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Kumar S, VanDolah H, Rasheed AD, Budd S, Anderson K, Papolos AI, M BBK, Singam NSV, Rao A, Groninger H. Optimizing outcomes: Impact of palliative care consultation timing in the cardiovascular intensive care unit. Heart Lung 2024; 68:265-271. [PMID: 39142088 DOI: 10.1016/j.hrtlng.2024.08.011] [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: 06/10/2024] [Revised: 08/07/2024] [Accepted: 08/09/2024] [Indexed: 08/16/2024]
Abstract
BACKGROUND ICU patients and their families experience significant stress due to illness severity and prognostic uncertainty, making palliative care (PC) integral for symptom management, family support, and end-of-life care goals. The impact of PC in the Cardiac Intensive Care Unit (CICU) remains unstudied. OBJECTIVE We explore the impact of early palliative care consultation (PCC) on patient outcomes in the CICU, including mortality, length of stay, and family meeting frequency. METHODS This retrospective study at MedStar Washington Hospital Center included 209 adult patients admitted to the CICU between December 2021 and June 2022 receiving PCC. We compared outcomes between those receiving early (<72 h) and late (>72 h) PCC, including mortality, length of stay, and family meeting frequency. Statistical analysis included Wilcoxon rank sum tests, Chi-squared tests, Fisher's exact test, and Poisson regression models. RESULTS The study included 209 patients admitted to the (M age = 68 years, SD = 14; 45 % female; 62 % Black, 30 % White) who received PCC, most (79 %) within 72 h. Early PCC was associated with shorter CICU stays (median, 3 vs. 5.5 days; p = 0.005). Early PCC patients had higher odds of family meetings (IRR=3.59; p < 0.001) and experienced a change in code status sooner (median 1 day vs. 3 days, p < 0.001). Late PCC patients were more likely to undergo tracheostomy (13.6% vs. 2.4 %; p = 0.007), cardioversion (9.1% vs. 1.8 %; p = 0.037), and have PEG tubes placed (13.6% vs. 2.4 %; p = 0.007). CONCLUSIONS Early PCC in the CICU is associated with shorter CICU stays, fewer procedures, and more frequent family meetings.
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Affiliation(s)
- Sant Kumar
- MedStar Georgetown University Hospital, Washington, DC, United States
| | - Hunter VanDolah
- Georgetown University School of Medicine, Washington, DC, United States
| | | | - Serenity Budd
- MedStar Health Research Institute, Hyattsville, MD, United States
| | - Kelley Anderson
- Georgetown University School of Nursing, Washington, DC, United States
| | - Alexander I Papolos
- Department of Critical Care, MedStar Washington Hospital Center, Washington, DC, United States; Divison of Cardiology, MedStar Washington Hospital Center, Washington, DC, United States
| | - Benjamin B Kenigsberg M
- Department of Critical Care, MedStar Washington Hospital Center, Washington, DC, United States; Divison of Cardiology, MedStar Washington Hospital Center, Washington, DC, United States
| | - Narayana Sarma V Singam
- Department of Critical Care, MedStar Washington Hospital Center, Washington, DC, United States; Divison of Cardiology, MedStar Washington Hospital Center, Washington, DC, United States
| | - Anirudh Rao
- Section of Palliative Care, MedStar Washington Hospital Center, Washington, DC, United States
| | - Hunter Groninger
- Section of Palliative Care, MedStar Washington Hospital Center, Washington, DC, United States.
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2
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García-Delgado M, Rodríguez-García R, Ochagavía A, Rodríguez-Esteban MDLÁ. The medical treatment of cardiogenic shock. Med Intensiva 2024; 48:477-486. [PMID: 38834498 DOI: 10.1016/j.medine.2024.05.012] [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: 05/10/2024] [Accepted: 05/18/2024] [Indexed: 06/06/2024]
Abstract
Cardiogenic shock is characterized by tissue hypoperfusion due to the inadequate cardiac output to maintain the tissue oxygen demand. Despite some advances in cardiogenic shock management, extremely high mortality is still associated with this clinical syndrome. Its management is based on the immediate stabilization of hemodynamic parameters through medical care and the use of mechanical circulatory supports in specialized centers. This review aims to understand the cardiogenic shock current medical treatment, consisting mainly of inotropic drugs, vasopressors and coronary revascularization. In addition, we highlight the relevance of applying measures to other organ levels based on the optimization of mechanical ventilation and the appropriate initiation of renal replacement therapy.
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Affiliation(s)
- Manuel García-Delgado
- Servicio de Medicina Intensiva, Hospital Universitario Virgen de las Nieves, Granada, Spain; Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain
| | - Raquel Rodríguez-García
- Servicio de Medicina Intensiva, Hospital Universitario Central de Asturias, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Spain; CIBER-Enfermedades Respiratorias, Instituto de Salud Carlos III, Spain.
| | - Ana Ochagavía
- Servicio de Medicina Intensiva, Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
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3
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McGeehan CB, Rushton CH. Ethical Challenges and Implications of Deactivating Mechanical Circulatory Support for Patients With Preserved Cognitive Function. AACN Adv Crit Care 2022; 33:289-296. [PMID: 36067263 DOI: 10.4037/aacnacc2022757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Caitlin B McGeehan
- Caitlin B. McGeehan is Palliative Care Nurse Coordinator and Lead Clinical Nurse, Johns Hopkins Hospital, Blalock 359, 600 North Wolfe St, Baltimore, MD 21287
| | - Cynda Hylton Rushton
- Cynda Hylton Rushton is the Anne and George Bunting Professor of Clinical Ethics, Johns Hopkins University Berman Institute of Bioethics & School of Nursing, Baltimore, Maryland
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4
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Abstract
Pressure injury treatments are tailored to the characteristics of the wound. Wound depth, exudate, presence of infection, and patient goals of care will guide appropriate dressing and treatment selection. The interprofessional team, patient, and family should collaborate to create a plan of care for wound healing.
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Affiliation(s)
- Andrea L Roufogalis
- Wound Care Team, VA Puget Sound Healthcare System, 1660 South Columbian Way, B1 R330 Seattle WA 98108, USA
| | - Melissa L Hutchinson
- Wound Care Team, VA Puget Sound Healthcare System, 1660 South Columbian Way, B1 R330 Seattle WA 98108, USA.
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5
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Han JJ, Luc JGY, Pak E. Ethical Dilemmas Associated With the COVID-19 Pandemic: Dealing With the Unknowns and Unanswerables During Training. J Am Coll Cardiol 2020; 76:1266-1269. [PMID: 32883420 PMCID: PMC7458529 DOI: 10.1016/j.jacc.2020.07.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Jason J Han
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Jessica G Y Luc
- Division of Cardiovascular Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Esther Pak
- Division of Cardiology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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6
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Slavin SD, Warraich HJ. El momento óptimo para comenzar los cuidados paliativos en insuficiencia cardiaca: una revisión narrativa. Rev Esp Cardiol 2020. [DOI: 10.1016/j.recesp.2019.07.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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7
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The right time for palliative care in heart failure: a review of critical moments for palliative care intervention. ACTA ACUST UNITED AC 2019; 73:78-83. [PMID: 31611151 DOI: 10.1016/j.rec.2019.07.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 07/30/2019] [Indexed: 01/11/2023]
Abstract
Heart failure (HF) is a progressive condition with high mortality and heavy symptom burden. Despite guideline recommendations, cardiologists refer to palliative care at rates much lower than other specialties and very late in the course of the disease, often in the final 3 days of life. One reason for delayed referral is that prognostication is challenging in patients with HF, making it unclear when and how the limited resources of specialist palliative care will be most beneficial. It might be more prudent to consider palliative care referrals at critical moments in the trajectory of patients with HF. These include: a) the development of poor prognostic signs in the outpatient setting; b) hospitalization or intensive care unit admission, and c) at the time of evaluation for certain procedures, such as left ventricular assist device placement and ablation for refractory ventricular arrhythmias, among others. In this review, we also summarize the results of clinical trials evaluating palliative interventions in these settings.
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8
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Erikson A, Puntillo K, McAdam J. Family members' opinions about bereavement care after cardiac intensive care unit patients' deaths. Nurs Crit Care 2019; 24:209-221. [DOI: 10.1111/nicc.12439] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 04/30/2019] [Accepted: 05/02/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Alyssa Erikson
- Department of NursingCalifornia State University Monterey Bay, Seaside California
| | - Kathleen Puntillo
- Department of NursingUniversity of California San Francisco California
| | - Jennifer McAdam
- Department of NursingSamuel Merritt University Oakland California
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9
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Boriani G, Fauchier L, Aguinaga L, Beattie JM, Blomstrom Lundqvist C, Cohen A, Dan GA, Genovesi S, Israel C, Joung B, Kalarus Z, Lampert R, Malavasi VL, Mansourati J, Mont L, Potpara T, Thornton A, Lip GYH, Gorenek B, Marin F, Dagres N, Ozcan EE, Lenarczyk R, Crijns HJ, Guo Y, Proietti M, Sticherling C, Huang D, Daubert JP, Pokorney SD, Cabrera Ortega M, Chin A. European Heart Rhythm Association (EHRA) consensus document on management of arrhythmias and cardiac electronic devices in the critically ill and post-surgery patient, endorsed by Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Cardiac Arrhythmia Society of Southern Africa (CASSA), and Latin American Heart Rhythm Society (LAHRS). Europace 2018; 21:7-8. [DOI: 10.1093/europace/euy110] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 04/26/2018] [Indexed: 02/05/2023] Open
Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Laurent Fauchier
- Centre Hospitalier Universitaire Trousseau et Université François Rabelais, Tours, France
| | | | - James M Beattie
- Cicely Saunders Institute, King’s College London, London, UK
| | | | | | - Gheorghe-Andrei Dan
- Cardiology Department, University of Medicine and Pharmacy “Carol Davila”, Colentina University Hospital, Bucharest, Romania
| | - Simonetta Genovesi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano and Nephrology Unit, San Gerardo Hospital, Monza, Italy
| | - Carsten Israel
- Evangelisches Krankenhaus Bielefeld GmbH, Bielefeld, Germany
| | - Boyoung Joung
- Cardiology Division, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Zbigniew Kalarus
- SMDZ in Zabrze, Medical University of Silesia, Katowice; Department of Cardiology, Silesian Center for Heart Diseases, Zabrze, Poland
| | | | - Vincenzo L Malavasi
- Cardiology Division, Department of Nephrologic, Cardiac, Vascular Diseases, Azienda ospedaliero-Universitaria di Modena, Modena, Italy
| | - Jacques Mansourati
- University Hospital of Brest and University of Western Brittany, Brest, France
| | - Lluis Mont
- Arrhythmia Section, Cardiovascular Clínical Institute, Hospital Clinic, Universitat Barcelona, Barcelona, Spain
| | - Tatjana Potpara
- School of Medicine, Belgrade University, Belgrade, Serbia
- Cardiology Clinic, Clinical Centre of Serbia, Belgrade, Serbia
| | | | - Gregory Y H Lip
- Institute of Cardiovascular Sciences, University of Birmingham, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | | | | | | | - Radosław Lenarczyk
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Harry J Crijns
- Cardiology Maastricht UMC+ and Cardiovascular Research Institute Maastricht, Netherlands
| | - Yutao Guo
- Chinese PLA General Hospital, Beijing, People’s Republic of China
| | - Marco Proietti
- Institute of Cardiovascular Sciences, University of Birmingham, UK
- Department of Internal Medicine and Medical Specialties, Sapienza-University of Rome, Rome, Italy
| | | | - Dejia Huang
- Cardiology Division, Department of Medicine, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | | | - Sean D Pokorney
- Electrophysiology Section, Division of Cardiology, Duke University, Durham, NC, USA
| | - Michel Cabrera Ortega
- Department of Arrhythmia and Cardiac Pacing, Cardiocentro Pediatrico William Soler, Boyeros, La Havana Cuba
| | - Ashley Chin
- Department of Medicine, Groote Schuur Hospital, University of Cape Town, South Africa
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10
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Williams SB, Dahnke MD. Clarification and Mitigation of Ethical Problems Surrounding Withdrawal of Extracorporeal Membrane Oxygenation. Crit Care Nurse 2018; 36:56-65. [PMID: 27694358 DOI: 10.4037/ccn2016504] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is temporary life-support technology that provides time to rest the cardiac and respiratory system of critically ill people with acute, reversible medical conditions. Health care providers face emotional and challenging situations, where death may result, when withdrawing ECMO. A deepening of understanding of the ethical issues involved can aid clinicians in handling such difficult situations, leading to a possible mitigation of the moral problems. Toward this end, the ethical issues raised in the consideration of ECMO withdrawal are analyzed with respect to the ethical principles and concepts of autonomy, nonmaleficence/beneficence, medical futility, moral distress, and justice. In particular, these issues are considered in relation to how they affect and can be addressed by staff nurses and advanced practice nurses in the intensive care unit. Advanced practice nurses in particular can represent the voice of nurses to promote a healthier workplace in situations of moral distress related to stopping ECMO life-support technology and in developing clear and consistent guidelines for ceasing ECMO treatment, all leading toward clarification and mitigation of the ethical problems surrounding the withdrawal of this critical technology.
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Affiliation(s)
- Susan B Williams
- Susan B. Williams is an expert intensive care nurse and clinical specialist in extracorporeal membrane oxygenation who worked for 25 years in the newborn/infant intensive care unit at The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.Michael Dahnke is a bioethicist and adjunct instructor in the School of Nursing at the College of New Rochelle, New Rochelle, New York, and adjunct instructor in the philosophy department at the College of Staten Island, New York, New York
| | - Michael D Dahnke
- Susan B. Williams is an expert intensive care nurse and clinical specialist in extracorporeal membrane oxygenation who worked for 25 years in the newborn/infant intensive care unit at The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.Michael Dahnke is a bioethicist and adjunct instructor in the School of Nursing at the College of New Rochelle, New Rochelle, New York, and adjunct instructor in the philosophy department at the College of Staten Island, New York, New York.
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11
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Brady DR. Planning for Deactivation of Implantable Cardioverter Defibrillators at the End of Life in Patients With Heart Failure. Crit Care Nurse 2018; 36:24-31. [PMID: 27908943 DOI: 10.4037/ccn2016362] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Implantable cardioverter defibrillators (ICDs) may be burdensome in end-stage heart failure. At the end of life, as many as one-fifth to one-third of patients experience an ICD shock. Critical care nurses should be aware of the potential burden of these shocks at the end of life as well as the ethics and organizational policies surrounding ICD deactivation. This literature review examines the issues surrounding ICD therapy at the end of life. Based on this author's findings, recommendations for discussing and implementing ICD deactivation are offered. Health care organizations should have clear policies addressing ICD deactivation to provide for seamless integration of palliative care services throughout the course of heart failure. These policies should empower nurses to activate resources in a timely manner and should clearly outline processes for ICD deactivation.
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Affiliation(s)
- Destiny R Brady
- Destiny R. Brady teaches critical care nursing at Saint Anselm College in Manchester, New Hampshire.
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12
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Bonnefoy-Cudraz E, Bueno H, Casella G, De Maria E, Fitzsimons D, Halvorsen S, Hassager C, Iakobishvili Z, Magdy A, Marandi T, Mimoso J, Parkhomenko A, Price S, Rokyta R, Roubille F, Serpytis P, Shimony A, Stepinska J, Tint D, Trendafilova E, Tubaro M, Vrints C, Walker D, Zahger D, Zima E, Zukermann R, Lettino M. Editor's Choice - Acute Cardiovascular Care Association Position Paper on Intensive Cardiovascular Care Units: An update on their definition, structure, organisation and function. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2017; 7:80-95. [PMID: 28816063 DOI: 10.1177/2048872617724269] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Acute cardiovascular care has progressed considerably since the last position paper was published 10 years ago. It is now a well-defined, complex field with demanding multidisciplinary teamworking. The Acute Cardiovascular Care Association has provided this update of the 2005 position paper on acute cardiovascular care organisation, using a multinational working group. The patient population has changed, and intensive cardiovascular care units now manage a large range of conditions from those simply requiring specialised monitoring, to critical cardiovascular diseases with associated multi-organ failure. To describe better intensive cardiovascular care units case mix, acuity of care has been divided into three levels, and then defining intensive cardiovascular care unit functional organisation. For each level of intensive cardiovascular care unit, this document presents the aims of the units, the recommended management structure, the optimal number of staff, the need for specially trained cardiologists and cardiovascular nurses, the desired equipment and architecture, and the interaction with other departments in the hospital and other intensive cardiovascular care units in the region/area. This update emphasises cardiologist training, referring to the recently updated Acute Cardiovascular Care Association core curriculum on acute cardiovascular care. The training of nurses in acute cardiovascular care is additionally addressed. Intensive cardiovascular care unit expertise is not limited to within the unit's geographical boundaries, extending to different specialties and subspecialties of cardiology and other specialties in order to optimally manage the wide scope of acute cardiovascular conditions in frequently highly complex patients. This position paper therefore addresses the need for the inclusion of acute cardiac care and intensive cardiovascular care units within a hospital network, linking university medical centres, large community hospitals, and smaller hospitals with more limited capabilities.
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Affiliation(s)
| | - Hector Bueno
- 2 Centro Nacional de Investigaciones Cardiovasculares, Cardiology Department, Hospital Universitario 12 de Octubre, Spain
| | - Gianni Casella
- 3 Department of Cardiology, Ospedale Maggiore, Bologna, Italy
| | - Elia De Maria
- 4 Cardiology Unit, Ramazzini Hospital, Carpi (Modena), Italy
| | | | - Sigrun Halvorsen
- 6 Department of Cardiology, Oslo University Hospital Ulleval and University of Oslo, Oslo, Norway
| | | | - Zaza Iakobishvili
- 8 Department of Cardiology, Beilinson Hospital, Rabin Medical Center, Israel
| | | | - Toomas Marandi
- 10 North Estonia Medical Centre, Tallinn and University of Tartu, Tartu, Estonia
| | - Jorge Mimoso
- 11 Department of Cardiology, Centro Hospitalar do Algarve, Faro, Portugal
| | | | | | - Richard Rokyta
- 14 Department of Cardiology, University Hospital and Faculty of Medicine Pilsen, Charles University, Czech Republic
| | - Francois Roubille
- 15 Cardiology Department, University Hospital of Montpellier, France
| | - Pranas Serpytis
- 16 Centre of Cardiology and Angiology, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Avi Shimony
- 17 Department of Cardiology, Soroka University Medical Center,Ben-Gurion University, Israel
| | | | - Diana Tint
- 19 ICCO Clinics, Faculty of Medicine, Transilvania University Brasov, Romania
| | | | - Marco Tubaro
- 21 ICCU, Division of Cardiology, San Filippo Neri Hospital, Rome, Italy
| | | | - David Walker
- 23 East Sussex Healthcare NHS Trust, Hastings, UK
| | - Doron Zahger
- 24 Faculty of Health Sciences, Ben Gurion University of the NegevBeer Sheva, Israel
| | - Endre Zima
- 25 Semmelweis University Heart and Vascular Center, CardiacIntensive Care Unit, Budapest, Hungary
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13
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Barg FK, Kellom K, Ziv T, Hull SC, Suhail-Sindhu S, Kirkpatrick JN. LVAD-DT: Culture of Rescue and Liminal Experience in the Treatment of Heart Failure. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2017; 17:3-11. [PMID: 28112612 DOI: 10.1080/15265161.2016.1265162] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The purpose of this article is to investigate how cultural meanings associated with the left ventricular assist device (LVAD) inform acceptance and experience of this innovative technology when it is used as a destination therapy. We conducted open-ended, semistructured interviews with family caregivers and patients who had undergone LVAD-DT procedures at six U.S. hospitals. A grounded theory approach was used for the analysis. Thirty-nine patients and 42 caregivers participated. Participants described a sense of obligation to undergo the procedure because of its promise for salvation. However, once the device was implanted, patients described being placed into a liminal state of being neither sick nor healthy, with no culturally scripted role. Consideration of end-of-life decisions was complicated by the uncertainties about how patients with LVADs die. Pre-implantation communications among patient, family, and clinicians should take into account the impact of the technology on meaning, identity, and patient experience.
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Affiliation(s)
- Frances K Barg
- a Perelman School of Medicine at the University of Pennsylvania
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14
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Ivascu NS, Tabaie S, Meltzer EC. Ethics. Oncology 2017. [DOI: 10.4018/978-1-5225-0549-5.ch028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
In all areas of medicine physicians are confronted with a myriad ethical problems. It is important that intensivists are well versed on ethical issues that commonly arise in the critical care setting. This chapter will serve to provide a review of common topics, including informed consent, decision-making capacity, and surrogate decision-making. It will also highlight special circumstances related to cardiac surgical critical care, including ethical concerns associated with emerging technologies in cardiac care.
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15
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The ethics of unilateral implantable cardioverter defibrillators and cardiac resynchronization therapy with defibrillator deactivation: patient perspectives. Europace 2016; 19:1343-1348. [DOI: 10.1093/europace/euw227] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 06/28/2016] [Indexed: 11/14/2022] Open
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16
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Wordingham SE, McIlvennan CK, Dionne-Odom JN, Swetz KM. Complex Care Options for Patients With Advanced Heart Failure Approaching End of Life. Curr Heart Fail Rep 2016; 13:20-9. [PMID: 26829929 DOI: 10.1007/s11897-016-0282-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Care for patients with advanced cardiac disease continues to evolve in a complex milieu of therapeutic options, advanced technological interventions, and efforts at improving patient-centered care and shared decision-making. Despite improvements in quality of life and survival with these interventions, optimal supportive care across the advanced illness trajectory remains diverse and heterogeneous. Herein, we outline challenges in prognostication, communication, and caregiving in advanced heart failure and review the unique needs of patients who experience frequent hospitalizations, require chronic home inotropic support, and who have implantable cardioverter-defibrillators and mechanical circulatory support in situ, to name a few.
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Affiliation(s)
- Sara E Wordingham
- Department of Medicine, Division of Hematology/Oncology, Palliative Medicine, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA.
| | - Colleen K McIlvennan
- Section of Advanced Heart Failure and Transplantation, Division of Cardiology, University of Colorado School of Medicine, Aurora and Colorado Cardiovascular Outcomes Research Consortium, Denver, CO, USA.
| | | | - Keith M Swetz
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research, Education, and Clinical Center; Birmingham VA Medical Center; and Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, AL, USA.
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17
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Barik M. In response to Evolutionary change: The new face of Annals of Cardiac Anesthesia. Ann Card Anaesth 2015; 18:416. [PMID: 26139751 PMCID: PMC4881704 DOI: 10.4103/0971-9784.159814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Mayadhar Barik
- Department of Nuclear Medicine and Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
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18
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Lopes RD, Gharacholou SM, Holmes DN, Thomas L, Wang TY, Roe MT, Peterson ED, Alexander KP. Cumulative incidence of death and rehospitalization among the elderly in the first year after NSTEMI. Am J Med 2015; 128:582-90. [PMID: 25660246 DOI: 10.1016/j.amjmed.2014.12.032] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 12/29/2014] [Accepted: 12/30/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Age is associated with outcomes in non-ST-segment elevation myocardial infarction; however, less is known about rehospitalization or death among elderly survivors. We aimed to evaluate mortality and cause-specific rehospitalization rates in this growing population of older adults with ischemic heart disease. METHODS We linked 36,711 patients aged ≥65 years who survived an index non-ST-segment elevation myocardial infarction from the CRUSADE registry to Medicare claims data for follow-up. One-year survival estimates were compared by age group-65-79, 80-84, 85-89, and ≥90 years-and Cox models were used to analyze the association between age and 1-year mortality. RESULTS Death at 1 year increased markedly with age (from 13.3% for 65-79 years to 45.5% for ≥90 years). In contrast, rehospitalization rates at 1 year were similar and high across ages (65-79 years, 52.7%; ≥90 years, 56.5%), with nearly as many noncardiovascular-related as cardiovascular-related rehospitalizations. At 1 year, nonagenarians had substantially higher rates of death with or without preceding rehospitalization and twice the adjusted mortality than the group aged 65-79 years. CONCLUSIONS Evolving care delivery models should consider the high mortality in older adults after a non-ST-segment elevation myocardial infarction. Contrary to expectations, rehospitalization rates do not rise substantially with advancing age, and rehospitalization is often for noncardiac diagnoses.
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Affiliation(s)
- Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC.
| | | | - DaJuanicia N Holmes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Laine Thomas
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Tracy Y Wang
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Matthew T Roe
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
| | - Karen P Alexander
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC
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Naib T, Lahewala S, Arora S, Gidwani U. Palliative care in the cardiac intensive care unit. Am J Cardiol 2015; 115:687-90. [PMID: 25727085 DOI: 10.1016/j.amjcard.2014.12.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 12/11/2014] [Accepted: 12/11/2014] [Indexed: 11/24/2022]
Abstract
Patients admitted to today's cardiac intensive care units (CICUs) have increasingly complex medical conditions; consequently, palliative care is becoming an integral component of their care. Although there is a robust body of literature emanating from other intensive care unit settings, there has been less discussion about the role of palliative care in the CICU. This study examined all admissions to the Mount Sinai Hospital CICU from January 1 through December 31, 2012. Of the 1,368 patients admitted, there were 117 CICU patient deaths. End-of-life discussions were carried out in 85 patients (72.6%) who died during that hospital admission; the primary CICU team led these discussions and helped with decision making in >1/2 of them. For the 85 patients who had goals of care (GOC) discussions, there was a higher rate of redirected GOC toward comfort care or no escalation of care (38.8% vs 3.1%, p <0.001) and withdrawal of life-sustaining treatments, such as mechanical ventilation and vasopressors (23.5% vs 6.3%, p = 0.02) compared with patients for whom no GOC discussions were held. Among patients who had GOC discussions, there was no statistically significant difference for patients who had their mechanical circulatory support, defibrillator, or pacing therapies turned off compared with patients who were not involved in GOC discussions. With the exception of discontinuation of mechanical circulatory support which took place for 6 of the 7 patients in the CICU, end-of-life interventions were split evenly between the palliative care unit and the CICU. There was no difference in CICU length of stay or days to mortality from the time of CICU admission between the 2 groups. In conclusion, our study demonstrates the effect of palliative care and end-of-life decision making in the CICU. As such, we advocate for increased palliative care education and training among clinicians who are involved in cardiac critical care.
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Fenstad ER, Shanafelt TD, Sloan JA, Novotny PJ, Durst LA, Frantz RP, McGoon MD, Swetz KM. Physician attitudes toward palliative care for patients with pulmonary arterial hypertension: results of a cross-sectional survey. Pulm Circ 2015; 4:504-10. [PMID: 25621164 DOI: 10.1086/677365] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 04/16/2014] [Indexed: 11/03/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a chronic, symptomatic, life-threatening illness; however, it is complex, with variable expression regarding impact on quality of life (QOL). This study investigated attitudes and comfort of physicians regarding palliative care (PC) for patients with PAH and explored potential barriers to PC in PAH. An internet-based, mixed-methods survey was distributed to Pulmonary Hypertension Clinicians and Researchers, a professional organization within the Pulmonary Hypertension Association. Only responses from physicians involved in clinical care of patients with PAH were analyzed. Of 355 clinicians/researchers, 79 (22%) returned surveys, including 76 (21%) providers involved in clinical care. Responding physicians were mainly pulmonologists (67%), practiced in university/academic medical centers (89%), had been in practice a mean of 12 ± 7 years, cared for a median of 100 PAH patients per year, and reported a high level of confidence in managing PAH (87%), advanced PAH-specific pharmacologic interventions (95%), and end-of-life care (88%). Smaller proportions were comfortable managing pain (62%) and QOL issues (78%). Most physicians (91%) reported utilizing PC consultation at least once in the prior year, primarily in the setting of end-of-life/active dying (59%), hospice referral (46%), or symptomatic dyspnea/impaired QOL (40%). The most frequent reasons for not referring patients to PC included nonapproval by the patient/family (51%) and concern that PC is "giving up hope" (43%). PAH may result in symptoms that impair QOL despite optimal PAH therapy; however, PC awareness and utilization for PAH providers is low. Opportunities may exist to integrate PC into care for PAH patients.
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Affiliation(s)
- Eric R Fenstad
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Tait D Shanafelt
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeff A Sloan
- Section of Cancer Center Statistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Paul J Novotny
- Section of Cancer Center Statistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Louise A Durst
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert P Frantz
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael D McGoon
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Keith M Swetz
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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