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Barclay G, Barbato M, Yerbury R, Harnish L, Miranda N. Bispectral Index monitoring of palliative sedation for home withdrawal of tracheostomy ventilation: A case report. Palliat Med 2024:2692163241257580. [PMID: 38835175 DOI: 10.1177/02692163241257580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
BACKGROUND Tracheostomy ventilation in motor neurone disease is an uncommon life-sustaining treatment. Best practice is having a plan for ventilation withdrawal, but the literature to guide practice is limited. Case reports have documented standard doses of opioids and benzodiazepines used for sedation in such cases. CASE A 49-year-old man was diagnosed with motor neurone disease in 2016. He commenced tracheostomy ventilation in 2018. In 2022 and 2023, planning was undertaken, at the patient's request, for withdrawal of tracheostomy ventilation at home, when he was no longer able to communicate with technology. CASE PLANNING Planning included Bispectral Index monitoring prior to cessation of ventilation, ensuring this only occurred when deep sedation was achieved. After ventilation withdrawal in 2023, a retrospective review of medications given and his level of sedation on monitoring was undertaken, with family consent. OUTCOME Ventilation withdrawal was initiated after deep sedation was achieved, 6 h after commencing subcutaneous infusions of morphine, midazolam, clonazepam and phenobarbital. LESSONS Doses required to achieve acceptable sedation exceeded literature reports. Achieving deep sedation was a longer than expected process. CONCLUSION More research using an objective measure of sedation is required, as clinical assessment of sedation in this context is compromised.
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Affiliation(s)
- Greg Barclay
- Palliative Care Services, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia
- Graduate School of Medicine, University of Wollongong, Wollongong, NSW, Australia
| | - Michael Barbato
- Honorary Research Fellow, Palliative Care Services, Illawarra Shoalhaven Local Heath District, Wollongong, NSW, Australia
| | - Rachel Yerbury
- School of Psychology and Public Health, La Trobe University, Bundoora, VIC, Australia
| | - Laura Harnish
- Palliative Care Services, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia
| | - Nilda Miranda
- Palliative Care Services, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia
- School of Nursing, University of Wollongong, Wollongong, NSW, Australia
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Auffray L, Mora P, Giabicani M, Engrand N, Audibert G, Perrigault PF, Fazilleau C, Gravier-Dumonceau R, Le Dorze M. Tension between continuous and deep sedation and assistance in dying: a national survey of intensive care professionals' perceptions. Anaesth Crit Care Pain Med 2024; 43:101317. [PMID: 38934930 DOI: 10.1016/j.accpm.2023.101317] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 10/22/2023] [Accepted: 10/23/2023] [Indexed: 06/28/2024]
Abstract
INTRODUCTION The situation in France is unique, having a legal framework for continuous and deep sedation (CDS). However, its use in intensive care units (ICU), combined with the withdrawal of life-sustaining therapies, still raises ethical issues, particularly its potential to hasten death. The legalization of assistance in dying, i.e., assisted suicide or euthanasia at the patient's request, is currently under discussion in France. The objectives of this national survey were first, to assess whether ICU professionals perceive CDS administered to ICU patients as a practice that hastens death, in addition to relieving unbearable suffering, and second, to assess ICU professionals' perceptions of assistance in dying. METHODS A national survey with online questionnaires for ICU physicians and nursesaddressed through the French Society of Anesthesiology and Critical Care Medicine. RESULTS A total of 956 ICU professionals responded to the survey (38% physicians and 62% nurses). Of these, 22% of physicians and 12% of nurses (p < 0.001) felt that the purpose of CDS was to hasten death. For 20% of physicians, CDS combined with terminal extubation was considered an assistance in dying. For 52% of ICU professionals, the current framework did not sufficiently cover the range of situations that occur in the ICU. A favorable opinion on the potential legalization of assistance in dying was observed in 83% of nurses and 71% of physicians (p < 0.001), with no preference between assisted suicide and euthanasia. CONCLUSION Our findings highlight the tension between CDS and assisted suicide/euthanasia in the specific context of intensive care and suggest that ICU professionals would be supportive of a legislative evolution.
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Affiliation(s)
- Louis Auffray
- Department of Anaesthesiology and Critical Care, University Hospital Timone, Assistance Publique des Hôpitaux de Marseille, Aix-Marseille University, France
| | - Pierre Mora
- Department of Anaesthesiology and Critical Care, University Hospital Timone, Assistance Publique des Hôpitaux de Marseille, Aix-Marseille University, France
| | - Mikhaël Giabicani
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, Assistance Publique des Hôpitaux de Paris, Sorbonne Université, Centre de Recherche des Cordeliers, Laboratoire ETREs, Partis, France
| | - Nicolas Engrand
- Intensive Care Unit and Anaesthesiology Department, Rothschild Foundation Hospital, 29 Rue Manin, 75019 Paris, France
| | - Gérard Audibert
- Department of Anaesthesology and Critical Care, Nancy University Hospital, University of Lorraine, France
| | - Pierre-François Perrigault
- Department of Anaesthesology and Critical Care, Montpellier University Hospital, University of Montpellier, France
| | - Claire Fazilleau
- Sorbonne Université, GRC 29, Assistance Publique des Hôpitaux de Paris, DMU DREAM, Pitié-Salpétrière Hospital, Department of Anaesthesiology, Critical Care and Perioperative Medicine, Paris, France
| | - Robinson Gravier-Dumonceau
- Aix Marseille University, APHM, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, ISSPAM, Hop Timone, BioSTIC, Biostatistique et Technologies de l'Information et de la Communication, Marseille, France
| | - Matthieu Le Dorze
- Department of Anaesthesiology and Critical Care, Hôpital Lariboisière, FHU PROMICE, DMU PARABOL, AP-HP Nord, Paris, France. Inserm U942 MASCOT, Université de Paris, Inserm U1018 CESP, Université Paris Saclay, Villejuif, France.
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Le Dorze M, Barthélémy R, Giabicani M, Audibert G, Cousin F, Gakuba C, Robert R, Chousterman B, Perrigault PF. Continuous and deep sedation until death after a decision to withdraw life-sustaining therapies in intensive care units: A national survey. Palliat Med 2023; 37:1202-1209. [PMID: 37306034 DOI: 10.1177/02692163231180656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Continuous and deep sedation until death is a much highly debated end-of-life practice. France is unique in having a regulatory framework for it. However, there are no data on its practice in intensive care units (ICUs). AIM The aim is to describe continuous and deep sedation in relation to the framework in the specific context of withdrawal of life-sustaining therapies in ICUs, that is, its decision-making process and its practice compared to other end-of-life practices in this setting. DESIGN AND SETTING French multicenter observational study. Consecutive ICU patients who died after a decision to withdraw life-sustaining therapies. RESULTS A total of 343 patients in 57 ICUs, 208 (60%) with continuous and deep sedation. A formalized procedure for continuous and deep sedation was available in 32% of the ICUs. Continuous and deep sedation was not the result of a collegial decision-making process in 17% of cases, and did not involve consultation with an external physician in 29% of cases. The most commonly used sedative medicines were midazolam (10 [5-18] mg h-1) and propofol (200 [120-250] mg h -1). The Richmond Agitation Sedation Scale (RASS) was -5 in 60% of cases. Analgesia was associated with sedation in 94% of cases. Compared with other end-of-life sedative practices (n = 98), medicines doses were higher with no difference in the depth of sedation. CONCLUSIONS This study shows a poor compliance with the framework for continuous and deep sedation. It highlights the need to formalize it to improve the decision-making process and the match between the intent, the practice and the actual effect.
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Affiliation(s)
- Matthieu Le Dorze
- Department of Anesthesia and Critical Care Medicine, DMU PARABOL, Lariboisière Hospital, AP-HP Nord, Paris, France
- Université Paris-Saclay, CESP U1018, Inserm, Paris, France
- Université de Paris, UMR-S 942 (MASCOT), Inserm, Paris, France
| | - Romain Barthélémy
- Department of Anesthesia and Critical Care Medicine, DMU PARABOL, Lariboisière Hospital, AP-HP Nord, Paris, France
- Université de Paris, UMR-S 942 (MASCOT), Inserm, Paris, France
| | - Mikhael Giabicani
- Department of Anaesthesia and Critical Care, AP-HP, Beaujon Hospital, Paris, France
- Sorbonne Université, Inserm, Centre de Recherche des Cordeliers, Laboratoire ETREs, Paris, France
| | - Gérard Audibert
- Department of Anaesthesia and Critical Care Medicine, CHRU Nancy, Université de Lorraine, Nancy, France
| | - François Cousin
- Centre national des soins palliatifs et de la fin de vie (CNSPFV), Paris, France
| | - Clément Gakuba
- Department of Anesthesia and Critical Care Medicine, Caen, France
| | - René Robert
- Médecine Intensive Réanimation, CHU Poitiers, F-86000, Poitiers, France
- Université de Poitiers, CIC Inserm ALIVE, F-86000, Poitiers, France
| | - Benjamin Chousterman
- Department of Anesthesia and Critical Care Medicine, DMU PARABOL, Lariboisière Hospital, AP-HP Nord, Paris, France
- Université de Paris, UMR-S 942 (MASCOT), Inserm, Paris, France
| | - Pierre-François Perrigault
- Department of Anesthesia and Critical Care Medicine, Gui de Chauliac University Hospital, Université de Montpellier, Montpellier, France
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Ashkenazy S, Weissman C, DeKeyser Ganz F. Intensive Care Unit Caregivers Perception of Patient Discomfort: A Qualitative Study. Pain Manag Nurs 2022; 23:711-719. [PMID: 36137880 DOI: 10.1016/j.pmn.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 07/20/2022] [Accepted: 08/16/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Being hospitalized in an intensive care unit ICU often involves pain and discomfort. While pain is commonly alleviated with analgesics, discomfort is more difficult to diagnose and treat, thus potentially leading to incorrect analgesic administration. AIM To describe intensive care unit practitioners' perceptions of discomfort in the ICU, and their methods to discern between pain and non-pain discomfort. METHODS Twenty-five intensive care unit practitioners (7 doctors and 18 nurses) were interviewed from medical and general intensive care units at one institution in Jerusalem, Israel. Data collection was performed using semi-structured interviews. Interviews were audio-recorded and transcribed. Transcriptions were coded and categorized by two researchers independently. Content analysis identified common themes. RESULTS Two main discomfort themes were identified: unpleasant physical sensations and unpleasant psychologic feelings, with further subcategories. Physiologic and non-physiologic signs such as facial expression and motor activity helped to diagnose discomfort. Trial and error and cause and effect were used to differentiate pain from other sources of discomfort. CONCLUSIONS Practitioners saw pain as a dominant source of discomfort. Treating overall discomfort should focus on improving the quality of the total intensive care unit experience. Strategies to diagnose non-pain discomfort and pain were similar. Differentiating pain from non-pain discomfort is essential in order to provide appropriate treatment for pain and non-pain-related discomfort.
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Affiliation(s)
- Shelly Ashkenazy
- Hadassah Hebrew University School of Nursing, Hadassah Medical Center, Jerusalem, Israel.
| | - Charles Weissman
- Hadassah-Hebrew University Medical Center, Hebrew University - Hadassah School of Medicine, Jerusalem, Israel
| | - Freda DeKeyser Ganz
- Hadassah Hebrew University School of Nursing, Hadassah Medical Center, Jerusalem, Israel; Hadassah Hebrew University School of Nursing and Jerusalem College of Technology, Jerusalem, Israel
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Dying in the ICU : Changes in end of life decisions from 2011 to 2018 in the ICU of a communal tertiary hospital in Germany. DIE ANAESTHESIOLOGIE 2022; 71:930-940. [PMID: 35925156 DOI: 10.1007/s00101-022-01127-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 03/22/2022] [Accepted: 04/09/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND With modern intensive care medicine, even older patients and those with pre-existing conditions can survive critical illnesses and major operations; however, unreflected application of intensive care treatment might lead to a state called chronic critical illness. Today, withholding treatment and/or treatment withdrawal precede many deaths in the intensice care unit (ICU). We looked at changes in measures at the end of life and withholding or withdrawal of treatment in the ICU of a German tertiary hospital in 2017/2018 compared to 2011/2012. METHODS In this retrospective explorative study, we analyzed end of life practices in adult patients who died in an intermediate care unit (IMC)/ICU of Klinikum Hanau in 2017/2018. We compared these data with data from the same hospital in 2011/2012 RESULTS: Of the 1246 adult patients who died in Klinikum Hanau in 2017/2018, 433 (35%) died in an ICU or IMC unit. Deceased ICU patients were 74.0 ± 12.5 years and 86.6% were older than 60 years. At least one life-sustaining measure was withheld in 278 (76.2%) and withdrawn in 159 (46.3%) of patients. More than three quarters of patients (n = 276, 75.6%) had a do not resuscitate (DNR) order and in about half of the patients invasive ventilation (n = 175, 49.9%) or renal replacement therapy (n = 191, 52.3%) was limited. In 113 patients (31.0%) catecholamine treatment was withdrawn, in 72 (19.7%) patients invasive ventilation and in 49 (13.4%) patients renal replacement therapy. Compared to 2011/2012, we saw an increase by ~15% (absolute increase) in withholding and withdrawal of treatment and observed an effect of documents like advance directive or healthcare proxy. CONCLUSION In 76.2% of deceased ICU patients withholding treatment and in 43.6% treatment withdrawal preceded death. Compared to 2011/2012 treatment was withheld or withdrawn more often. Compared to 2011/2012, we saw an increase (~15% absolute) in withholding and withdrawal of treatment. After withholding or withdrawal of treatment, most patients died within 3 and 2 days, respectively.
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Sloss R, Mehta R, Metaxa V. End-of-Life and Palliative Care in a Critical Care Setting: The Crucial Role of the Critical Care Pharmacist. PHARMACY 2022; 10:pharmacy10050107. [PMID: 36136840 PMCID: PMC9498871 DOI: 10.3390/pharmacy10050107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 08/23/2022] [Accepted: 08/26/2022] [Indexed: 11/16/2022] Open
Abstract
Critical care pharmacists play an important role in ICU patient care, with evidence showing reductions in drug prescribing errors, adverse drug events and costs, as well as improvement in clinical outcomes, such as mortality and length of ICU stay. Caring for critically ill patients around the end of their life is complicated by the acute onset of their illness and the fact that most of them are unable to communicate any distressing symptoms. Critical care pharmacists are an integral part of the ICU team during a patient’s end-of-life care and their multifaceted role includes clinical support for bedside staff, education, and training, as well as assistance with equipment and logistics. In this article, we highlight the important role of the ICU pharmacist using a ‘real-life’ clinical case from our hospital.
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Affiliation(s)
- Rhona Sloss
- Pharmacy Department, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK
- Department of Critical Care Medicine, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK
- Correspondence:
| | - Reena Mehta
- Pharmacy Department, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK
- Department of Critical Care Medicine, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK
- Faculty of Life Sciences and Medicine, School of Cancer & Pharmaceutical Sciences, King’s College London, London WC2R 2LS, UK
| | - Victoria Metaxa
- Department of Critical Care Medicine, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK
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Dilemas bioéticos experimentados por el cuidador respiratorio durante el retiro de la ventilación mecánica en adultos al final de la vida. MOVIMIENTO CIENTÍFICO 2022. [DOI: 10.33881/2011-7191.mct.15205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Introducción: sobre el retiro de la ventilación mecánica al final de la vida, la literatura ha documentado brechas conceptuales en los cuidadores respiratorios y los consecuentes dilemas bioéticos a los que se enfrentan estos profesionales. Objetivo: analizar los dilemas bioéticos que experimentan los cuidadores respiratorios durante el retiro de la ventilación mecánica en adultos al final de la vida a partir de una revisión integradora de la literatura publicada entre 2010 y 2021. Metodología: revisión integrativa de la literatura siguiendo los lineamientos de Whittemore & Knafl (2005) y Guirao Goris (2015). Para el análisis de la información se realizó una evaluación crítica de la literatura acopiada para identificar patrones de comportamiento de los cuidadores respiratorios. Resultados: las enfermedades no transmisibles y crónicas fueron identificadas como las principales condiciones clínicas que determinan la toma de decisiones del cuidador respiratorio en el retiro de la ventilación mecánica paliativa; prolongar la vida de forma artificial a pacientes en estado terminal fue el dilema bioético más frecuente. Conclusiones: los profesionales del cuidado respiratorio enfrentan dilemas éticos en el retiro de la ventilación mecánica al final de la vida de pacientes con afecciones oncológicas y no oncológica; la toma de decisiones se realiza principalmente con base en los principios bioéticos clásicos de Respeto por la autonomía, Beneficencia, No maleficencia y Justicia. Se evidencia la carencia de estudios sobre bioética en diálogo con lineamientos de la Declaración Universal sobre Bioética y Derechos humanos.
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Le Dorze M, Martin-Lefèvre L, Santin G, Robert R, Audibert G, Megarbane B, Puybasset L, Dorez D, Veber B, Kerbaul F, Antoine C. Critical pathways for controlled donation after circulatory death in France. Anaesth Crit Care Pain Med 2022; 41:101029. [PMID: 35121185 DOI: 10.1016/j.accpm.2022.101029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/22/2021] [Accepted: 12/06/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION In 2015, France authorised controlled donation after circulatory death (cDCD) according to a nationally approved protocol. The aim of this study is to provide an overview from the perspective of critical care specialists of cDCD. The primary objective is to assess how the organ donation procedure affects the withdrawal of life-sustaining therapies (WLST) process. The secondary objective is to assess the impact of cDCD donors' diagnoses on the whole process. MATERIAL AND METHODS This 2015-2019 prospective observational multicentre study evaluated the WLST process in all potential cDCD donors identified nationwide, comparing 2 different sets of subgroups: 1- those whose WLST began after organ donation was ruled out vs. while it was still under consideration; 2- those with a main diagnosis of post-anoxic brain injury (PABI) vs. primary brain injury (PBI) at the time of the WLST decision. RESULTS The study analysed 908 potential cDCD donors. Organ donation remained under consideration at WLST initiation for 54.5% of them with longer intervals between their WLST decision and its initiation (2 [1-4] vs. 1 [1-2] days, P < 0.01). Overall, 60% had post-anoxic brain injury. Time from ICU admission to WLST decision was longer for primary brain injury donors (10 [4-21] vs. 6 [4-9] days, P < 0.01). Median time to death (agonal phase) was 15 [15-20] minutes. CONCLUSIONS French cDCD donors are mostly related to post-anoxic brain injury. The organ donation process does not accelerate WLST decision but increases the interval between the WLST decision and its initiation.
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Affiliation(s)
- Matthieu Le Dorze
- Université de Paris, INSERM, U942 MASCOT, F-75006, paris, france, Department of Anaesthesia and Critical Care Medicine, AP-HP, Hôpital Lariboisière, F-75010, Paris, France.
| | - Laurent Martin-Lefèvre
- Organ Donation Service, Service de Médecine Intensive Réanimation, boulevard Stéphane Moreau, 85000 La Roche-sur-Yon, France
| | - Gaëlle Santin
- Agence de la biomédecine, Medical and Scientific Department, 1, avenue du stade de France, 93212 Saint-Denis, France
| | - René Robert
- University of Poitiers, CHU de Poitiers, Service de Médecine Intensive Réanimation, CIC Inserm 1402, 2, rue de la Milétrie, 86021 Poitiers, France
| | - Gérard Audibert
- University of Lorraine, Department of Anaesthesiology and Critical Care Medicine, Nancy University Hospital, 29, avenue du Maréchal de Lattre de Tassigny, 54035 Nancy, France
| | - Bruno Megarbane
- University of Paris, INSERM UMRS-1144, Department of Medical and Toxicological Critical Care, AP-HP, Lariboisière Hospital, 2, rue Ambroise Paré, 75475 Paris cedex 10, France
| | - Louis Puybasset
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and Critical Care Medicine, AP-HP, Pitié-Salpêtrière Hospital, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - Didier Dorez
- Organ Donation Service, Centre Hospitalier Annecy-genevois, 1, avenue de l'Hôpital, 74370 Epagny Metz-Tessy, France
| | - Benoît Veber
- SFAR Ethics Committee, Surgical Intensive Care Unit, Rouen University Hospital, 37, boulevard Gambetta, 76000 Rouen, France
| | - François Kerbaul
- Agence de la biomédecine, Medical and Scientific Department, 1, avenue du stade de France, 93212 Saint-Denis, France
| | - Corinne Antoine
- Agence de la biomédecine, Medical and Scientific Department, 1, avenue du stade de France, 93212 Saint-Denis, France
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End of life in the critically ill patient: evaluation of experience of end of life by caregivers (EOLE study). Ann Intensive Care 2021; 11:162. [PMID: 34825996 PMCID: PMC8626545 DOI: 10.1186/s13613-021-00944-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/25/2021] [Indexed: 11/28/2022] Open
Abstract
Background The death rate in intensive care units (ICUs) can reach 20%. More than half occurs after a decision of care withholding/withdrawal. We aimed at describing and evaluating the experience of ICU physicians and nurses involved in the end-of-life (EOL) procedure. Primary objective was the evaluation of the experience of EOL assessed by the CAESAR questionnaire. Secondary objectives were to describe factors associated with a low or high score and to examine the association between Numeric Analogic Scale and quality of EOL. Methods Consecutive adult patients deceased in 52 ICUs were included between April and June 2018. Characteristics of patients and caregivers, therapeutics and care involved after withdrawal were recorded. CAESAR score included 15 items, rated from 1 (traumatic experience) to 5 (comforting experience). The sum was rated from 15 to 75 (the highest, the best experience). Numeric Analogic Scale was rated from 0 (worst EOL) to 10 (optimal EOL). Results Five hundred and ten patients were included, 403 underwent decision of care withholding/withdrawal, and among them 362 underwent effective care withdrawal. Among the 510 patients, mean CAESAR score was 55/75 (± 6) for nurses and 62/75 (± 5) for physicians (P < 0.001). Mean Numeric Analogic Scale was 8 (± 2) for nurses and 8 (± 2) for physicians (P = 0.06). CAESAR score and Numeric Analogic Scale were significantly but weakly correlated. They were significantly higher for both nurses and physicians if the patient died after a decision of withholding/withdrawal. In multivariable analysis, among the 362 patients with effective care withdrawal, disagreement on the intensity of life support between caregivers, non-invasive ventilation and monitoring and blood tests the day of death were associated with lower score for nurses. For physicians, cardiopulmonary resuscitation the day of death was associated with lower score in multivariable analysis. Conclusion Experience of EOL was better in patients with withholding/withdrawal decision as compared to those without. Our results suggest that improvement of nurses’ participation in the end-of-life process, as well as less invasive care, would probably improve the experience of EOL for both nurses and physicians. Registration: ClinicalTrial.gov: NCT03392857. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00944-z.
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Bretonniere S, Fournier V. Continuous Deep Sedation Until Death: First National Survey in France after the 2016 Law Promulgating It. J Pain Symptom Manage 2021; 62:e13-e19. [PMID: 33819514 DOI: 10.1016/j.jpainsymman.2021.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 03/12/2021] [Accepted: 03/13/2021] [Indexed: 10/21/2022]
Abstract
CONTEXT The French parliament passed a groundbreaking law in 2016, opening a right for patients to access continuous and deep sedation until death (CDS) at the end of life, under conditions. Parliamentarians' goal was to consolidate patients' rights whilst avoiding legislating on medical aid in dying. OBJECTIVES To conduct a first national retrospective survey on CDS to evaluate the number of CDS requested, proposed and performed in 2017 and to elicit qualitative data from physicians on the practice and on the terms used by patients to refer to CDS. METHODS Early 2018, an online survey was sent to all French hospitals, nursing homes, hospital at homes services and general practitioners (GPs). Descriptive statistics and qualitative inductive content analysis were used to analyze the data and comments of respondents. RESULTS The qualitative data show that respondents generally approve the law on CDS as it sets a legal framework; nonetheless, there is a persistent controversy about CDS vs. euthanasia for some physicians in all settings. GPs reported limited access to midazolam and the difficulty in organizing multidisciplinary procedures as major constraints. In hospital settings in particular, differentiating CDS from other sedation practices is uneasy. All physicians reported patients use multiple elements of language to request CDS. CONCLUSION After the law was passed in France, CDS were requested, proposed and performed in all medical settings, in nursing homes, at home. The qualitative data presented here show the relevance of exploring physicians' reflexive stances on this practice in different settings and within the context of a patient-physician relationship marked by a new patient's right. The study highlights the wide range of elements of language used by patients at the end of life, as understood by respondent physicians to mean a request for CDS and underscores the polymorphous meaning of CDS.
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Affiliation(s)
- Sandrine Bretonniere
- Centre national des soins palliatifs et de la fin de vie (S.B.), Paris Cedex 19, France.
| | - Veronique Fournier
- Centre national des soins palliatifs et de la fin de vie, Centre d'éthique clinique, Assistance publique-Hôpitaux de Paris (V.F.), Paris, France
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Uggeri S, Gilioli F, Cosenza R, Nasi F, Moreali S, Guicciardi N. COVID-19 pneumonia: a tailor-made dress for a Down syndrome patient. ITALIAN JOURNAL OF MEDICINE 2021. [DOI: 10.4081/itjm.2021.1377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We report here a case of coronavirus disease 2019 pneumonia in a 40-year-old Caucasian woman with Down syndrome admitted to the Internal Medicine Unit. She was initially treated with hydroxychloroquine and azithromycin. When respiratory conditions dramatically worsened, she was not admitted to the intensive care unit because of impaired cognitive function. Thus helmet-based continuous positive airway pressure was started. The respiratory conditions progressively improved, reaching spontaneous breathing.
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Conflicts of interest in the context of end of life care for potential organ donors in Australia. J Crit Care 2020; 59:166-171. [DOI: 10.1016/j.jcrc.2020.06.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 06/01/2020] [Accepted: 06/22/2020] [Indexed: 12/17/2022]
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Efstathiou N, Vanderspank-Wright B, Vandyk A, Al-Janabi M, Daham Z, Sarti A, Delaney JW, Downar J. Terminal withdrawal of mechanical ventilation in adult intensive care units: A systematic review and narrative synthesis of perceptions, experiences and practices. Palliat Med 2020; 34:1140-1164. [PMID: 32597309 DOI: 10.1177/0269216320935002] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND During the terminal withdrawal of life-sustaining measures for intensive care patients, the removal of respiratory support remains an ambiguous practice. Globally, perceptions and experiences of best practice vary due to the limited evidence in this area. AIM To identify, appraise and synthesise the latest evidence around terminal withdrawal of mechanical ventilation in adult intensive care units specific to perceptions, experiences and practices. DESIGN Mixed methods systematic review and narrative synthesis. A review protocol was registered on PROSPERO (CRD42018086495). DATA SOURCES Four electronic databases were systematically searched (Medline, Embase, CENTRAL and CINAHL). Obtained articles published between January 2008 and January 2020 were screened for eligibility. All included papers were appraised using relevant appraisal tools. RESULTS Twenty-five papers were included in the review. Findings from the included papers were synthesised into four themes: 'clinicians' perceptions and practices'; 'time to death and predictors'; 'analgesia and sedation practices'; 'physiological and psychological impact'. CONCLUSIONS Perceptions, experiences and practices of terminal withdrawal of mechanical ventilation vary significantly across the globe. Current knowledge highlights that the time to death after withdrawal of mechanical ventilation is very short. Predictors for shorter duration could be considered by clinicians and guide the choice of pharmacological interventions to address distressing symptoms that patients may experience. Clinicians ought to prepare patients, families and relatives for the withdrawal process and the expected progression and provide them with immediate and long-term support following withdrawal. Further research is needed to improve current evidence and better inform practice guidelines.
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Affiliation(s)
- Nikolaos Efstathiou
- College of Medical and Dental Sciences, Institute of Clinical Sciences, School of Nursing, University of Birmingham, Birmingham, UK
| | | | - Amanda Vandyk
- Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, ON, Canada
| | - Mustafa Al-Janabi
- Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, ON, Canada
| | - Zeinab Daham
- Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, ON, Canada
| | - Aimee Sarti
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - James Downar
- Divisions of Critical Care and Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
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Sandiumenge A, Lomero Martinez MDM, Sánchez Ibáñez J, Seoane Pillado T, Montaña-Carreras X, Molina-Gomez JD, Llauradó-Serra M, Dominguez-Gil B, Masnou N, Bodi M, Pont T. Online education about end-of-life care and the donation process after brain death and circulatory death. Can we influence perception and attitudes in critical care doctors? A prospective study. Transpl Int 2020; 33:1529-1540. [PMID: 32881149 DOI: 10.1111/tri.13728] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 08/18/2020] [Accepted: 08/24/2020] [Indexed: 11/28/2022]
Abstract
Impact of training on end-of-life care (EOLC) and the deceased donation process in critical care physicians' perceptions and attitudes was analysed. A survey on attitudes and perceptions of deceased donation as part of the EOLC process was delivered to 535 physicians working in critical care before and after completion of a online training programme (2015-17). After training, more participants agreed that nursing staff should be involved in the end-of-life decision process (P < 0.001) and that relatives should not be responsible for medical decisions (P < 0.001). Postcourse, more participants considered 'withdrawal/withholding' as similar actions (P < 0.001); deemed appropriate the use of pre-emptive sedation in all patients undergoing life support treatment adequacy (LSTA; P < 0.001); and were favourable to approaching family about donation upon LSTA agreement, as well as admitting them in the intensive care unit (P < 0.001) to allow the possibility of donation. Education increased the number of participants prone to initiate measures to preserve the organs for donation before the declaration of death in patients undergoing LSTA (P < 0.001). Training increased number of positive terms selected by participants to describe donation after brain and circulatory death. Training programmes may be useful to improve physicians' perception and attitude about including donation as part of the patient's EOLC.
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Affiliation(s)
- Alberto Sandiumenge
- Department of Donor and Transplant, Transplant Coordination, Clinical Research/Epidemiology In Pneumonia and Sepsis (CRIPS), Vall d´Hebrón University Hospital, Barcelona, Spain
| | | | | | - Teresa Seoane Pillado
- Preventive Medicine and Public Health Unit, Department of Health Sciences, University of A Coruña-INIBIC, A Coruña, Spain
| | | | | | - Mireia Llauradó-Serra
- Nursing Department, Universitat Internacional de Catalunya, Sant Cugat del Vallès, Spain
| | | | - Nuria Masnou
- Department of Organ Donation and Transplantation, University Hospital Girona Dr Josep Trueta, Girona, Spain
| | - Maria Bodi
- Critical Care Department, Pere Virgili Research Institute, Joan XXIII University Hospital, Rovira i Virgili University, Tarragona, Spain
| | - Teresa Pont
- Department of Donor and Transplant, Transplant Coordination, Clinical Research/Epidemiology In Pneumonia and Sepsis (CRIPS), Vall d´Hebrón University Hospital, Barcelona, Spain
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15
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Laserna A, Durán-Crane A, López-Olivo MA, Cuenca JA, Fowler C, Díaz DP, Cardenas YR, Urso C, O'Connell K, Fowler C, Price KJ, Sprung CL, Nates JL. Pain management during the withholding and withdrawal of life support in critically ill patients at the end-of-life: a systematic review and meta-analysis. Intensive Care Med 2020; 46:1671-1682. [PMID: 32833041 PMCID: PMC7444163 DOI: 10.1007/s00134-020-06139-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 05/26/2020] [Indexed: 01/08/2023]
Abstract
Purpose To review and summarize the most frequent medications and dosages used during withholding and withdrawal of life-prolonging measures in critically ill patients in the intensive care unit. Methods We searched PubMed, EMBASE, the Cochrane Database of Systematic Reviews, and the Virtual Health Library from inception through March 2019. We considered any study evaluating pharmaceutical interventions for pain management during the withholding or withdrawing of life support in adult critically ill patients at the end-of-life. Two independent investigators performed the screening and data extraction. We pooled data on utilization rate of analgesic and sedative drugs and summarized the dosing between the moment prior to withholding or withdrawal of life support and the moment before death. Results Thirteen studies met inclusion criteria. Studies were conducted in the United States (38%), Canada (31%), and the Netherlands (31%). Eleven studies were single-cohort and twelve had a Newcastle–Ottawa Scale score of less than 7. The mean age of the patients ranged from 59 to 71 years, 59–100% were mechanically ventilated, and 47–100% of the patients underwent life support withdrawal. The most commonly used opioid and sedative were morphine [utilization rate 60% (95% CI 48–71%)] and midazolam [utilization rate 28% (95% CI 23–32%)], respectively. Doses increased during the end-of-life process (pooled mean increase in the dose of morphine: 2.6 mg/h, 95% CI 1.2–4). Conclusions Pain control is centered on opioids and adjunctive benzodiazepines, with dosages exceeding those recommended by guidelines. Despite consistency among guidelines, there is significant heterogeneity among practices in end-of-life care. Electronic supplementary material The online version of this article (10.1007/s00134-020-06139-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Andres Laserna
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, NY, USA
| | | | - María A López-Olivo
- Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John A Cuenca
- Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cosmo Fowler
- Department of Medicine, Case Western Reserve University-MetroHealth Medical Center, Cleveland, OH, USA
| | - Diana Paola Díaz
- Department of Critical Care, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Yenny R Cardenas
- Department of Critical Care, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Catherine Urso
- Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keara O'Connell
- Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Clara Fowler
- Research Services and Assessment, Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kristen J Price
- Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Charles L Sprung
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Joseph L Nates
- Department of Critical Care, Division of Anesthesiology, Critical Care, and Pain, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Azoulay É, Beloucif S, Guidet B, Pateron D, Vivien B, Le Dorze M. Admission decisions to intensive care units in the context of the major COVID-19 outbreak: local guidance from the COVID-19 Paris-region area. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:293. [PMID: 32503593 PMCID: PMC7274070 DOI: 10.1186/s13054-020-03021-2] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 05/25/2020] [Indexed: 12/15/2022]
Abstract
SARS-CoV-2 has caused a global pandemic unprecedented in size, spread, severity, and mortality. The influx of patients with severe or life-threatening disease means that in some cases, the available medical resources are not sufficient to meet the needs of all patients. Hence, healthcare providers may be forced to make difficult choices about which patients should be referred to the ICU. This document is intended to provide conceptual support to all healthcare teams currently engaged in the frontline management of the COVID-19 pandemic. It aims to assist physicians in the decision-making process for ICU admission and to help them provide uninterrupted and high-quality care.
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Affiliation(s)
- Élie Azoulay
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, Paris University, 1 Avenue Claude Vellefaux, 75010, Paris, France.
| | - Sadek Beloucif
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, Paris University, 1 Avenue Claude Vellefaux, 75010, Paris, France.,Anesthesia and Critical Care Department, Avicenne Hospital, Paris, France
| | - Bertrand Guidet
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, Paris University, 1 Avenue Claude Vellefaux, 75010, Paris, France.,Medecine Intensive et Réanimation Department, Saint-Antoine Hospital, Paris, France
| | - Dominique Pateron
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, Paris University, 1 Avenue Claude Vellefaux, 75010, Paris, France.,Emergency Department, Saint-Antoine Hospital, Paris, France
| | - Benoît Vivien
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, Paris University, 1 Avenue Claude Vellefaux, 75010, Paris, France.,Emergency Department, Neckers Hospital, Paris, France
| | - Matthieu Le Dorze
- Médecine Intensive et Réanimation, APHP, Hôpital Saint-Louis, Paris University, 1 Avenue Claude Vellefaux, 75010, Paris, France.,Anesthesia and Critical Care Department, Lariboisiere Hospital, Paris, France
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