1
|
Wtorek P, Weiss MJ, Singh JM, Hrymak C, Chochinov A, Grunau B, Paunovic B, Shemie SD, Lalani J, Piggott B, Stempien J, Archambault P, Seleseh P, Fowler R, Leeies M. Beliefs of physician directors on the management of devastating brain injuries at the Canadian emergency department and intensive care unit interface: a national site-level survey. Can J Anaesth 2024:10.1007/s12630-024-02749-7. [PMID: 38570415 DOI: 10.1007/s12630-024-02749-7] [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: 06/04/2023] [Revised: 01/24/2024] [Accepted: 01/29/2024] [Indexed: 04/05/2024] Open
Abstract
PURPOSE Insufficient evidence-based recommendations to guide care for patients with devastating brain injuries (DBIs) leave patients vulnerable to inconsistent practice at the emergency department (ED) and intensive care unit (ICU) interface. We sought to characterize the beliefs of Canadian emergency medicine (EM) and critical care medicine (CCM) physician site directors regarding current management practices for patients with DBI. METHODS We conducted a cross-sectional survey of EM and CCM physician directors of adult EDs and ICUs across Canada (December 2022 to March 2023). Our primary outcome was the proportion of respondents who manage (or consult on) patients with DBI in the ED. We conducted subgroup analyses to compare beliefs of EM and CCM physicians. RESULTS Of 303 eligible respondents, we received 98 (32%) completed surveys (EM physician directors, 46; CCM physician directors, 52). Most physician directors reported participating in the decision to withdraw life-sustaining measures (WLSM) for patients with DBI in the ED (80%, n = 78), but 63% of these (n = 62) said this was infrequent. Physician directors reported that existing neuroprognostication methods are rarely sufficient to support WLSM in the ED (49%, n = 48) and believed that an ICU stay is required to improve confidence (99%, n = 97). Most (96%, n = 94) felt that providing caregiver visitation time prior to WLSM was a valid reason for ICU admission. CONCLUSION In our survey of Canadian EM and CCM physician directors, 80% participated in WLSM in the ED for patients with DBI. Despite this, most supported ICU admission to optimize neuroprognostication and patient-centred end-of-life care, including organ donation.
Collapse
Affiliation(s)
- Piotr Wtorek
- Section of Critical Care Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
- Health Sciences Centre, JJ399-820 Sherbrook St., Ann Thomas Building, Winnipeg, MB, R3A 1R9, Canada.
| | - Matthew J Weiss
- Transplant Québec, Montreal, QC, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Division of Critical Care, Department of Pediatrics, Centre Mère-Enfant Soleil du CHU de Québec, Quebec City, QC, Canada
| | - Jeffrey M Singh
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Carmen Hrymak
- Section of Critical Care Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
- Transplant Manitoba, Gift of Life Program, Shared Health Manitoba, Winnipeg, MB, Canada
| | - Alecs Chochinov
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Brian Grunau
- Department of Emergency Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Bojan Paunovic
- Section of Critical Care Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Sam D Shemie
- McGill University, Montreal Children's Hospital, Montreal, QC, Canada
| | | | | | - James Stempien
- Department of Emergency Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Patrick Archambault
- Department of Anesthesiology and Critical Care, Université Laval, Laval, QC, Canada
| | - Parisa Seleseh
- Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Rob Fowler
- Department of Critical Care Medicine, Sunnybrook Hospital, Toronto, ON, Canada
| | - Murdoch Leeies
- Section of Critical Care Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
- Transplant Manitoba, Gift of Life Program, Shared Health Manitoba, Winnipeg, MB, Canada
| |
Collapse
|
2
|
Shahin J, Scales NB, Johara F, Hogue M, Hornby L, Shemie S, Schmidt M, Waldauf P, Duska F, Wind T, Van Mook WN, Dhanani S. Is the process of withdrawal of life-sustaining measures in the intensive care unit different for deceased organ donors compared with other dying patients? A secondary analysis of prospectively collected data. BMJ Open 2023; 13:e069536. [PMID: 37597867 PMCID: PMC10441082 DOI: 10.1136/bmjopen-2022-069536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 07/10/2023] [Indexed: 08/21/2023] Open
Abstract
OBJECTIVE To investigate whether observable differences exist between patterns of withdrawal of life-sustaining measures (WLSM) for patients eligible for donation after circulatory death (DCD) in whom donation was attempted compared with those patients in whom no donation attempts were made. SETTING Adult intensive care units from 20 centres in Canada, the Czech Republic and the Netherlands. DESIGN Secondary analysis of quantitative data collected as part of a large, prospective, cohort study (the Death Prediction and Physiology after Removal of Therapy study). PARTICIPANTS Patients ≥18 years of age who died after a controlled WLSM in an intensive care unit. Patients were classified as not DCD eligible, DCD eligible with DCD attempted or DCD eligible but DCD was not attempted. PRIMARY AND SECONDARY OUTCOME MEASURES The process of WLSM (timing and type and, if applicable, dosages of measures withdrawn, dosages of analgesics/sedatives) was compared between groups. RESULTS Of the 635 patients analysed, 85% had either cardiovascular support stopped or were extubated immediately on WLSM. Of the DCD eligible patients, more were immediately extubated at the initiation of WLSM when DCD was attempted compared with when DCD was not attempted (95% vs 61%, p<0.0001). Initiation of WLSM with the immediate cessation of cardiovascular measures or early extubation was associated with earlier time to death, even after adjusting for confounders (OR 2.94, 95% CI 1.39 to 6.23, at 30 min). Other than in a few patients who received propofol, analgesic and sedative dosing after WLSM between DCD attempted and DCD eligible but not attempted patients was not significantly different. All patients died. CONCLUSIONS Patients in whom DCD is attempted may receive a different process of WLSM. This highlights the need for a standardised and transparent process for end-of-life care across the spectrum of critically ill patients and potential organ donors.
Collapse
Affiliation(s)
- J Shahin
- Division of Critical Care, Respiratory Epidemiology and Clinical Research Unit, McGill University Faculty of Medicine, Montreal, Québec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Québec, Canada
| | | | - F Johara
- Research Institute of the McGill University Health Centre, Montreal, Québec, Canada
| | - M Hogue
- CHEO, Ottawa, Ontario, Canada
| | - Laura Hornby
- System Development, Canadian Blood Services Organ Donation and Transplantation, Ottawa, Ontario, Canada
| | - Sam Shemie
- Division of Critical Care, Department of Pediatrics, Montreal Childrens Hospital, Montreal, Québec, Canada
- System Development, Canadian Blood Services, Ottawa, Ontario, Canada
| | - M Schmidt
- Third Faculty of Medicine, Charles University, Praha, Czech Republic
- FNKV University Hospital, Prague, Czech Republic
| | - P Waldauf
- Third Faculty of Medicine, Charles University, Praha, Czech Republic
- FNKV University Hospital, Prague, Czech Republic
| | - F Duska
- Third Faculty of Medicine, Charles University, Praha, Czech Republic
- FNKV University Hospital, Prague, Czech Republic
| | - Tineke Wind
- Maastricht University Medical Centre, Maastricht, The Netherlands
- Heart and Vascular Center, Maastricht, The Netherlands
| | - W N Van Mook
- Deparment of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Sonny Dhanani
- Critical Pediatric Critical Care Medicine, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
3
|
Silva A, Arora S, Dhanani S, Rochon A, Giorno LP, Jackson E, Hornby L, Latifi M, Lotherington K, Luctkar-Flude M, Petry S, Wilson L, Silva E Silva V. Quality improvement tools to manage deceased organ donation processes: a scoping review. BMJ Open 2023; 13:e070333. [PMID: 36731923 PMCID: PMC9896188 DOI: 10.1136/bmjopen-2022-070333] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To collate and summarise the literature on the quality improvement tools that have been developed for deceased organ donation processes after circulatory determination of death and neurological determination of death. DESIGN Scoping review using the Joanna Briggs Institute framework. DATA SOURCES We searched for published (MEDLINE, Embase, PsycINFO, CINAHL, Web of Science) and unpublished literature (organ donation organisation websites worldwide). The search was initially conducted on 17 July 2021 and updated on 1 June 2022. Included articles discussed the creation and/or use of quality improvement tools to manage deceased organ donation processes. Two independent reviewers screened the references, extracted and analysed the data. RESULTS 40 references were included in this review, and most records were written in English (n=38), originated in Canada (n=21), published between 2016 and 2022 (n=22), and were specific for donation after neurological determination of death (n=20). The tools identified included checklists, algorithms, flow charts, charts, pathways, decision tree maps and mobile apps. These tools were applied in the following phases of the organ donation process: (1) potential donor identification, (2) donor referral, (3) donor assessment and risk, (4) donor management, (5) withdrawal of life-sustaining measures, (6) death determination, (7) organ retrieval and (8) overall organ donation process. CONCLUSIONS We conducted a thorough investigation of the available quality improvement tools for deceased organ donation processes. The existing evidence lacks details in the report of methods used for development, testing and impact of these tools, and we could not locate tools specific for some phases of the organ donation process. Lastly, by mapping existing tools, we aim to facilitate both clinician choices among available tools, as well as research work building on existing knowledge.
Collapse
Affiliation(s)
- Amina Silva
- Research Institute, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | | | - Sonny Dhanani
- Critical Care, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Andrea Rochon
- School of Nursing, Queen's University, Kingston, Ontario, Canada
| | - Luciana P Giorno
- School of Nursing, Federal University of the ABC, Santo Andre, SP, Brazil
| | - Elayne Jackson
- Research Institute, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Laura Hornby
- Research Institute, Canadian Blood Services, Ottawa, Ontario, Canada
| | - Marzieh Latifi
- Sina Organ procurement unit, Tehran, Iran (the Islamic Republic of)
| | | | | | - Stefany Petry
- School of Nursing, Federal University of Santa Catarina, Florianopolis, Santa Catarina, Brazil
| | | | | |
Collapse
|
4
|
Orr S, Efstathiou N, Baernholdt M, Vanderspank-Wright B. ICU Clinicians' Experiences of Terminal Weaning and Extubation. J Pain Symptom Manage 2022; 63:e521-e528. [PMID: 35093503 DOI: 10.1016/j.jpainsymman.2022.01.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/17/2022] [Accepted: 01/21/2022] [Indexed: 11/21/2022]
Abstract
CONTEXT Aside from spontaneous death, a majority of ICU deaths occur after a decision to either withhold or withdraw life-sustaining measures, including withdrawal of ventilatory support. While terminal weaning or terminal extubation are both used, the lack of evidence on the superiority of one method over the other can create challenges for ICU clinicians. There is a need to explore clinicians' experiences related to terminal weaning/extubation to understand their decision-making processes as well as the context and mechanisms that guide this process. OBJECTIVES This study aimed to explore ICU clinicians'experiences of Terminal Weaning of Mechanical Ventilation (TWMV) in order to better understand the process, and clinicians' feelings about the process. METHODS This study used an exploratory descriptive qualitative design. Data were collected via semi-structured, face-to-face interviews with 20 ICU clinicians. An inductive, data driven thematic analysis approach was used for data analysis. RESULTS Analysis of the data resulted in four themes: Fine-tuning the Process of TWMV; Focusing on the Family; Ensuring Patient-Centered Care; and Impact on Health care Clinicians and Support Needs. CONCLUSION The identified themes provide insight into the complexity of the withdrawal of mechanical ventilation within the context of end-of-life care in the ICU. The themes highlight the need for clear communication of a TWMV plan between clinicians to avoid conflict during the process, ensuring medication is in place for potential distressing symptoms, incorporating patient and family wishes in planning, supporting the family during the process, and training and support for clinicians.
Collapse
Affiliation(s)
- Shelly Orr
- Research Operations Program Director (S.O.), Virginia Commonwealth University Health System, Richmond, Virginia, USA; Lecturer (N.E.), University of Birmingham, Birmingham, England, UK; Associate Dean for Global Initiatives and Professor (M.B.), University of North Carolina, Chapel Hill, North Carolina, USA; Associate Professor (B.V.W), University of Ottawa, Ottawa, Ontario, Canada.
| | - Nikolaos Efstathiou
- Research Operations Program Director (S.O.), Virginia Commonwealth University Health System, Richmond, Virginia, USA; Lecturer (N.E.), University of Birmingham, Birmingham, England, UK; Associate Dean for Global Initiatives and Professor (M.B.), University of North Carolina, Chapel Hill, North Carolina, USA; Associate Professor (B.V.W), University of Ottawa, Ottawa, Ontario, Canada
| | - Marianne Baernholdt
- Research Operations Program Director (S.O.), Virginia Commonwealth University Health System, Richmond, Virginia, USA; Lecturer (N.E.), University of Birmingham, Birmingham, England, UK; Associate Dean for Global Initiatives and Professor (M.B.), University of North Carolina, Chapel Hill, North Carolina, USA; Associate Professor (B.V.W), University of Ottawa, Ottawa, Ontario, Canada
| | - Brandi Vanderspank-Wright
- Research Operations Program Director (S.O.), Virginia Commonwealth University Health System, Richmond, Virginia, USA; Lecturer (N.E.), University of Birmingham, Birmingham, England, UK; Associate Dean for Global Initiatives and Professor (M.B.), University of North Carolina, Chapel Hill, North Carolina, USA; Associate Professor (B.V.W), University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
5
|
Santos PARD, Teixeira PJZ, Moraes Neto DMD, Cypel M. Donation after circulatory death and lung transplantation. J Bras Pneumol 2022; 48:e20210369. [PMID: 35475865 PMCID: PMC9064622 DOI: 10.36416/1806-3756/e20210369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 12/17/2021] [Indexed: 11/17/2022] Open
Abstract
Lung transplantation is the most effective modality for the treatment of patients with end-stage lung diseases. Unfortunately, many people cannot benefit from this therapy due to insufficient donor availability. In this review and update article, we discuss donation after circulatory death (DCD), which is undoubtedly essential among the strategies developed to increase the donor pool. However, there are ethical and legislative considerations in the DCD process that are different from those of donation after brain death (DBD). Among others, the critical aspects of DCD are the concept of the end of life, cessation of futile treatments, and withdrawal of life-sustaining therapy. In addition, this review describes a rationale for using lungs from DCD donors and provides some important definitions, highlighting the key differences between DCD and DBD, including physiological aspects pertinent to each category. The unique ability of lungs to maintain cell viability without circulation, assuming that oxygen is supplied to the alveoli-an essential aspect of DCD-is also discussed. Furthermore, an updated review of the clinical experience with DCD for lung transplantation across international centers, recent advances in DCD, and some ethical dilemmas that deserve attention are also reported.
Collapse
Affiliation(s)
- Pedro Augusto Reck Dos Santos
- . Department of Cardiothoracic Surgery, Mayo Clinic (AZ) USA.,. Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre (RS) Brasil
| | - Paulo José Zimermann Teixeira
- . Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre (RS) Brasil.,. Departamento de Clínica Médica, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre (RS) Brasil
| | | | - Marcelo Cypel
- . Division of Thoracic Surgery, University of Toronto, University Health Network, Toronto (ON) Canada
| |
Collapse
|
6
|
Domínguez-Gil B, Ascher N, Capron AM, Gardiner D, Manara AR, Bernat JL, Miñambres E, Singh JM, Porte RJ, Markmann JF, Dhital K, Ledoux D, Fondevila C, Hosgood S, Van Raemdonck D, Keshavjee S, Dubois J, McGee A, Henderson GV, Glazier AK, Tullius SG, Shemie SD, Delmonico FL. Expanding controlled donation after the circulatory determination of death: statement from an international collaborative. Intensive Care Med 2021; 47:265-281. [PMID: 33635355 PMCID: PMC7907666 DOI: 10.1007/s00134-020-06341-7] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 12/21/2020] [Indexed: 12/14/2022]
Abstract
A decision to withdraw life-sustaining treatment (WLST) is derived by a conclusion that further treatment will not enable a patient to survive or will not produce a functional outcome with acceptable quality of life that the patient and the treating team regard as beneficial. Although many hospitalized patients die under such circumstances, controlled donation after the circulatory determination of death (cDCDD) programs have been developed only in a reduced number of countries. This International Collaborative Statement aims at expanding cDCDD in the world to help countries progress towards self-sufficiency in transplantation and offer more patients the opportunity of organ donation. The Statement addresses three fundamental aspects of the cDCDD pathway. First, it describes the process of determining a prognosis that justifies the WLST, a decision that should be prior to and independent of any consideration of organ donation and in which transplant professionals must not participate. Second, the Statement establishes the permanent cessation of circulation to the brain as the standard to determine death by circulatory criteria. Death may be declared after an elapsed observation period of 5 min without circulation to the brain, which confirms that the absence of circulation to the brain is permanent. Finally, the Statement highlights the value of perfusion repair for increasing the success of cDCDD organ transplantation. cDCDD protocols may utilize either in situ or ex situ perfusion consistent with the practice of each country. Methods to accomplish the in situ normothermic reperfusion of organs must preclude the restoration of brain perfusion to not invalidate the determination of death.
Collapse
Affiliation(s)
| | - Nancy Ascher
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Alexander M Capron
- Scott H. Bice Chair in Healthcare Law, Policy and Ethics, Department of Medicine and Law, University of Southern California, Los Angeles, CA, USA
| | - Dale Gardiner
- Intensive Care Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Alexander R Manara
- Consultant in Intensive Care Medicine, The Intensive Care Unit, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - James L Bernat
- Department of Neurology and Medicine, Active Emeritus, Dartmouth Geisel School of Medicine, Hanover, NH, USA
| | - Eduardo Miñambres
- Transplant Coordination Unit and Service of Intensive Care, University Hospital Marqués de Valdecilla-IDIVAL, School of Medicine, University of Cantabria, Santander, Spain
| | - Jeffrey M Singh
- University of Toronto, and Trillium Gift of Life Network, Toronto, Canada
| | - Robert J Porte
- Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - James F Markmann
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Kumud Dhital
- Department of Cardiothoracic Surgery, Sant Vincent'S Hospital, Sidney, Australia
| | - Didier Ledoux
- Department of Anesthesia and Intensive Care, University of Liège, Liège, Belgium
| | - Constantino Fondevila
- General and Digestive Surgery, Hospital Clínic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain
| | - Sarah Hosgood
- Department of Surgery, University of Cambridge, Cambridge, UK
| | - Dirk Van Raemdonck
- University Hospitals Leuven and Catholic University Leuven, Leuven, Belgium
| | - Shaf Keshavjee
- Toronto General Hospital, University of Toronto, Toronto, Canada
| | - James Dubois
- Bioethics Research Center, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Andrew McGee
- Australian Centre for Health Law Research, Faculty of Law, Queensland University of Technology, Brisbane City, Australia
| | - Galen V Henderson
- Director of Neurocritical Care, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Stefan G Tullius
- Division of Transplant Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sam D Shemie
- Pediatric Intensive Care, Montreal Children's Hospital, McGill University, Medical Advisor, Deceased Donation, Canadian Blood Services, Montreal, Canada
| | - Francis L Delmonico
- Chief Medical Officer, New England Donor Services, 60 1st Ave, Waltham, MA, 02451, USA.
- Department of Surgery, Harvard Medical School at Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
| |
Collapse
|