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Beck K, Vincent A, Cam H, Becker C, Gross S, Loretz N, Müller J, Amacher SA, Bohren C, Sutter R, Bassetti S, Hunziker S. Medical futility regarding cardiopulmonary resuscitation in in-hospital cardiac arrests of adult patients: A systematic review and Meta-analysis. Resuscitation 2021; 172:181-193. [PMID: 34896244 DOI: 10.1016/j.resuscitation.2021.11.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 11/29/2021] [Indexed: 11/19/2022]
Abstract
AIM For some patients, survival with good neurologic function after cardiopulmonary resuscitation (CPR) is highly unlikely, thus CPR would be considered medically futile. Yet, in clinical practice, there are no well-established criteria, guidelines or measures to determine futility. We aimed to investigate how medical futility for CPR in adult patients is defined, measured, and associated with do-not-resuscitate (DNR) code status as well as to evaluate the predictive value of clinical risk scores through meta-analysis. METHODS We searched Embase, PubMed, CINAHL, and PsycINFO from the inception of each database up to January 22, 2021. Data were pooled using a fixed-effects model. Data collection and reporting followed the PRISMA guidelines. RESULTS Thirty-one studies were included in the systematic review and 11 in the meta-analysis. Medical futility defined by risk scores was associated with a significantly higher risk of in-hospital mortality (5 studies, 3102 participants with Pre-Arrest Morbidity (PAM) and Prognosis After Resuscitation (PAR) score; overall RR 3.38 [95% CI 1.92-5.97]) and poor neurologic outcome/in-hospital mortality (6 studies, 115,213 participants with Good Outcome Following Attempted Resuscitation (GO-FAR) and Prediction of Outcome for In-Hospital Cardiac Arrest (PIHCA) score; RR 6.93 [95% CI 6.43-7.47]). All showed high specificity (>90%) for identifying patients with poor outcome. CONCLUSION There is no international consensus and a lack of specific definitions of CPR futility in adult patients. Clinical risk scores might aid decision-making when CPR is assumed to be futile. Future studies are needed to assess their clinical value and reliability as a measure of futility regarding CPR.
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Affiliation(s)
- Katharina Beck
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland
| | - Alessia Vincent
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland; Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Missionsstrasse 60/62, 4055 Basel, Switzerland
| | - Hasret Cam
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland
| | - Christoph Becker
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland; Department of Emergency Medicine, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Sebastian Gross
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland
| | - Nina Loretz
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland
| | - Jonas Müller
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland
| | - Simon A Amacher
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland; Clinic of Intensive Care, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Chantal Bohren
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland
| | - Raoul Sutter
- Clinic of Intensive Care, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland; Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Stefano Bassetti
- Medical Faculty, University of Basel, Klingelbergstrasse 61, 4031 Basel, Switzerland; Division of Internal Medicine, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Sabina Hunziker
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland; Medical Faculty, University of Basel, Klingelbergstrasse 61, 4031 Basel, Switzerland.
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Saltbæk L, Michelsen HM, Nelausen KM, Theile S, Dehlendorff C, Dalton SO, Nielsen DL. Cancer patients, physicians, and nurses differ in their attitudes toward the decisional role in do-not-resuscitate decision-making. Support Care Cancer 2020; 28:6057-6066. [PMID: 32291599 DOI: 10.1007/s00520-020-05460-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 04/04/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Do-not-resuscitate (DNR) decision-making in severely ill patients presents many difficult medical, ethical, and legal challenges. The primary aim of this study was to explore cancer patients' and health care professionals' attitudes regarding DNR decision-making authority and timing of the decision. METHODS This study was a questionnaire survey among Danish cancer patients and their attending physicians and nurses in an oncology outpatient setting. Potential differences between patients', physicians', and nurses' answers to the questionnaire were analyzed using Fisher's exact test. RESULTS Responses from 904 patients, 59 physicians, and 160 nurses were analyzed. The majority in all three groups agreed that DNR decisions should be made in collaboration between physician and patient. However, one-third of the patients answered that the patient alone should make the decision regarding DNR, which contrasts with the physicians' and nurses' attitudes, 0% and 6% pointing to the patient as sole decision-maker, respectively. In case of disagreement between patient and physician, a majority of both patients (66%) and physicians (86%) suggested themselves as the ultimate decision-maker. Additionally, 43% of patients but only 19% of physicians preferred the DNR discussion being brought up early in the course of the disease. CONCLUSIONS With regard to the decisional role of patient vs. physician and the timing of the DNR discussion, we found a substantial discrepancy between the attitudes of cancer patients and physicians. This discrepancy calls for a greater awareness and discussion of this sensitive topic among both health care professionals and the public.
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Affiliation(s)
- Lena Saltbæk
- Department of Oncology, Herlev and Gentofte University Hospital, Borgmester Ib Juuls Vej 7, DK-2730, Herlev, Denmark.
- Survivorship and Inequality in Cancer, Danish Cancer Society Research Center, Strandboulevarden 49, DK-2100, Copenhagen, Denmark.
- Department of Oncology, Zealand University Hospital, Ringstedgade 61, DK-4700, Næstved, Denmark.
| | - Hanne M Michelsen
- Department of Oncology, Herlev and Gentofte University Hospital, Borgmester Ib Juuls Vej 7, DK-2730, Herlev, Denmark
| | - Knud M Nelausen
- Department of Oncology, Herlev and Gentofte University Hospital, Borgmester Ib Juuls Vej 7, DK-2730, Herlev, Denmark
| | - Susann Theile
- Department of Oncology, Herlev and Gentofte University Hospital, Borgmester Ib Juuls Vej 7, DK-2730, Herlev, Denmark
| | - Christian Dehlendorff
- Unit of Statistics and Pharmacoepidemiology, Danish Cancer Society Research Center, Strandboulevarden 49, DK-2100, Copenhagen, Denmark
| | - Susanne O Dalton
- Survivorship and Inequality in Cancer, Danish Cancer Society Research Center, Strandboulevarden 49, DK-2100, Copenhagen, Denmark
- Department of Oncology, Zealand University Hospital, Ringstedgade 61, DK-4700, Næstved, Denmark
| | - Dorte L Nielsen
- Department of Oncology, Herlev and Gentofte University Hospital, Borgmester Ib Juuls Vej 7, DK-2730, Herlev, Denmark
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Denis N, Timsit JF, Giaj Levra M, Sakhri L, Duruisseaux M, Schwebel C, Merle P, Pinsolle J, Ferrer L, Moro-Sibilot D, Toffart AC. Impact of systematic advanced care planning in lung cancer patients: A prospective study. Respir Med Res 2019; 77:11-17. [PMID: 31927479 DOI: 10.1016/j.resmer.2019.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 08/24/2019] [Accepted: 09/29/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND End-of-life (EOL) communication is crucial, particularly for cancer patients. While advanced care planning is still uncommon, we sought to investigate its impact on care intensity in case of organ failure in lung cancer patients. METHODS We prospectively included consecutive lung cancer patients hospitalised at the Grenoble University Hospital, France, between January 1, 2014 and March 31, 2016. Patients could be admitted several times and benefited from advanced care planning based on three care intensities: intensive care, maximal medical care, and exclusive palliative care. Patients' wishes were addressed. RESULTS Data of 739 hospitalisations concerning 482 patients were studied. During the three first admissions, 173 (25%) patients developed organ failure, with intensive care proposed to 56 (32%), maximal medical care to 104 (60%), and exclusive palliative care to 13 (8%). Median time to organ failure was 9 days [IQR 25%-75%: 3-13]. All patients benefited from care intensity that was either equal to or lower than the care proposed. Specific wishes were recorded for 158 (91%) patients, with a discussion about EOL conditions held in 116 (73%). CONCLUSIONS In case of organ failure, advanced care planning helps provide reasonable care intensity. The role of the patient's wishes as to the proposed care must be further investigated. CLINICAL TRIAL REGISTRATION The study was registered at www.ClinicalTrials.gov with the identifier NCT02852629.
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Affiliation(s)
- N Denis
- Department of pneumology, CHU Grenoble Alpes, 38000 Grenoble, France
| | - J-F Timsit
- Department of medical and infectious resuscitation, hôpital Bichat Claude Bernard, 75018 Paris, France
| | - M Giaj Levra
- Department of pneumology, CHU Grenoble Alpes, 38000 Grenoble, France
| | - L Sakhri
- Department of oncology, Institut Daniel Hollard, groupe hospitalier mutualiste, 38000 Grenoble, France
| | - M Duruisseaux
- Department of pneumology, hôpital Louis Pradel, Institut de Cancérologie des Hospices Civils de Lyon, 69500 Bron, France
| | - C Schwebel
- Pôle urgences médecine aiguë, department of intensive care and resuscitation, centre hospitalier universitaire Grenoble Alpes, 38000 Grenoble, France; Laboratoires des pharmaceutiques biocliniques U 1039, université Grenoble Alpes, 38700 La Tronche, France
| | - P Merle
- UMR Inserm 1240, department of pneumology, CHU G Montpied, 63000 Clermont-Ferrand, France
| | - J Pinsolle
- Department of pneumology, CHU Grenoble Alpes, 38000 Grenoble, France
| | - L Ferrer
- Department of pneumology, CHU Grenoble Alpes, 38000 Grenoble, France
| | - D Moro-Sibilot
- Department of pneumology, CHU Grenoble Alpes, 38000 Grenoble, France; Inserm U 1209/CNRS UMR 5309, Centre de Recherche UGA, Institut pour l'Avancée des Biosciences, 38700 La Tronche, France
| | - A-C Toffart
- Department of pneumology, CHU Grenoble Alpes, 38000 Grenoble, France; Inserm U 1209/CNRS UMR 5309, Centre de Recherche UGA, Institut pour l'Avancée des Biosciences, 38700 La Tronche, France.
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Do-not-resuscitate orders in cancer patients: a review of literature. Support Care Cancer 2016; 25:677-685. [PMID: 27771786 DOI: 10.1007/s00520-016-3459-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 10/10/2016] [Indexed: 10/20/2022]
Abstract
Discussing do-not-resuscitate (DNR) orders is part of daily hospital practice in oncology departments. Several medical factors and patient characteristics are associated with issuing DNR orders in cancer patients. DNR orders are often placed late in the disease process. This may be a cause for disagreements between doctors and between doctors and patients and may cause for unnecessary treatments and admissions. In addition, DNR orders on itself may influence the rest of the medical treatment for patients. We present recommendations for discussing DNR orders and medical futility in practice through shared decision-making. Prospective studies are needed to investigate in which a patient's cardiopulmonary resuscitation (CPR) is futile and whether or not DNR orders influence the medical care of patients.
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Bosscher MRF, van Leeuwen BL, Hoekstra HJ. Surgical emergencies in oncology. Cancer Treat Rev 2014; 40:1028-36. [PMID: 24933674 DOI: 10.1016/j.ctrv.2014.05.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 05/09/2014] [Accepted: 05/12/2014] [Indexed: 02/06/2023]
Abstract
An oncologic emergency is defined as an acute, potentially life threatening condition in a cancer patient that has developed as a result of the malignant disease or its treatment. Many oncologic emergencies are signs of advanced, end-stage malignant disease. Oncologic emergencies can be divided into medical or surgical. The literature was reviewed to construct a summary of potential surgical emergencies in oncology that any surgeon can be confronted with in daily practice, and to offer insight into the current approach for these wide ranged emergencies. Cancer patients can experience symptoms of obstruction of different structures and various causes. Obstruction of the gastrointestinal tract is the most frequent condition seen in surgical practice. Further surgical emergencies include infections due to immune deficiency, perforation of the gastrointestinal tract, bleeding events, and pathological fractures. For the institution of the appropriate treatment for any emergency, it is important to determine the underlying cause, since emergencies can be either benign or malignant of origin. Some emergencies are well managed with conservative or non-invasive treatment, whereas others require emergency surgery. The patient's performance status, cancer stage and prognosis, type and severity of the emergency, and the patient's wishes regarding invasiveness of treatment are essential during the decision making process for optimal management.
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Affiliation(s)
- M R F Bosscher
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, HPC BA31, P.O. Box 30.001, 9700 RB Groningen, The Netherlands.
| | - B L van Leeuwen
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, HPC BA31, P.O. Box 30.001, 9700 RB Groningen, The Netherlands.
| | - H J Hoekstra
- Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, HPC BA31, P.O. Box 30.001, 9700 RB Groningen, The Netherlands.
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