were heads of the family, and their employment is the primary source of income for the family members. Most (60.9%) of the patients belonged to lower socioeconomic status. Critically ill patients spend a maximum (38169.6±3996.2) amount for pharmaceutical expenses. Eventually, the family members accompanying patients lost maximum working days because of the long length of hospital stay. Below upper-lower (p=0.046) class socioeconomic family, age less than 40 (p=0.018) years, and those families depending (p=0.003) on patients' income significantly reported higher socioeconomic burden. Conclusions Critical care hospitalization of patients increases the socioeconomic burden on the whole family, especially in lower-middle-income countries like India. It soberly affects younger age group patients with low socioeconomic status and families depending on the patient's income during their man days.
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Abstract
OBJECTIVES To identify nursing research priorities in pediatric critical care in Asia. DESIGN We conducted a modified three-round eDelphi survey with pediatric critical care nurses in Asia. The eDelphi technique has been extensively used within health research to achieve a common viewpoint from experts using questionnaires to gather research priorities. In round 1, participants were asked to list three to five research topics that they deemed important. These topics were thematically analyzed and categorized into a questionnaire. Participants rated the research topics in round 2 on a 6-point scale (1 = not important to 6 = extremely important). In round 3, the same questionnaire was used with addition of the calculated mean scores from round 2 for each topic. Research topics ranked among the top 10 were considered extremely important. SETTINGS Twenty-two PICUs in eight Asian countries. SUBJECTS Clinical nurses, managers, educators, and researchers. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In round 1, 146 PICU nurses across eight countries provided 520 research topics. Topics from round 1 were categorized into seven domains with 52 research topics. Prioritized research topics included early recognition of patient deterioration (mean 5.58 ± 0.61), prevention of healthcare-associated infections (mean 5.47 ± 0.70), and interventions to reduce compassion fatigue (mean 5.45 ± 0.80). The top three research domains were end-of-life care (mean 5.34 ± 0.68), professionalism (mean 5.34 ± 0.69), and management of pain, sedation, and delirium (5.32 ± 0.72). CONCLUSIONS This first PICU nursing research prioritization exercise within Asia identified key nursing research themes that should be prioritized and provide a framework for future collaborative studies.
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Rao SR, Salins N, Joshi U, Patel J, Remawi BN, Simha S, Preston N, Walshe C. Palliative and end-of-life care in intensive care units in low- and middle-income countries: A systematically constructed scoping review. J Crit Care 2022; 71:154115. [PMID: 35907272 DOI: 10.1016/j.jcrc.2022.154115] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/28/2022] [Accepted: 07/11/2022] [Indexed: 11/26/2022]
Abstract
PURPOSE Death is common in intensive care units, and integrating palliative care enhances outcomes. Most research has been conducted in high-income countries. The aim is to understand what is known about the type and topics of research on the provision of palliative care within intensive care units in low- and middle-income countries MATERIALS AND METHODS: Scoping review with nine databases systematically searched for literature published in English on palliative care in intensive care units in low- and middle- income settings (01/01/1990 to 31/05/2021). Two reviewers independently checked search results and extracted textual data, which were analyzed and represented as themes. RESULTS Thirty papers reported 19 empirical studies, two clinical case reports and six discussion papers. Papers originated from Asia and Africa, primarily using observational designs and qualitative approaches, with no trials or other robust evaluative or comparative studies. No studies directly sought data from patients or families. Five areas of research focus were identified: withholding and withdrawing treatment; professional knowledge and skills; patient and family views; culture and context; and costs of care. CONCLUSIONS Palliative care in intensive care units in low-and middle-income countries is understudied. Research focused on the specific needs of intensive care in low- and middle-income countries is required to ensure optimal patient outcomes.
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Affiliation(s)
- Seema Rajesh Rao
- Karunashraya Institute for Palliative Care Education and Research, Bangalore Hospice Trust, Karunashraya, Bangalore, India.
| | - Naveen Salins
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal, Manipal Academy of Higher Education, India.
| | - Udita Joshi
- Karunashraya Institute for Palliative Care Education and Research, Bangalore Hospice Trust, Karunashraya, Bangalore, India
| | - Jatin Patel
- Karunashraya Institute for Palliative Care Education and Research, Bangalore Hospice Trust, Karunashraya, Bangalore, India
| | - Bader Nael Remawi
- Lancaster Medical School, Faculty of Health and Medicine, Lancaster University, UK.
| | - Srinagesh Simha
- Karunashraya Institute for Palliative Care Education and Research, Bangalore Hospice Trust, Karunashraya, Bangalore, India
| | - Nancy Preston
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, UK.
| | - Catherine Walshe
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, UK.
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Barratt-Due A, Noremark KAL, Søreide E, Sjøbø BÅ, Guttormsen AB, Yoshido HHL, Aguilar RZ, Oscanoa FAM, Alisasis AU, Robles JB, Pasanting-Lim RAB, Tan BC, Andruszkiewicz P, Jakubowska K, Cox CM, Alvarez AM, Oliveira BS, Montanha GM, Barros NC, Pereira CS, Messias AM, Monteiro JM, Araujo AM, Catorze NT, Marum SM, Bouw MJ, Gomes RM, Brito VA, Castro S, Estilita JM, Barros FM, Serra IM, Martinho AM, Tomescu DR, Marcu A, Bedreag OH, Papurica M, Corneci DE, Negoita SI, Grigoriev E, Gritsan AI, Gazenkampf AA, Almekhlafi G, Albarrak MM, Mustafa GM, Maghrabi KA, Salahuddin N, Aisa TM, Al Jabbary AS, Tabhan E, Arabi YM, Trinidad OA, Al Dorzi HM, Tabhan EE, Bolon S, Smith O, Mancebo J, Aguirre-Bermeo H, Lopez-Delgado JC, Esteve F, Rialp G, Forteza C, De Haro C, Artigas A, Albaiceta GM, De Cima-Iglesias S, Seoane-Quiroga L, Ceniceros-Barros A, Ruiz-Aguilar AL, Claraco-Vega LM, Soler JA, Lorente MDC, Hermosa C, Gordo F, Prieto-González M, López-Messa JB, Perez MP, Pere CP, Allue RM, Roche-Campo F, Ibañez-Santacruz M, Temprano S, Pintado MC, De Pablo R, Gómez PRA, Ruiz SR, Moles SI, Jurado MT, Arizmendi A, Piacentini EA, Franco N, Honrubia T, Perez Cheng M, Perez Losada E, Blanco J, Yuste LJ, Carbayo-Gorriz C, Cazorla-Barranquero FG, Alonso JG, Alda RS, Algaba Á, Navarro G, Cereijo E, Diaz-Rodriguez E, Marcos DP, Montero LA, Para LH, Sanchez RJ, Blasco Navalpotro MA, Abad RD, Montiel González R, Toribio DP, Castro AG, Artiga MJD, Penuelas O, Roser TP, Olga MF, Curto EG, Sánchez RM, Imma VP, Elisabet GM, Claverias L, Magret M, Pellicer AM, Rodriguez LL, Sánchez-Ballesteros J, González-Salamanca Á, Jimenez AG, Huerta FP, Diaz JCJS, Lopez EB, Moya DDL, Alfonso AAT, Eugenio Luis PS, Cesar PS, Rafael SI, Virgilio CG, Recio NN, Adamsson RO, Rylander CC, Holzgraefe B, Broman LM, Wessbergh J, Persson L, Schiöler F, Kedelv H, Tibblin AO, Appelberg H, Hedlund L, Helleberg J, Eriksson KE, Glietsch R, Larsson N, Nygren I, Nunes SL, Morin AK, Kander T, Adolfsson A, Piquilloud L, Zender HO, Leemann-Refondini C, Elatrous S, Bouchoucha S, Chouchene I, Ouanes I, Ben Souissi A, Kamoun S, Demirkiran O, Aker M, Erbabacan E, Ceylan I, Girgin NK, Ozcelik M, Ünal N, Meco BC, Akyol OO, Derman SS, Kennedy B, Parhar K, Srinivasa L, McNamee L, McAuley D, Steinberg J, Hopkins P, Mellis C, Stansil F, Kakar V, Hadfield D, Brown C, Vercueil A, Bhowmick K, Humphreys SK, Ferguson A, Mckee R, Raj AS, Fawkes DA, Watt P, Twohey L, Thomas RRJM, Morton A, Kadaba V, Smith MJ, Hormis AP, Kannan SG, Namih M, Reschreiter H, Camsooksai J, Kumar A, Rugonfalvi S, Nutt C, Oneill O, Seasman C, Dempsey G, Scott CJ, Ellis HE, Mckechnie S, Hutton PJ, Di Tomasso NN, Vitale MN, Griffin RO, Dean MN, Cranshaw JH, Willett EL, Ioannou N, Gillis S, Csabi P, Macfadyen R, Dawson H, Preez PD, Williams AJ, Boyd O, De Gordoa LOR, Bramall J, Symmonds S, Chau SK, Wenham T, Szakmany T, Toth-Tarsoly P, Mccalman KH, Alexander P, Stephenson L, Collyer T, Chapman R, Cooper R, Allan RM, Sim M, Wrathall DW, Irvine DA, Zantua KS, Adams JC, Burtenshaw AJ, Sellors GP, Welters ID, Williams KE, Hessell RJ, Oldroyd MG, Battle CE, Pillai S, Kajtor I, Sivashanmugave M, Okane SC, Donnelly A, Frigyik AD, Careless JP, May MM, Stewart R, Trinder TJ, Hagan SJ, Wise MP, Cole JM, MacFie CC, Dowling AT, Hurtado J, Nin N, Hurtado J, Nuñez E, Pittini G, Rodriguez R, Imperio MC, Santos C, França AG, Ebeid A, Deicas A, Serra C, Uppalapati A, Kamel G, Banner-Goodspeed VM, Beitler JR, Mukkera SR, Kulkarni S, Lee J, Mesar T, Shinn Iii JO, Gomaa D, Tainter C, Mesar T, Cowley RA, Yeatts DJ, Warren J, Lanspa MJ, Miller RR, Grissom CK, Brown SM, Bauer PR, Gosselin RJ, Kitch BT, Cohen JE, Beegle SH, Gueret RM, Tulaimat A, Choudry S, Stigler W, Batra H, Huff NG, Lamb KD, Oetting TW, Mohr NM, Judy C, Saito S, Kheir FM, Schlichting AB, Delsing A, Elmasri M, Crouch DR, Ismail D, Blakeman TC, Dreyer KR, Gomaa D, Baron RM, Grijalba CQ, Hou PC, Seethala R, Aisiku I, Henderson G, Frendl G, Hou SK, Owens RL, Schomer A, Bumbasirevic V, Jovanovic B, Surbatovic M, Veljovic M, Van Haren F. Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies. THE LANCET GLOBAL HEALTH 2022; 10:e227-e235. [PMID: 34914899 PMCID: PMC8766316 DOI: 10.1016/s2214-109x(21)00485-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 09/05/2021] [Accepted: 10/01/2021] [Indexed: 12/19/2022] Open
Abstract
Background Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference –1·69 [–9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5–8] vs 6 [5–8] cm H2O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52–23·52]; p<0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75–0·86]; p<0·0001). Interpretation Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status. Funding No funding.
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Change in perception of the quality of death in the intensive care unit by healthcare workers associated with the implementation of the "well-dying law". Intensive Care Med 2022; 48:281-289. [PMID: 34973069 PMCID: PMC8866363 DOI: 10.1007/s00134-021-06597-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/27/2021] [Indexed: 12/02/2022]
Abstract
Purpose The importance of dying with dignity in the intensive care unit (ICU) has been emphasized. The South Korean government implemented the “well-dying law” in 2018, which enables patients to refuse futile life-sustaining treatment (LST) after being determined as terminally ill. We aimed to study whether the well-dying law is associated with a significant change in the quality of death in the ICU. Methods The Quality of Dying and Death (QODD) questionnaires were prospectively collected from the doctors and nurses of deceased patients of four South Korean medical ICUs after the law was passed (January 2019 to May 2020). Results were compared with those of our previous study, which used the same metric before the law was passed (June 2016 to May 2017). We compared baseline characteristics of the deceased patients, enrolled staff, QODD scores, and staff opinions about withdrawing LST from before to after the law was passed. Results After the well-dying law was passed, deceased patients (N = 252) were slightly older (68.6 vs. 66.6, p = 0.03) and fewer patients were admitted to the ICU for post-resuscitation care (10.3% vs. 20%, p = 0.003). The mean total QODD score significantly increased after the law was passed (36.9 vs. 31.3, p = 0.001). The law had a positive independent association with the increased QODD score in a multiple regression analysis. Conclusion Our study is the first to show that implementing the well-dying law is associated with quality of death in the ICU, although the quality of death in South Korea remains relatively low and should be further improved. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06597-7.
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14
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Han Chin Y, Yu Leon Yaow C, En Teoh S, Zhi Qi Foo M, Luo N, Graves N, Eng Hock Ong M, Fu Wah Ho A. Long-term outcomes after out-of-hospital cardiac arrest: a systematic review and meta-analysis. Resuscitation 2021; 171:15-29. [PMID: 34971720 DOI: 10.1016/j.resuscitation.2021.12.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/21/2021] [Accepted: 12/21/2021] [Indexed: 12/21/2022]
Abstract
AIMS Long term outcomes after out-of-hospital cardiac arrest (OHCA) are not well understood. This study aimed to evaluate the long-term (1-year and beyond) survival outcomes, including overall survival and survival with favorable neurological status and the quality-of-life (QOL) outcomes, among patients who survived the initial OHCA event (30 days or till hospital discharge). METHODS Embase, Medline and PubMed were searched for primary studies (randomized controlled trials, cohort and cross-sectional studies) which reported the long-term survival outcomes of OHCA patients. Data abstraction and quality assessment was conducted, and survival at predetermined timepoints were assessed via single-arm meta-analyses of proportions, using generalized linear mixed models. Comparative meta-analyses were conducted using the Mantel-Haenszel Risk Ratio (RR) estimates, using the DerSimonian and Laird model. RESULTS 67 studies were included, and among patients that survived to hospital discharge or 30-days, 77.3% (CI=71.2-82.4), 69.6% (CI=54.5-70.3), 62.7% (CI=54.5-70.3), 46.5% (CI=32.0-61.6), and 20.8% (CI=7.8-44.9) survived to 1-, 3-, 5-, 10- and 15-years respectively. Compared to Asia, the probability of 1-year survival was greater in Europe (RR=2.1, CI=1.8-2.3), North America (RR=2.0, CI=1.7-2.2) and Oceania (RR=1.9,CI=1.6-2.1). Males had a higher 1-year survival (RR:1.41, CI=1.25-1.59), and patients with initial shockable rhythm had improved 1-year (RR=3.07, CI=1.78-5.30) and 3-year survival (RR=1.45, CI=1.19-1.77). OHCA occurring in residential locations had worse 1-year survival (RR=0.42, CI=0.25-0.73). CONCLUSION Our study found that up to 20.8% of OHCA patients survived to 15-years, and survival was lower in Asia compared to the other regions. Further analysis on the differences in survival between the regions are needed to direct future long-term treatment of OHCA patients.
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Affiliation(s)
- Yip Han Chin
- School of Medicine, National University Singapore, Singapore, Singapore
| | | | - Seth En Teoh
- School of Medicine, National University Singapore, Singapore, Singapore
| | - Mabel Zhi Qi Foo
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - Nan Luo
- Saw Swee Hock School of Public Health, National University Singapore, Singapore
| | - Nicholas Graves
- Pre-hospital and Emergency Research Centre, Duke-NUS Medical School, Singapore
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore; Pre-hospital and Emergency Research Centre, Duke-NUS Medical School, Singapore
| | - Andrew Fu Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore; Saw Swee Hock School of Public Health, National University Singapore, Singapore; Pre-hospital and Emergency Research Centre, Duke-NUS Medical School, Singapore.
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15
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Phua J, Lim CM, Faruq MO, Nafees KMK, Du B, Gomersall CD, Ling L, Divatia JV, Hashemian SMR, Egi M, Konkayev A, Mat-Nor MB, Shrestha GS, Hashmi M, Palo JEM, Arabi YM, Tan HL, Dissanayake R, Chan MC, Permpikul C, Patjanasoontorn B, Son DN, Nishimura M, Koh Y. The story of critical care in Asia: a narrative review. J Intensive Care 2021; 9:60. [PMID: 34620252 PMCID: PMC8496144 DOI: 10.1186/s40560-021-00574-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 09/08/2021] [Indexed: 12/29/2022] Open
Abstract
Background Asia has more critically ill people than any other part of our planet. The aim of this article is to review the development of critical care as a specialty, critical care societies and education and research, the epidemiology of critical illness as well as epidemics and pandemics, accessibility and cost and quality of critical care, culture and end-of-life care, and future directions for critical care in Asia.
Main body Although the first Asian intensive care units (ICUs) surfaced in the 1960s and the 1970s and specialisation started in the 1990s, multiple challenges still exist, including the lack of intensivists, critical care nurses, and respiratory therapists in many countries. This is aggravated by the brain drain of skilled ICU staff to high-income countries. Critical care societies have been integral to the development of the discipline and have increasingly contributed to critical care education, although critical care research is only just starting to take off through collaboration across groups. Sepsis, increasingly aggravated by multidrug resistance, contributes to a significant burden of critical illness, while epidemics and pandemics continue to haunt the continent intermittently. In particular, the coronavirus disease 2019 (COVID-19) has highlighted the central role of critical care in pandemic response. Accessibility to critical care is affected by lack of ICU beds and high costs, and quality of critical care is affected by limited capability for investigations and treatment in low- and middle-income countries. Meanwhile, there are clear cultural differences across countries, with considerable variations in end-of-life care. Demand for critical care will rise across the continent due to ageing populations and rising comorbidity burdens. Even as countries respond by increasing critical care capacity, the critical care community must continue to focus on training for ICU healthcare workers, processes anchored on evidence-based medicine, technology guided by feasibility and impact, research applicable to Asian and local settings, and rallying of governments for support for the specialty.
Conclusions Critical care in Asia has progressed through the years, but multiple challenges remain. These challenges should be addressed through a collaborative approach across disciplines, ICUs, hospitals, societies, governments, and countries.
Supplementary Information The online version contains supplementary material available at 10.1186/s40560-021-00574-4.
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Affiliation(s)
- Jason Phua
- FAST and Chronic Programmes, Alexandra Hospital, National University Health System, Singapore, Singapore.,Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore, Singapore
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Mohammad Omar Faruq
- General Intensive Care Unit, Emergency and COVID ICU, United Hospital Ltd, Dhaka, Bangladesh
| | - Khalid Mahmood Khan Nafees
- Ministry of Health, Department of Critical Care Medicine, RIPAS Hospital, Bandar Seri Begawan, Brunei Darussalam
| | - Bin Du
- State Key Laboratory of Complex Severe and Rare Diseases, Medical ICU, Peking Union Medical College Hospital, Beijing, China
| | - Charles D Gomersall
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Lowell Ling
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Jigeeshu Vasishtha Divatia
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Seyed Mohammad Reza Hashemian
- Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Moritoki Egi
- Department of Anesthesiology and Intensive Care Medicine, Kobe University Hospital, Kobe, Japan
| | - Aidos Konkayev
- Anaesthesiology and Reanimatology Department, Astana Medical University, Astana, Kazakhstan.,Anaesthesia and ICU Department, Institution of Traumatology and Orthopedics, Astana, Kazakhstan
| | - Mohd Basri Mat-Nor
- Department of Anaesthesiology and Intensive Care, International Islamic University Malaysia, Kuantan, Malaysia
| | - Gentle Sunder Shrestha
- Department of Anaesthesiology, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Madiha Hashmi
- Department of Critical Care Medicine, Ziauddin University, Karachi, Pakistan
| | | | - Yaseen M Arabi
- King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia
| | - Hon Liang Tan
- Mount Elizabeth Novena Hospital, Singapore, Singapore
| | - Rohan Dissanayake
- Department of Intensive Care Medicine, Gosford Hospital, Gosford, NSW, Australia
| | - Ming-Cheng Chan
- Section of Critical Care and Respiratory Therapy, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,College of Science, Tunghai University, Taichung, Taiwan
| | - Chairat Permpikul
- Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Boonsong Patjanasoontorn
- Pulmonary and Critical Care Medicine, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Do Ngoc Son
- Critical Care Unit, Center for Emergency Medicine, Bach Mai Hospital, Hanoi, Vietnam
| | | | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
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Lumb PD, Adler DC, Al Rahma H, Amin P, Bakker J, Bhagwanjee S, Du B, Bryan-Brown CW, Dobb G, Gingles B, Jacobi J, Koh Y, Razek AA, Peden C, Shrestha GS, Shukri K, Singer M, Taylor P, Williams G. International Critical Care-From an Indulgence of the Best-Funded Healthcare Systems to a Core Need for the Provision of Equitable Care. Crit Care Med 2021; 49:1589-1605. [PMID: 34259443 DOI: 10.1097/ccm.0000000000005188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Philip D Lumb
- Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | | | | | - Pravin Amin
- Bombay Hospital Institute of Medical Sciences, Bombay, India
| | | | | | - Bin Du
- Peking Union Medical College, Beijing, China
| | | | - Geoffrey Dobb
- Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, Australia
| | | | | | - Younsuck Koh
- University of Ulsan College of Medicine, Seoul, South Korea
| | | | - Carol Peden
- Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | | | - Khalid Shukri
- King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | | | - Phil Taylor
- World Federation of Intensive and Critical Care (WFICC)
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17
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Avidan A, Sprung CL, Schefold JC, Ricou B, Hartog CS, Nates JL, Jaschinski U, Lobo SM, Joynt GM, Lesieur O, Weiss M, Antonelli M, Bülow HH, Bocci MG, Robertsen A, Anstey MH, Estébanez-Montiel B, Lautrette A, Gruber A, Estella A, Mullick S, Sreedharan R, Michalsen A, Feldman C, Tisljar K, Posch M, Ovu S, Tamowicz B, Demoule A, DeKeyser Ganz F, Pargger H, Noto A, Metnitz P, Zubek L, de la Guardia V, Danbury CM, Szűcs O, Protti A, Filipe M, Simpson SQ, Green C, Giannini AM, Soliman IW, Piras C, Caser EB, Hache-Marliere M, Mentzelopoulos SD. Variations in end-of-life practices in intensive care units worldwide (Ethicus-2): a prospective observational study. THE LANCET RESPIRATORY MEDICINE 2021; 9:1101-1110. [PMID: 34364537 DOI: 10.1016/s2213-2600(21)00261-7] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 05/20/2021] [Accepted: 05/25/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND End-of-life practices vary among intensive care units (ICUs) worldwide. Differences can result in variable use of disproportionate or non-beneficial life-sustaining interventions across diverse world regions. This study investigated global disparities in end-of-life practices. METHODS In this prospective, multinational, observational study, consecutive adult ICU patients who died or had a limitation of life-sustaining treatment (withholding or withdrawing life-sustaining therapy and active shortening of the dying process) during a 6-month period between Sept 1, 2015, and Sept 30, 2016, were recruited from 199 ICUs in 36 countries. The primary outcome was the end-of-life practice as defined by the end-of-life categories: withholding or withdrawing life-sustaining therapy, active shortening of the dying process, or failed cardiopulmonary resuscitation (CPR). Patients with brain death were included in a separate predefined end-of-life category. Data collection included patient characteristics, diagnoses, end-of-life decisions and their timing related to admission and discharge, or death, with comparisons across different regions. Patients were studied until death or 2 months from the first limitation decision. FINDINGS Of 87 951 patients admitted to ICU, 12 850 (14·6%) were included in the study population. The number of patients categorised into each of the different end-of-life categories were significantly different for each region (p<0·001). Limitation of life-sustaining treatment occurred in 10 401 patients (11·8% of 87 951 ICU admissions and 80·9% of 12 850 in the study population). The most common limitation was withholding life-sustaining treatment (5661 [44·1%]), followed by withdrawing life-sustaining treatment (4680 [36·4%]). More treatment withdrawing was observed in Northern Europe (1217 [52·8%] of 2305) and Australia/New Zealand (247 [45·7%] of 541) than in Latin America (33 [5·8%] of 571) and Africa (21 [13·0%] of 162). Shortening of the dying process was uncommon across all regions (60 [0·5%]). One in five patients with treatment limitations survived hospitalisation. Death due to failed CPR occurred in 1799 (14%) of the study population, and brain death occurred in 650 (5·1%). Failure of CPR occurred less frequently in Northern Europe (85 [3·7%] of 2305), Australia/New Zealand (23 [4·3%] of 541), and North America (78 [8·5%] of 918) than in Africa (106 [65·4%] of 162), Latin America (160 [28·0%] of 571), and Southern Europe (590 [22·5%] of 2622). Factors associated with treatment limitations were region, age, and diagnoses (acute and chronic), and country end-of-life legislation. INTERPRETATION Limitation of life-sustaining therapies is common worldwide with regional variability. Withholding treatment is more common than withdrawing treatment. Variations in type, frequency, and timing of end-of-life decisions were observed. Recognising regional differences and the reasons behind these differences might help improve end-of-life care worldwide. FUNDING None.
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Affiliation(s)
- Alexander Avidan
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Charles L Sprung
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Joerg C Schefold
- Inselspital, Department of Intensive Care Medicine, University of Bern, Bern, Switzerland
| | - Bara Ricou
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | - Christiane S Hartog
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany, and Klinik Bavaria, Kreischa, Germany
| | - Joseph L Nates
- Critical Care Department, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ulrich Jaschinski
- Department of Anesthesiology and Critical Care Medicine, University Hospital Augsburg, Augsburg, Germany
| | - Suzana M Lobo
- Intensive Care Division, São José do Rio Preto School of Medicine, São Jose do Rio Preto, São Paulo, Brazil
| | - Gavin M Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong
| | - Olivier Lesieur
- Intensive Care Unit, Saint Louis General Hospital, La Rochelle, France
| | - Manfred Weiss
- Clinic of Anaesthesiology and Intensive Care Medicine, University Hospital Medical School, Ulm, Germany
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Hans-Henrik Bülow
- Department of Anesthesiology and Intensive Care, Holbaek University Hospital, Zealand Region, Denmark
| | - Maria G Bocci
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Annette Robertsen
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | | | | | - Alexandre Lautrette
- Medical Intensive Care Unit, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Anastasiia Gruber
- Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Angel Estella
- Intensive Care Department, University Hospital SAS of Jerez, Jerez de la Frontera, Spain
| | | | - Roshni Sreedharan
- Department of General Anesthesiology, Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Andrej Michalsen
- Department of Anesthesiology and Critical Care, Medizin Campus Bodensee-Tettnang Hospital, Tettnang, Germany
| | - Charles Feldman
- Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kai Tisljar
- Intensive Care Unit, University Hospital and University of Basel, Basel, Switzerland
| | - Martin Posch
- Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Steven Ovu
- Critical Care Department, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Barbara Tamowicz
- Faculty of Health Sciences, Poznan University of Medical Sciences, Poznań, Poland
| | - Alexandre Demoule
- Service de Médecine intensive- Réanimation, AP-HP Sorbonne Université, Site Pitié-Salpêtrière, and UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, INSERM, Paris, France
| | - Freda DeKeyser Ganz
- Hadassah Hebrew University School of Nursing and Jerusalem College of Technology, Faculty of Life and Health Sciences, Jerusalem, Israel
| | - Hans Pargger
- Intensive Care Unit, University Hospital and University of Basel, Basel, Switzerland
| | - Alberto Noto
- Department of Human Pathology of the Adult and Evolutive Age "Gaetano Barresi", Division of Anesthesia and Intensive Care, University of Messina, Messina, Italy
| | - Philipp Metnitz
- Department of General Anaesthesiology, Emergency and Intensive Care Medicine, LKH-University Hospital of Graz, Graz, Austria
| | - Laszlo Zubek
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Veronica de la Guardia
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Orsolya Szűcs
- 1st Department of Surgery and Interventional Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Alessandro Protti
- Department of Anesthesia, Intensive Care, and Emergency Medicine, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Mario Filipe
- Department of Anesthesiology and Critical Care Medicine, DPC Hospital Budapest, Semmelweis University, Budapest, Hungary
| | - Steven Q Simpson
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas, Kansas City, KS, USA
| | - Cameron Green
- Department of Intensive Care, Peninsula Health, Melbourne, VIC, Australia
| | - Alberto M Giannini
- Division of Pediatric Anesthesia and Intensive Care, ASST-Spedali Civili, Brescia, Italy
| | - Ivo W Soliman
- Department of Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Eliana B Caser
- Department of Internal Medicine, University Federal do Espírito Santo, Espírito Santo, Brazil
| | - Manuel Hache-Marliere
- Department of Critical Care Medicine, CEDIMAT, Santo Domingo, Dominican Republic, and Department of Internal Medicine, Jacobi Medical Center-AECOM, Bronx, NY, USA
| | - Spyros D Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelsimos General Hospital, Athens, Greece
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18
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Yang CH, Wu CY, Low JTS, Chuang YS, Huang YW, Hwang SJ, Chen PJ. Exploring the Impact of Different Types of Do-Not-Resuscitate Consent on End-of-Life Treatments among Patients with Advanced Kidney Disease: An Observational Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:8194. [PMID: 34360487 PMCID: PMC8346049 DOI: 10.3390/ijerph18158194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/27/2021] [Accepted: 07/30/2021] [Indexed: 11/16/2022]
Abstract
Background: Patients with advanced kidney disease have a symptomatic and psychological burden which warrant renal supportive care or palliative care. However, the impact of do-not-resuscitate consent type (signed by patients or surrogates) on end-of-life treatments in these patients remains unclear. Objective: We aim to identify influential factors correlated with different do-not-resuscitate consent types in patients with advanced kidney disease and the impact of do-not-resuscitate consent types on various life-prolonging treatments. Methods: This was a retrospective observational study. We included patients aged 20 years and over, diagnosed with advanced kidney disease and receiving palliative and hospice care consultation services between January 2014 and December 2018 in a tertiary teaching hospital in Taiwan. We reviewed medical records and used logistic regression to identify factors associated with do-not-resuscitate consent types and end-of-life treatments. Results: A total of 275 patients were included, in which 21% signed their do-not-resuscitate consents. A total of 233 patients were followed until death, and 32% of the decedents continued hemodialysis, 75% underwent nasogastric (NG) tube placement, and 70% took antibiotics in their final seven days of life. Do-not-resuscitate consents signed by patients were associated with reduced life-prolonging treatments including feeding tube placement and antibiotic use in the last seven days (odd ratio and 95% confidence interval were 0.16, 0.07-0.34 and 0.33, 0.16-0.69, respectively) compared to do-not-resuscitate consents signed by surrogates. Conclusions: Do-not-resuscitate consent signed by patients and not by surrogates may reflect better patients' autonomy and reduced life-prolonging treatments in the final seven days of patients with advanced kidney disease.
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Affiliation(s)
- Chiu-Hsien Yang
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (C.-H.Y.); (C.-Y.W.); (Y.-S.C.)
| | - Chien-Yi Wu
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (C.-H.Y.); (C.-Y.W.); (Y.-S.C.)
| | - Joseph T. S. Low
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London W1T 7NF, UK;
| | - Yun-Shiuan Chuang
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (C.-H.Y.); (C.-Y.W.); (Y.-S.C.)
| | - Yu-Wen Huang
- Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan;
| | - Shang-Jyh Hwang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan;
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| | - Ping-Jen Chen
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan; (C.-H.Y.); (C.-Y.W.); (Y.-S.C.)
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London W1T 7NF, UK;
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung 807, Taiwan
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19
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Mentzelopoulos SD, Couper K, Van de Voorde P, Druwé P, Blom M, Perkins GD, Lulic I, Djakow J, Raffay V, Lilja G, Bossaert L. [Ethics of resuscitation and end of life decisions]. Notf Rett Med 2021; 24:720-749. [PMID: 34093076 PMCID: PMC8170633 DOI: 10.1007/s10049-021-00888-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/14/2022]
Abstract
These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.
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Affiliation(s)
- Spyros D. Mentzelopoulos
- Evaggelismos Allgemeines Krankenhaus, Abteilung für Intensivmedizin, Medizinische Fakultät der Nationalen und Kapodistrischen Universität Athen, 45–47 Ipsilandou Street, 10675 Athen, Griechenland
| | - Keith Couper
- Universitätskliniken Birmingham NHS Foundation Trust, UK Critical Care Unit, Birmingham, Großbritannien
- Medizinische Fakultät Warwick, Universität Warwick, Coventry, Großbritannien
| | - Patrick Van de Voorde
- Universitätsklinikum und Universität Gent, Gent, Belgien
- staatliches Gesundheitsministerium, Brüssel, Belgien
| | - Patrick Druwé
- Abteilung für Intensivmedizin, Universitätsklinikum Gent, Gent, Belgien
| | - Marieke Blom
- Medizinisches Zentrum der Universität Amsterdam, Amsterdam, Niederlande
| | - Gavin D. Perkins
- Medizinische Fakultät Warwick, Universität Warwick, Coventry, Großbritannien
| | | | - Jana Djakow
- Intensivstation für Kinder, NH Hospital, Hořovice, Tschechien
- Abteilung für Kinderanästhesiologie und Intensivmedizin, Universitätsklinikum und Medizinische Fakultät der Masaryk-Universität, Brno, Tschechien
| | - Violetta Raffay
- School of Medicine, Europäische Universität Zypern, Nikosia, Zypern
- Serbischer Wiederbelebungsrat, Novi Sad, Serbien
| | - Gisela Lilja
- Universitätsklinikum Skane, Abteilung für klinische Wissenschaften Lund, Neurologie, Universität Lund, Lund, Schweden
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20
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Rodriguez-Ruiz E, Campelo-Izquierdo M, Mansilla Rodríguez M, Lence Massa BE, Estany-Gestal A, Blanco Hortas A, Cruz-Guerrero R, Galbán Rodríguez C, Rodríguez-Calvo MS, Rodríguez-Núñez A. Shifting trends in modes of death in the Intensive Care Unit. J Crit Care 2021; 64:131-138. [PMID: 33878518 DOI: 10.1016/j.jcrc.2021.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 02/25/2021] [Accepted: 04/06/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To describe the way patients die in a Spanish ICU, and how the modes of death have changed in the last 10 years. MATERIALS AND METHODS Retrospective observational study evaluating all patients who died in a Spanish tertiary ICU over a 10-year period. Modes of death were classified as death despite maximal support (D-MS), brain death (BD), and death following life-sustaining treatment limitation (D-LSTL). RESULTS Amongst 9264 ICU admissions, 1553 (16.8%) deaths were recorded. The ICU mortality rate declined (1.7%/year, 95% CI 1.4-2.0; p = 0.021) while ICU admissions increased (3.5%/year, 95% CI 3.3-3.7; p < 0.001). More than half of the patients (888, 57.2%) died D-MS, 389 (25.0%) died after a shared decision of D-LSTL and 276 (17.8%) died due to BD. Modes of death have changed significantly over the past decade. D-LSTL increased by 15.1%/year (95% CI 14.4-15.8; p < 0.001) and D-MS at the end-of-life decreased by 7.1%/year (95% CI 6.6-7.6; p < 0.001). The proportion of patients diagnosed with BD remained stable over time. CONCLUSIONS End-of-life practices and modes of death in our ICU have steadily changed. The proportion of patients who died in ICU following limitation of life-prolonging therapies substantially increased, whereas death after maximal support occurred significantly less frequently.
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Affiliation(s)
- Emilio Rodriguez-Ruiz
- Intensive Care Medicine Department, University Clinic Hospital of Santiago de Compostela (CHUS), Galician Public Health System (SERGAS), Santiago de Compostela, Spain; Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain.
| | - Maitane Campelo-Izquierdo
- Division of Nursing, Intensive Care Medicine Department, University Clinic Hospital of Santiago de Compostela (CHUS), Galician Public Health System (SERGAS), Santiago de Compostela, Spain
| | - Montserrat Mansilla Rodríguez
- Division of Nursing, Intensive Care Medicine Department, University Clinic Hospital of Santiago de Compostela (CHUS), Galician Public Health System (SERGAS), Santiago de Compostela, Spain
| | - Beatriz Elena Lence Massa
- Intensive Care Medicine Department, University Clinic Hospital of Santiago de Compostela (CHUS), Galician Public Health System (SERGAS), Santiago de Compostela, Spain
| | - Ana Estany-Gestal
- Epidemiology and Clinical Research Unit, Health Research Institute of Santiago (IDIS), Santiago de Compostela and Lugo, Spain
| | - Andrés Blanco Hortas
- Epidemiology and Clinical Research Unit, Health Research Institute of Santiago (IDIS), Santiago de Compostela and Lugo, Spain
| | - Raquel Cruz-Guerrero
- CIBERER- Genomic Medicine Group, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Cristobal Galbán Rodríguez
- Intensive Care Medicine Department, University Clinic Hospital of Santiago de Compostela (CHUS), Galician Public Health System (SERGAS), Santiago de Compostela, Spain
| | | | - Antonio Rodríguez-Núñez
- Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain; Paediatric Critical, Intermediate and Palliative Care Section, Paediatric Area, University Clinic Hospital of Santiago de Compostela (CHUS), Galician Public Health System (SERGAS), Santiago de Compostela, Spain
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21
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Madotto F, McNicholas B, Rezoagli E, Pham T, Laffey JG, Bellani G. Death in hospital following ICU discharge: insights from the LUNG SAFE study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:144. [PMID: 33849625 PMCID: PMC8043098 DOI: 10.1186/s13054-021-03465-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 01/11/2021] [Indexed: 11/11/2022]
Abstract
Background To determine the frequency of, and factors associated with, death in hospital following ICU discharge to the ward. Methods The Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE study was an international, multicenter, prospective cohort study of patients with severe respiratory failure, conducted across 459 ICUs from 50 countries globally. This study aimed to understand the frequency and factors associated with death in hospital in patients who survived their ICU stay. We examined outcomes in the subpopulation discharged with no limitations of life sustaining treatments (‘treatment limitations’), and the subpopulations with treatment limitations.
Results 2186 (94%) patients with no treatment limitations discharged from ICU survived, while 142 (6%) died in hospital. 118 (61%) of patients with treatment limitations survived while 77 (39%) patients died in hospital. Patients without treatment limitations that died in hospital after ICU discharge were older, more likely to have COPD, immunocompromise or chronic renal failure, less likely to have trauma as a risk factor for ARDS. Patients that died post ICU discharge were less likely to receive neuromuscular blockade, or to receive any adjunctive measure, and had a higher pre- ICU discharge non-pulmonary SOFA score. A similar pattern was seen in patients with treatment limitations that died in hospital following ICU discharge. Conclusions A significant proportion of patients die in hospital following discharge from ICU, with higher mortality in patients with limitations of life-sustaining treatments in place. Non-survivors had higher systemic illness severity scores at ICU discharge than survivors. Trial Registration: ClinicalTrials.gov NCT02010073. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03465-0.
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Affiliation(s)
- Fabiana Madotto
- Value-Based Health Care Unit, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Bairbre McNicholas
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, Galway, Ireland.,School of Medicine, Clinical Sciences Institute, National University of Ireland, Galway, Ireland
| | - Emanuele Rezoagli
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Tài Pham
- Service de Médecine Intensive-Réanimation, Hôpitaux Universitaires Paris-Saclay, Hôpital de Bicêtre, APHP, Le Kremlin-Bicêtre, France.,Faculté de Médecine Paris-Saclay, Le Kremlin-Bicêtre, France
| | - John G Laffey
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, Galway, Ireland. .,School of Medicine, Clinical Sciences Institute, National University of Ireland, Galway, Ireland.
| | - Giacomo Bellani
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
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22
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Mentzelopoulos SD, Couper K, Voorde PVD, Druwé P, Blom M, Perkins GD, Lulic I, Djakow J, Raffay V, Lilja G, Bossaert L. European Resuscitation Council Guidelines 2021: Ethics of resuscitation and end of life decisions. Resuscitation 2021; 161:408-432. [PMID: 33773832 DOI: 10.1016/j.resuscitation.2021.02.017] [Citation(s) in RCA: 106] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.
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Affiliation(s)
| | - Keith Couper
- UK Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Warwick Medical School, University of Warwick, Coventry, UK
| | - Patrick Van de Voorde
- University Hospital and University Ghent, Belgium; Federal Department Health, Belgium
| | - Patrick Druwé
- Ghent University Hospital, Department of Intensive Care Medicine, Ghent, Belgium
| | - Marieke Blom
- Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Gavin D Perkins
- UK Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Czech Republic; Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital and Medical Faculty of Masaryk University, Brno, Czech Republic
| | - Violetta Raffay
- European University Cyprus, School of Medicine, Nicosia, Cyprus; Serbian Resuscitation Council, Novi Sad, Serbia
| | - Gisela Lilja
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
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23
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El Jawiche R, Hallit S, Tarabey L, Abou-Mrad F. Withholding and withdrawal of life-sustaining treatments in intensive care units in Lebanon: a cross-sectional survey of intensivists and interviews of professional societies, legal and religious leaders. BMC Med Ethics 2020; 21:80. [PMID: 32859185 PMCID: PMC7456082 DOI: 10.1186/s12910-020-00525-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 08/24/2020] [Indexed: 11/23/2022] Open
Abstract
Background Little is known about the attitudes and practices of intensivists working in Lebanon regarding withholding and withdrawing life-sustaining treatments (LSTs). The objectives of the study were to assess the points of view and practices of intensivists in Lebanon along with the opinions of medical, legal and religious leaders regarding withholding withdrawal of life-sustaining treatments in Lebanese intensive care units (ICU). Methods A web-based survey was conducted among intensivists working in Lebanese adult ICUs. Interviews were also done with Lebanese medical, legal and religious leaders. Results Of the 229 survey recipients, 83 intensivists completed it, i.e. a response rate of (36.3%). Most respondents were between 30 and 49 years old (72%), Catholic Christians (60%), anesthesiologists (63%), working in Beirut (47%). Ninety-two percent of them were familiar with the withholding and withdrawal concepts and 80% applied them. Poor prognosis of the acute and chronic disease and futile therapy were the main reasons to consider withholding and withdrawal of treatments. Ninety-five percent of intensivists agreed with the “Principle of Double Effect” (i.e. adding analgesia and or sedation to patients after the withholding/withdrawal decisions in order to prevent their suffering and allow their comfort, even though it might hasten the dying process). The main withheld therapies were vasopressors, respiratory assistance and CPR. Most of the respondents reported the decision was often to always multidisciplinary (92%), involving the family (68%), and the patient (65%), or his advance directives (77%) or his surrogate (81%) and the nurses (78%). The interviewees agreed there was a law governing withholding and withdrawal decisions/practices in Lebanon. Christians and Muslim Sunni leaders declared accepting those practices (withholding or withdrawing LSTs from patients when appropriate). Conclusion Withholding and withdrawal of LSTs in the ICU are known concepts among intensivists working in Lebanon and are being practiced. Our results could be used to inform and optimize therapeutic limitation in ICUs in the country.
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Affiliation(s)
- Rita El Jawiche
- Anesthesia Department, Bahman Hospital, Haret Hreik, near Masjed El Hassanein, Beirut, Lebanon.
| | - Souheil Hallit
- Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik (USEK), Jounieh, Lebanon. .,INSPECT-LB: Institut National de Santé Publique, Epidemiologie Clinique et Toxicologie- Liban, Beirut, Lebanon.
| | - Lubna Tarabey
- Institute of Social Sciences and Medical School, Lebanese University, Hadath, Lebanon
| | - Fadi Abou-Mrad
- Neurology Division and Memory Clinic, Saint Charles Hospital, Baabda, Lebanon.,Division of Medical Ethics & Forensic Medicine, Lebanese University, Hadath, Lebanon
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24
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Abstract
Divatia JV. End-of-life Care in the Intensive Care Unit: Better Late Than Never? Indian J Crit Care Med 2020;24(6):375-377.
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Affiliation(s)
- Jigeeshu V Divatia
- Department of Anesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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25
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26
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Elahi C, Williamson T, Spears CA, Williams S, Nambi Najjuma J, Staton CA, Nickenig Vissoci JR, Fuller A, Kitya D, Haglund MM. Estimating prognosis for traumatic brain injury patients in a low-resource setting: how do providers compare to the CRASH risk calculator? J Neurosurg 2020; 134:1285-1293. [PMID: 32244205 DOI: 10.3171/2020.2.jns192512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 02/04/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Traumatic brain injury (TBI), a burgeoning global health concern, is one condition that could benefit from prognostic modeling. Risk stratification of TBI patients on presentation to a health facility can support the prudent use of limited resources. The CRASH (Corticosteroid Randomisation After Significant Head Injury) model is a well-established prognostic model developed to augment complex decision-making. The authors' current study objective was to better understand in-hospital decision-making for TBI patients and determine whether data from the CRASH risk calculator influenced provider assessment of prognosis. METHODS The authors performed a choice experiment using a simulated TBI case. All participant doctors received the same case, which included a patient history, vitals, and physical examination findings. Half the participants also received the CRASH risk score. Participants were asked to estimate the patient prognosis and decide the best next treatment step. The authors recruited a convenience sample of 28 doctors involved in TBI care at both a regional and a national referral hospital in Uganda. RESULTS For the simulated case, the CRASH risk scores for 14-day mortality and an unfavorable outcome at 6 months were 51.4% (95% CI 42.8%, 59.8%) and 89.8% (95% CI 86.0%, 92.6%), respectively. Overall, participants were overoptimistic when estimating the patient prognosis. Risk estimates by doctors provided with the CRASH risk score were closer to that score than estimates made by doctors in the control group; this effect was more pronounced for inexperienced doctors. Surgery was selected as the best next step by 86% of respondents. CONCLUSIONS This study was a novel assessment of a TBI prognostic model's influence on provider estimation of risk in a low-resource setting. Exposure to CRASH risk score data reduced overoptimistic prognostication by doctors, particularly among inexperienced providers.
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Affiliation(s)
- Cyrus Elahi
- 2Duke Global Health Institute.,6Paul L. Foster School of Medicine, El Paso, Texas; and
| | - Theresa Williamson
- 1Duke University Division of Global Neurosurgery and Neurology.,3Department of Neurosurgery, Duke University Hospital
| | | | | | - Josephine Nambi Najjuma
- 5Mbarara University of Science and Technology, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Catherine A Staton
- 1Duke University Division of Global Neurosurgery and Neurology.,2Duke Global Health Institute.,7Duke Surgery, Division of Emergency Medicine, Durham, North Carolina
| | | | - Anthony Fuller
- 1Duke University Division of Global Neurosurgery and Neurology.,2Duke Global Health Institute.,3Department of Neurosurgery, Duke University Hospital.,4Duke University School of Medicine, Durham, North Carolina
| | - David Kitya
- 5Mbarara University of Science and Technology, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Michael M Haglund
- 1Duke University Division of Global Neurosurgery and Neurology.,2Duke Global Health Institute.,3Department of Neurosurgery, Duke University Hospital.,4Duke University School of Medicine, Durham, North Carolina
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27
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Sprung CL, Ricou B, Hartog CS, Maia P, Mentzelopoulos SD, Weiss M, Levin PD, Galarza L, de la Guardia V, Schefold JC, Baras M, Joynt GM, Bülow HH, Nakos G, Cerny V, Marsch S, Girbes AR, Ingels C, Miskolci O, Ledoux D, Mullick S, Bocci MG, Gjedsted J, Estébanez B, Nates JL, Lesieur O, Sreedharan R, Giannini AM, Fuciños LC, Danbury CM, Michalsen A, Soliman IW, Estella A, Avidan A. Changes in End-of-Life Practices in European Intensive Care Units From 1999 to 2016. JAMA 2019; 322:1692-1704. [PMID: 31577037 PMCID: PMC6777263 DOI: 10.1001/jama.2019.14608] [Citation(s) in RCA: 96] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
IMPORTANCE End-of-life decisions occur daily in intensive care units (ICUs) around the world, and these practices could change over time. OBJECTIVE To determine the changes in end-of-life practices in European ICUs after 16 years. DESIGN, SETTING, AND PARTICIPANTS Ethicus-2 was a prospective observational study of 22 European ICUs previously included in the Ethicus-1 study (1999-2000). During a self-selected continuous 6-month period at each ICU, consecutive patients who died or had any limitation of life-sustaining therapy from September 2015 until October 2016 were included. Patients were followed up until death or until 2 months after the first treatment limitation decision. EXPOSURES Comparison between the 1999-2000 cohort vs 2015-2016 cohort. MAIN OUTCOMES AND MEASURES End-of-life outcomes were classified into 5 mutually exclusive categories (withholding of life-prolonging therapy, withdrawing of life-prolonging therapy, active shortening of the dying process, failed cardiopulmonary resuscitation [CPR], brain death). The primary outcome was whether patients received any treatment limitations (withholding or withdrawing of life-prolonging therapy or shortening of the dying process). Outcomes were determined by senior intensivists. RESULTS Of 13 625 patients admitted to participating ICUs during the 2015-2016 study period, 1785 (13.1%) died or had limitations of life-prolonging therapies and were included in the study. Compared with the patients included in the 1999-2000 cohort (n = 2807), the patients in 2015-2016 cohort were significantly older (median age, 70 years [interquartile range {IQR}, 59-79] vs 67 years [IQR, 54-75]; P < .001) and the proportion of female patients was similar (39.6% vs 38.7%; P = .58). Significantly more treatment limitations occurred in the 2015-2016 cohort compared with the 1999-2000 cohort (1601 [89.7%] vs 1918 [68.3%]; difference, 21.4% [95% CI, 19.2% to 23.6%]; P < .001), with more withholding of life-prolonging therapy (892 [50.0%] vs 1143 [40.7%]; difference, 9.3% [95% CI, 6.4% to 12.3%]; P < .001), more withdrawing of life-prolonging therapy (692 [38.8%] vs 695 [24.8%]; difference, 14.0% [95% CI, 11.2% to 16.8%]; P < .001), less failed CPR (110 [6.2%] vs 628 [22.4%]; difference, -16.2% [95% CI, -18.1% to -14.3%]; P < .001), less brain death (74 [4.1%] vs 261 [9.3%]; difference, -5.2% [95% CI, -6.6% to -3.8%]; P < .001) and less active shortening of the dying process (17 [1.0%] vs 80 [2.9%]; difference, -1.9% [95% CI, -2.7% to -1.1%]; P < .001). CONCLUSIONS AND RELEVANCE Among patients who had treatment limitations or died in 22 European ICUs in 2015-2016, compared with data reported from the same ICUs in 1999-2000, limitations in life-prolonging therapies occurred significantly more frequently and death without limitations in life-prolonging therapies occurred significantly less frequently. These findings suggest a shift in end-of-life practices in European ICUs, but the study is limited in that it excluded patients who survived ICU hospitalization without treatment limitations.
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Affiliation(s)
- Charles L. Sprung
- Department of Anesthesiology, Critical Care Medicine, and Pain Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Bara Ricou
- Department of Anesthesiology, Pharmacology, and Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | - Christiane S. Hartog
- Department of Anesthesiology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin and Klinik Bavaria, Kreischa, Germany
| | - Paulo Maia
- Intensive Care Department, Hospital S. Antonio, Centro Hospitalar do Porto, Porto, Portugal
| | - Spyros D. Mentzelopoulos
- First Department of Intensive Care Medicine, University of Athens Medical School, Evaggelsimos General Hospital, Athens, Greece
| | - Manfred Weiss
- Clinic of Anaesthesiology, University Hospital Medical School, Ulm, Germany
| | - Phillip D. Levin
- General Intensive Care Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Laura Galarza
- Intensive Care Unit, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
| | - Veronica de la Guardia
- Department of Anesthesiology, Critical Care Medicine, and Pain Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Joerg C. Schefold
- Inselspital, Department of Intensive Care Medicine, University of Bern, Switzerland
| | - Mario Baras
- The Hebrew University—Hadassah School of Public Health, Jerusalem, Israel
| | - Gavin M. Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Hans-Henrik Bülow
- Department of Anesthesiology and Intensive Care, Holbaek University Hospital, Zealand Region, Denmark
| | - Georgios Nakos
- Department of Intensive Care Medicine, University of Ioannina, Ioannina, Greece
| | - Vladimir Cerny
- Department of Anesthesiology, Perioperative Medicine, and Intensive Care, J.E. Purkinje University, Masaryk Hospital Usti nad Labem, Czech Republic
| | - Stephan Marsch
- Medical Intensive Care, University of Basel Hospital, Basel, Switzerland
| | - Armand R. Girbes
- Department of Intensive Care Medicine, VU Medical Center, Amsterdam, the Netherlands
| | - Catherine Ingels
- Intensive Care Medicine, University Hospitals K.U. Leuven, Leuven Belgium
| | - Orsolya Miskolci
- Mater Misericordiae University Hospital, Intensive Care Unit, Dublin, Ireland
| | - Didier Ledoux
- Department of Anesthesiology and Intensive Care Medicine, University of Liege, Liege, Belgium
| | | | - Maria G. Bocci
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Jakob Gjedsted
- Department of Anesthesia and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Belén Estébanez
- Intensive Care Unit, Hospital Universitario La Paz, Madrid, Spain
| | - Joseph L. Nates
- Critical Care Department, The University of Texas MD Anderson Cancer Center, Houston
| | - Olivier Lesieur
- Intensive Care Unit, Saint Louis General Hospital, La Rochelle, France
| | - Roshni Sreedharan
- Department of General Anesthesiology, Center for Critical Care Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Alberto M. Giannini
- Division of Pediatric Anesthesia and Intensive Care, ASST Spedali Civili, Brescia, Italy
| | | | | | - Andrej Michalsen
- Department of Anesthesiology and Critical Care, Medizin Campus Bodensee-Tettnang Hospital, Tettnang, Germany
| | - Ivo W. Soliman
- Department of Intensive Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Angel Estella
- Intensive Care Department, University Hospital SAS of Jerez, Jerez de la Frontera, Spain
| | - Alexander Avidan
- Department of Anesthesiology, Critical Care Medicine, and Pain Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
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Brodie D, Slutsky AS, Combes A. Extracorporeal Life Support for Adults With Respiratory Failure and Related Indications: A Review. JAMA 2019; 322:557-568. [PMID: 31408142 DOI: 10.1001/jama.2019.9302] [Citation(s) in RCA: 220] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE The substantial growth over the last decade in the use of extracorporeal life support for adults with acute respiratory failure reveals an enthusiasm for the technology not always consistent with the evidence. However, recent high-quality data, primarily in patients with acute respiratory distress syndrome, have made extracorporeal life support more widely accepted in clinical practice. OBSERVATIONS Clinical trials of extracorporeal life support for acute respiratory failure in adults in the 1970s and 1990s failed to demonstrate benefit, reducing use of the intervention for decades and relegating it to a small number of centers. Nonetheless, technological improvements in extracorporeal support made it safer to use. Interest in extracorporeal life support increased with the confluence of 2 events in 2009: (1) the publication of a randomized clinical trial of extracorporeal life support for acute respiratory failure and (2) the use of extracorporeal life support in patients with severe acute respiratory distress syndrome during the influenza A(H1N1) pandemic. In 2018, a randomized clinical trial in patients with very severe acute respiratory distress syndrome demonstrated a seemingly large decrease in mortality from 46% to 35%, but this difference was not statistically significant. However, a Bayesian post hoc analysis of this trial and a subsequent meta-analysis together suggested that extracorporeal life support was beneficial for patients with very severe acute respiratory distress syndrome. As the evidence supporting the use of extracorporeal life support increases, its indications are expanding to being a bridge to lung transplantation and the management of patients with pulmonary vascular disease who have right-sided heart failure. Extracorporeal life support is now an acceptable form of organ support in clinical practice. CONCLUSIONS AND RELEVANCE The role of extracorporeal life support in the management of adults with acute respiratory failure is being redefined by advances in technology and increasing evidence of its effectiveness. Future developments in the field will result from technological advances, an increased understanding of the physiology and biology of extracorporeal support, and increased knowledge of how it might benefit the treatment of a variety of clinical conditions.
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Affiliation(s)
- Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York
- Center for Acute Respiratory Failure, NewYork-Presbyterian Hospital, New York
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Alain Combes
- Sorbonne Université INSERM Unité Mixte de Recherche (UMRS) 1166, Institute of Cardiometabolism and Nutrition, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (APHP) Hôpital Pitié-Salpêtrière, Paris, France
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Abstract
PURPOSE OF REVIEW The burden of critical illness in low-income and middle-income countries (LMICs) is substantial. A better understanding of critical care outcomes is essential for improving critical care delivery in resource-limited settings. In this review, we provide an overview of recent literature reporting on critical care outcomes in LMICs. We discuss several barriers and potential solutions for a better understanding of critical care outcomes in LMICs. RECENT FINDINGS Epidemiologic studies show higher in-hospital mortality rates for critically ill patients in LMICs as compared with patients in high-income countries (HICs). Recent findings suggest that critical care interventions that are effective in HICs may not be effective and may even be harmful in LMICs. Little data on long-term and morbidity outcomes exist. Better outcomes measurement is beginning to emerge in LMICs through decision support tools that report process outcome measures, studies employing mobile health technologies with community health workers and the development of context-specific severity of illness scores. SUMMARY Outcomes from HICs cannot be reliably extrapolated to LMICs, so it is important to study outcomes for critically ill patients in LMICs. Specific challenges to achieving meaningful outcomes studies in LMICs include defining the critically ill population when few ICU beds exist, the resource-intensiveness of long-term follow-up, and the need for reliable severity of illness scores to interpret outcomes. Although much work remains to be done, examples of studies overcoming these challenges are beginning to emerge.
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Ali MM, Khokhar MA. Issues Regarding End-of-Life Care in Pakistan. J Palliat Care 2019; 35:174-175. [PMID: 31271103 DOI: 10.1177/0825859719855953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Chang HT, Jerng JS, Chen DR. Reduction of healthcare costs by implementing palliative family conference with the decision to withdraw life-sustaining treatments. J Formos Med Assoc 2019; 119:34-41. [PMID: 30876787 DOI: 10.1016/j.jfma.2019.02.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 01/14/2019] [Accepted: 02/21/2019] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Evidence regarding the impact of early palliative family conferences (PFCs) and decision to withdraw life-sustaining treatment (DTW) on healthcare costs in an intensive care unit (ICU) setting is inconsistent. METHODS We retrospectively analyzed patients who died in an ICU from 2013 to 2016. PFCs held within 7 days after ICU admission and DTWs were verified by reviewing medical records and claims data. Comparisons were first made between patients with and without DTWs, and secondly, between DTW patients with and without PFCs within 7 days. Propensity score matching methods were used to examine the difference in costs between patients with and without DTWs and PFCs within 7 days. RESULTS Of the 579 patients included, those with DTWs (n = 73) had a longer ICU stay than those without (n = 506) (12.9 ± 7.1 vs. 8.4 ± 9.6 days, p < 0.001). The DTW patients were more likely to have a "do-not-resuscitate" order (p < 0.001) and PFCs within 7 days (p < 0.001) and had lower healthcare costs (USD 7358 ± 4116 vs. 8669 ± 9,535, p = 0.038). After matching, healthcare cost reduction for patients with DTWs, compared with those without DTWs, was USD 3467 [95% CI, 915-6019] (p < 0.001). Compared with DTW patients without PFCs within 7 days, the costs for DTW patients with PFCs within 7 days further reduced to USD 3042 [95%CI, 1358-4725] (p < 0.001). CONCLUSION Palliative family conferences held within 7 days after ICU admission with decisions to withdraw life-sustaining treatments significantly lowered healthcare costs.
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Affiliation(s)
- Hou-Tai Chang
- Department of Critical Care Medicine, Far Eastern Memorial Hospital, No. 21, Section 2, Nanya South Road, Banciao District, New Taipei City, 220, Taiwan; Department of Industrial Engineering and Management, Yuan-Ze University, 135 Yuan-Tung Road, Chung-Li, Taoyuan, 32003, Taiwan; Institute of Health Policy and Management, National Taiwan University, No. 17, Xu-Zhou Road, Taipei, 100, Taiwan
| | - Jih-Shuin Jerng
- Department of Internal Medicine, National Taiwan University Hospital, No. 7, Zhongshan South Road, Taipei, 100, Taiwan
| | - Duan-Rung Chen
- Institute of Health Policy and Management, National Taiwan University, No. 17, Xu-Zhou Road, Taipei, 100, Taiwan; Institute of Health Behavior and Community Sciences, National Taiwan University, College of Public Health, No. 17, Xu-Zhou Road, Taipei, 100, Taiwan.
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Ni P, Ko E, Mao J. Preferences for Feeding Tube Use and Their Determinants Among Cognitively Intact Nursing Home Residents in Wuhan, China: A Cross-Sectional Study. J Transcult Nurs 2019; 31:13-21. [PMID: 30810098 DOI: 10.1177/1043659619832078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: Standard advance care planning practice is yet to be established in Mainland, China, and little is known about feeding tube preferences among Chinese nursing home residents. The purpose of the study was to examine preferences for feeding tube use and its predictors among frail and cognitively competent nursing home residents in Wuhan, China. Method: A cross-sectional sample of 682 nursing home residents were interviewed face-to-face using a structured questionnaire from 2012 to 2014. Results: A total of 54.5% of participants would accept feeding tube. Participants who reported greater quality of life (odds ratio [OR] = 2.67), having health insurance (OR = 2.09) were more willing to accept feeding tube. Participants with greater impairment in physical health (OR = 0.94) were less willing to accept it. Discussion: Health care professionals need to routinely assess nursing home residents' feeding tube preferences. It is imperative to consider sociocultural perspectives in understanding Chinese older adults' decision making for end-of-life care.
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Affiliation(s)
- Ping Ni
- Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Eunjeong Ko
- San Diego State University, San Diego, CA, USA
| | - Jing Mao
- Huazhong University of Science and Technology, Wuhan, Hubei, China
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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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Abstract
PURPOSE OF REVIEW Published data and practice recommendations on end-of-life (EOL) generally reflect Western practice frameworks. Understanding worldwide practices is important because improving economic conditions are promoting rapid expansion of intensive care services in many previously disadvantaged regions, and increasing migration has promoted a new cultural diversity previously predominantly unicultural societies. This review explores current knowledge of similarities and differences in EOL practice between regions and possible causes and implications of these differences. RECENT FINDINGS Recent observational and survey data shows a marked variability in the practice of withholding and withdrawing life sustaining therapy worldwide. Some evidence supports the view that culture, religion, and socioeconomic factors influence EOL practice, and individually or together account for differences observed. There are also likely to be commonly desired values and expectations for EOL practice, and recent attempts at establishing where worldwide consensus may lie have improved our understanding of shared values and practices. SUMMARY Awareness of differences, understanding their likely complex causes, and using this knowledge to inform individualized care at EOL is likely to improve the quality of care for patients. Further research should clarify the causes of EOL practice variability, monitor trends, and objectively evaluate the quality of EOL practice worldwide.
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Propensity score-matching analyses on the effectiveness of integrated prospective payment program for patients with prolonged mechanical ventilation. Health Policy 2018; 122:970-976. [PMID: 30097352 DOI: 10.1016/j.healthpol.2018.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Revised: 07/09/2018] [Accepted: 07/12/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVES An integrated delivery system with a prospective payment program (IPP) for prolonged mechanical ventilation (PMV) was launched by Taiwan's National Health Insurance (NHI) due to the costly and limited ICU resources. This study aimed to analyze the effectiveness of IPP and evaluate the factors associated with successful weaning and survival among patients with PMV. METHODS Taiwan's NHI Research Database was searched to obtain the data of patients aged ≥17 years who had PMV from 2006 to 2010 (N=50,570). A 1:1 propensity score matching approach was used to compare patients with and without IPP (N=30,576). Cox proportional hazards modeling was used to examine the factors related to successful weaning and survival. RESULTS The related factors of lower weaning rate in IPP participants (hazard ratio [HR]=0.84), were older age, higher income, catastrophic illness (HR=0.87), and higher comorbidity. The effectiveness of IPP intervention for the PMV patients showed longer days of hospitalization, longer ventilation days, higher survival rate, and higher medical costs (in respiratory care center, respiratory care ward). The 6-month mortality rate was lower (34.0% vs. 32.9%). The death risk of IPP patients compared to those non-IPP patients was lower (HR=0.91, P<0.001). CONCLUSIONS The policy of IPP for PMV patients showed higher survival rate although it was costly and related to lower weaning rate.
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Attitudes towards end-of-life issues in intensive care unit among Italian anesthesiologists: a nation-wide survey. Support Care Cancer 2017; 26:1773-1780. [DOI: 10.1007/s00520-017-4014-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 12/05/2017] [Indexed: 01/08/2023]
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Patient-physician relationship in specific cultural settings. Intensive Care Med 2017; 44:646-648. [PMID: 29064048 DOI: 10.1007/s00134-017-4960-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 10/06/2017] [Indexed: 10/18/2022]
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Current challenges in the management of sepsis in ICUs in resource-poor settings and suggestions for the future. Intensive Care Med 2017; 43:612-624. [PMID: 28349179 DOI: 10.1007/s00134-017-4750-z] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 02/27/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Sepsis is a major reason for intensive care unit (ICU) admission, also in resource-poor settings. ICUs in low- and middle-income countries (LMICs) face many challenges that could affect patient outcome. AIM To describe differences between resource-poor and resource-rich settings regarding the epidemiology, pathophysiology, economics and research aspects of sepsis. We restricted this manuscript to the ICU setting even knowing that many sepsis patients in LMICs are treated outside an ICU. FINDINGS Although many bacterial pathogens causing sepsis in LMICs are similar to those in high-income countries, resistance patterns to antimicrobial drugs can be very different; in addition, causes of sepsis in LMICs often include tropical diseases in which direct damaging effects of pathogens and their products can sometimes be more important than the response of the host. There are substantial and persisting differences in ICU capacities around the world; not surprisingly the lowest capacities are found in LMICs, but with important heterogeneity within individual LMICs. Although many aspects of sepsis management developed in rich countries are applicable in LMICs, implementation requires strong consideration of cost implications and the important differences in resources. CONCLUSIONS Addressing both disease-specific and setting-specific factors is important to improve performance of ICUs in LMICs. Although critical care for severe sepsis is likely cost-effective in LMIC setting, more detailed evaluation at both at a macro- and micro-economy level is necessary. Sepsis management in resource-limited settings is a largely unexplored frontier with important opportunities for research, training, and other initiatives for improvement.
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Tripathy S, Routray PK, Mishra JC. Intensive Care Nurses' Attitude on Palliative and End of Life Care. Indian J Crit Care Med 2017; 21:655-659. [PMID: 29142376 PMCID: PMC5672670 DOI: 10.4103/ijccm.ijccm_240_16] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Intensive Care Unit (ICU) nurses have a vital role in the implementation of end of life (EOL) care. There is limited data on the attitude of ICU nurses toward EOL and palliation. Aim This study aimed to investigate knowledge, attitude, and beliefs of intensive care nurses in eastern India toward EOL. Materials and Methods A self-administered questionnaire was distributed to delegates in two regional critical care nurses' training programs. Results Of 178 questionnaires distributed, 138 completed, with a response rate of 75.5*. About half (48.5*) had more than 1 year ICU experience. A majority (81.9*) agreed that nurses should be involved in and initiate (62.3*) EOL discussions. Terms "EOL care or palliative care in ICU" were new for 19.6*; 21* and 55.8* disagreed with allowing peaceful death in terminal patients and unrestricted family visits, respectively. Work experience was associated with wanting unrestricted family visitation, discontinuing monitoring and investigations at EOL, equating withholding and withdrawal of treatment, and being a part of EOL team discussions (P = 0.005, 0.01, 0.01, and 0.001), respectively. Religiousness was associated with a greater desire to initiate EOL discussions (P = 0.001). Conclusion Greater emphasis on palliative care in critical care curriculum may improve awareness among critical care nurses.
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Affiliation(s)
- Swagata Tripathy
- Department of Anesthesia and and Intensive Care, AIIMS, Bhubaneswar, Odisha, India
| | - Pragyan K Routray
- Department of Intensive Care Medicine, Care Hospitals, Bhubaneswar, Odisha, India
| | - Jagdish C Mishra
- Department of Anesthesia and and Intensive Care, KIMS, Bhubaneswar, Odisha, India
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Potentially modifiable factors contributing to outcome from acute respiratory distress syndrome: the LUNG SAFE study. Intensive Care Med 2016; 42:1865-1876. [DOI: 10.1007/s00134-016-4571-5] [Citation(s) in RCA: 191] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 09/22/2016] [Indexed: 11/24/2022]
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Ho A, Tsai DFC. Making good death more accessible: end-of-life care in the intensive care unit. Intensive Care Med 2016; 42:1258-60. [PMID: 27260257 DOI: 10.1007/s00134-016-4396-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 05/17/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Anita Ho
- Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
| | - Daniel Fu-Chang Tsai
- Department & Research Institute of Medical Education & Bioethics, National Taiwan University College of Medicine, Taipei, Taiwan
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