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Cortegiani A, Ippolito M, Mercadante S. End-of-life Care in the Intensive Care Unit and Ethics of Withholding/Withdrawal of Life-sustaining Treatments. Anesthesiol Clin 2024; 42:407-419. [PMID: 39054016 DOI: 10.1016/j.anclin.2024.02.008] [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] [Indexed: 07/27/2024]
Abstract
The medical progress has produced improvements in critically ill patients' survival to early phases of life-threatening diseases, thus producing long intensive care stays and persisting disability, with uncertain long-term survival rates and quality of life. Thus, compassionate end-of-life care and the provision of palliative care, even overlapping with the most aggressive of curative intensive care unit (ICU) care has become crucial. Moreover, withdrawal or withholding of life-sustaining treatment may be adopted, allowing unavoidable deaths to occur, without prolonging agony or ICU stay. Our aim was to summarize the key element of end-of-life care in the ICU and the ethics of withholding/withdrawal life-sustaining treatments.
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Affiliation(s)
- Andrea Cortegiani
- Department of Precision Medicine in Medical, Surgical and Critical Care Area (Me.Pre.C.C.), University of Palermo, Palermo, Italy; Department of Anesthesia Analgesia Intensive Care and Emergency, University Hospital Policlinico 'Paolo Giaccone', Via del vespro 129, Palermo 90127, Italy.
| | - Mariachiara Ippolito
- Department of Precision Medicine in Medical, Surgical and Critical Care Area (Me.Pre.C.C.), University of Palermo, Palermo, Italy; Department of Anesthesia Analgesia Intensive Care and Emergency, University Hospital Policlinico 'Paolo Giaccone', Via del vespro 129, Palermo 90127, Italy
| | - Sebastiano Mercadante
- Main Regional Center of Pain Relief and Supportive/palliative Care, Nutrition (S.M.), La Maddalena Cancer Center, Via San Lorenzo, 312/D, Palermo 90146, Italy
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Feldman C, Joynt GM, Mentzelopoulos SD, Sprung CL, Avidan A, Richards GA. Limitations of life-sustaining therapies in South Africa. J Crit Care 2024; 82:154797. [PMID: 38554544 DOI: 10.1016/j.jcrc.2024.154797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/18/2024] [Accepted: 03/19/2024] [Indexed: 04/01/2024]
Abstract
PURPOSE Limitations of life sustaining therapies (LLST) are frequent in intensive care units (ICUs), but no previous studies have examined end-of-life (EOL) care and LLST in South Africa (SA). MATERIALS AND METHODS This study evaluated LLST in SA from the data of a prospective, international, multicentre, observational study (Ethicus-2) and compared practices with countries in the rest of the world. RESULTS LLST was relatively common in SA, and withholding was more frequent than withdrawing therapy. However, withdrawing and withholding therapy were less common, while failed CPR was more common, than in many other countries. No patients had an advance directive. Primary reasons for LLST in SA were poor quality of life, multisystem organ failure and patients' unresponsiveness to maximal therapy. Primary considerations for EOL decision-making were good medical practice and patients' best-interest, with the need for an ICU bed only rarely considered. CONCLUSIONS Withholding was more common than withdrawing treatment both in SA and worldwide, although both were significantly less frequent in SA compared with the world average.
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Affiliation(s)
- Charles Feldman
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Gavin M Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, China
| | - Spyros D Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelsimos General Hospital, Athens, Greece
| | - Charles L Sprung
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Alexander Avidan
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Guy A Richards
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Lissak IA, Young MJ. Limitation of life sustaining therapy in disorders of consciousness: ethics and practice. Brain 2024; 147:2274-2288. [PMID: 38387081 PMCID: PMC11224617 DOI: 10.1093/brain/awae060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 02/01/2024] [Accepted: 02/08/2024] [Indexed: 02/24/2024] Open
Abstract
Clinical conversations surrounding the continuation or limitation of life-sustaining therapies (LLST) are both challenging and tragically necessary for patients with disorders of consciousness (DoC) following severe brain injury. Divergent cultural, philosophical and religious perspectives contribute to vast heterogeneity in clinical approaches to LLST-as reflected in regional differences and inter-clinician variability. Here we provide an ethical analysis of factors that inform LLST decisions among patients with DoC. We begin by introducing the clinical and ethical challenge and clarifying the distinction between withdrawing and withholding life-sustaining therapy. We then describe relevant factors that influence LLST decision-making including diagnostic and prognostic uncertainty, perception of pain, defining a 'good' outcome, and the role of clinicians. In concluding sections, we explore global variation in LLST practices as they pertain to patients with DoC and examine the impact of cultural and religious perspectives on approaches to LLST. Understanding and respecting the cultural and religious perspectives of patients and surrogates is essential to protecting patient autonomy and advancing goal-concordant care during critical moments of medical decision-making involving patients with DoC.
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Affiliation(s)
- India A Lissak
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Michael J Young
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
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Choi HR, Ho MH, Lin CC. Navigating tensions when life-sustaining treatment is withdrawn: A thematic synthesis of nurses' and physicians' experiences. J Clin Nurs 2024; 33:2337-2356. [PMID: 38323726 DOI: 10.1111/jocn.17059] [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: 10/08/2023] [Revised: 12/18/2023] [Accepted: 01/23/2024] [Indexed: 02/08/2024]
Abstract
AIM To synthesise nurses' and physicians' experiences with withdrawing life-sustaining treatment in an intensive care unit. DESIGN The chosen methodology is thematic synthesis. The Preferred Reporting Items for Systematic Review and Meta-Analyses and Enhancing Transparency are used in Reporting the Synthesis of Qualitative Research Statement. METHODS AND DATA SOURCES A systematic search is conducted in APA PsycINFO, CINAHL Plus, EMBASE, PubMed and Web of Science following the inclusion and exclusion criteria in April 2023. Two reviewers independently screened and extracted the qualitative data. Subsequently, data analysis was conducted using thematic analysis of qualitative research. This study was not registered with any review registry due to the irrelevance of the data to health-related outcomes. RESULTS From the 16 articles, 267 quotes were extracted and analysed. The findings of the study revealed five analytical themes: (1) tensions between interdependent collaboration and hierarchical roles; (2) tensions between dignified dying or therapeutic perspectives; (3) family members' reflections of patient's wishes; (4) tensions in family members' positions; and (5) double-sidedness of distress. CONCLUSION This study contributes to nursing knowledge by providing a more nuanced understanding of this complex phenomenon of withdrawing life-sustaining treatment. The findings of this study have revealed significant variations globally in the practices surrounding the withdrawal of life-sustaining treatment in intensive care units, emphasising the need for further research to inform clinical practices that cater to diverse contexts. REPORTING METHOD Enhancing Transparency are used in Reporting the Synthesis of Qualitative Research Statement (ENTREQ statement). PATIENT OR PUBLIC CONTRIBUTION Since this study reported a potential collision between the patient's dignified dying and the family member's perceptions and interests, the family member's wishes should be carefully distinguished from the patient's quality of end of life in practice.
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Affiliation(s)
- Hye Ri Choi
- School of Nursing, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Mu-Hsing Ho
- School of Nursing, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Chia-Chin Lin
- Alice Ho Miu Ling Nethersole Charity Foundation, School of Nursing, University of Hong Kong, Pok Fu Lam, Hong Kong
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Asiri A, Alenezi FZ, Tamim H, Sadat M, Bin Humaid F, AlWehaibi W, Al-Dorzi HM, Alzoubi YA, Alanazi SA, Naidu B, Arabi YM. Practice and Predictors of Do-Not-Resuscitate Orders in a Tertiary-Care Intensive Care Unit in Saudi Arabia. Crit Care Res Pract 2024; 2024:5516516. [PMID: 38742230 PMCID: PMC11090671 DOI: 10.1155/2024/5516516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 02/18/2024] [Accepted: 04/13/2024] [Indexed: 05/16/2024] Open
Abstract
Introduction The objective of this study was to describe Do-Not-Resuscitate (DNR) practices in a tertiary-care intensive care unit (ICU) in Saudi Arabia, and determine the predictors and outcomes of patients who had DNR orders. Methods This retrospective cohort study was based on a prospectively collected database for a medical-surgicalIntensive CareDepartment in a tertiary-care center in Riyadh, Saudi Arabia (1999-2017). We compared patients who had DNR orders during the ICU stay with those with "full code." The primary outcome was hospital mortality. The secondary outcomes included ICU mortality, tracheostomy, duration of mechanical ventilation, and length of stay in the ICU and hospital. Results Among 24790 patients admitted to the ICU over the 19-year study period, 3217 (13%) had DNR orders during the ICU stay. Compared to patients with "full code," patients with DNR orders were older (median 67 years [Q1, Q3: 55, 76] versus 57 years [Q1, Q3: 33, 71], p < 0.0001), were more likely to be females (43% versus 38%, p < 0.0001), had worse premorbid functional status (WHO performance status scores 4-5: 606[18.9%] versus 1894[8.8%], p < 0.0001), higher prevalence of comorbid conditions, and higher APACHE II score (median 28 [Q1, Q3: 23, 34] versus 19 [Q1, Q3: 13, 25], p < 0.0001) and were more likely to be mechanically ventilated (83% versus 55%, p < 0.0001). Patients had DNR orders were more likely to die in the ICU (67.8% versus 8.5%, p < 0.0001) and hospital (82.4% versus 18.1%, p < 0.0001). On multivariable logistic regression analysis, the following were associated with an increased likelihood of DNR status: increasing age (odds ratio (OR) 1.01, 95% confidence interval (CI) 1.01-1.02), higher APACHE II score (OR 1.09, 95% CI 1.08-1.10), and worse WHO performance status score. Patients admitted in recent years (2012-2017 versus 2002-2005) were less likely to have DNR orders (OR 0.35, 95% CI 0.32-0.39, p < 0.0001). Patients with DNR orders had higher ICU mortality, more tracheostomies, longer duration of mechanical ventilation and length of ICU stay compared to patients with with "full code" but they had shorter length of hospital stay. Conclusion In a tertiary-care hospital in Saudi Arabia, 13% of critically ill patients had DNR orders during ICU stay. This study identified several predictors of DNR orders, including the severity of illness and poor premorbid functional status.
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Affiliation(s)
- Abdulrahman Asiri
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Farhan Zayed Alenezi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Hani Tamim
- American University of Beirut Medical Center, Clinical Research Institute, Beirut, Lebanon
- AlFaisal University, College of Medicine, Riyadh, Saudi Arabia
| | - Musharaf Sadat
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Felwa Bin Humaid
- King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Wedyan AlWehaibi
- King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Hasan M. Al-Dorzi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Yasir Adnan Alzoubi
- King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Samiyah Alrawey Alanazi
- King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Brintha Naidu
- King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | - Yaseen M. Arabi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
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Lou Y. End-of-life care discussions with healthcare providers and dying experiences: A latent class analysis using the health and retirement study. Arch Gerontol Geriatr 2024; 119:105319. [PMID: 38171033 DOI: 10.1016/j.archger.2023.105319] [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: 10/03/2023] [Revised: 12/12/2023] [Accepted: 12/17/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND The impact of provider-patient end-of-life care conversations on the dying experience as a multi-dimensional concept among non-White population is understudied. The study examines whether such discussions are effective at improving end-of-life experiences among U.S. older adults with diverse backgrounds. METHODS The analytic sample featured 9,733 older adults who died between 2002 and 2019 in the Health and Retirement Study. Latent class analysis was used with sixteen end-of-life indicators, including service utilization of seven aggressive and supportive care, symptom management, and quality of care. Multinomial logistic regression was conducted to estimate the effects of provider-patient end-of-life discussions on the predicted membership. RESULTS Three types of end-of-life experiences were identified. People in "minimum service user with good death" (44.54 %) were least likely to use any type of medical care, either aggressive or comforting, and had best end-of-life symptom management and quality of care. Intensive care users (20.70 %) are characterized by very high use of aggressive treatments and low use of supportive care. "Extensive service user with uncomfortable death" (34.76 %) had high likelihoods of using both aggressive and comforting care and had the worst dying experience. Older adults who discussed their end-of-life wishes with providers were 49 % and 51 % more likely to be an intensive care user and extensive service user with uncomfortable death, respectively, rather than a minimum service user with good death. CONCLUSION Discussing end-of-life care wishes with providers is associated with worse end-of-life experiences. Efforts are needed to facilitate early initiation and effectiveness of the provider-patient end-of-life care conversation.
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Affiliation(s)
- Yifan Lou
- School of Medicine, Department of Internal Medicine, Yale University, 300 George, 7th Floor, New Haven, CT 06511, United States.
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Fong C, Kueh WL, Lew SJW, Ho BCH, Wong YL, Lau YH, Chia YW, Tan HL, Seet YHC, Siow WT, MacLaren G, Agrawal R, Lim TJ, Lim SL, Lim TW, Ho VK, Soh CR, Sewa DW, Loo CM, Khan FA, Tan CK, Gokhale RS, Siau C, Lim NLSH, Yim CF, Venkatachalam J, Venkatesan K, Chia NCH, Liew MF, Li G, Li L, Myat SM, Zena Z, Zhuo S, Yueh LL, Tan CSF, Ma J, Yeo SL, Chan YH, Phua J. Predictors and outcomes of withholding and withdrawal of life-sustaining treatments in intensive care units in Singapore: a multicentre observational study. J Intensive Care 2024; 12:13. [PMID: 38528556 DOI: 10.1186/s40560-024-00725-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 03/13/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Clinical practice guidelines on limitation of life-sustaining treatments (LST) in the intensive care unit (ICU), in the form of withholding or withdrawal of LST, state that there is no ethical difference between the two. Such statements are not uniformly accepted worldwide, and there are few studies on LST limitation in Asia. This study aimed to evaluate the predictors and outcomes of withholding and withdrawal of LST in Singapore, focusing on the similarities and differences between the two approaches. METHODS This was a multicentre observational study of patients admitted to 21 adult ICUs across 9 public hospitals in Singapore over an average of three months per year from 2014 to 2019. The primary outcome measures were withholding and withdrawal of LST (cardiopulmonary resuscitation, invasive mechanical ventilation, and vasopressors/inotropes). The secondary outcome measure was hospital mortality. Multivariable generalised mixed model analysis was used to identify independent predictors for withdrawal and withholding of LST and if LST limitation predicts hospital mortality. RESULTS There were 8907 patients and 9723 admissions. Of the former, 80.8% had no limitation of LST, 13.0% had LST withheld, and 6.2% had LST withdrawn. Common independent predictors for withholding and withdrawal were increasing age, absence of chronic kidney dialysis, greater dependence in activities of daily living, cardiopulmonary resuscitation before ICU admission, higher Acute Physiology and Chronic Health Evaluation (APACHE) II score, and higher level of care in the first 24 h of ICU admission. Additional predictors for withholding included being of Chinese race, the religions of Hinduism and Islam, malignancy, and chronic liver failure. The additional predictor for withdrawal was lower hospital paying class (with greater government subsidy for hospital bills). Hospital mortality in patients without LST limitation, with LST withholding, and with LST withdrawal was 10.6%, 82.1%, and 91.8%, respectively (p < 0.001). Withholding (odds ratio 13.822, 95% confidence interval 9.987-19.132) and withdrawal (odds ratio 38.319, 95% confidence interval 24.351-60.298) were both found to be independent predictors of hospital mortality on multivariable analysis. CONCLUSIONS Differences in the independent predictors of withholding and withdrawal of LST exist. Even after accounting for baseline characteristics, both withholding and withdrawal of LST independently predict hospital mortality. Later mortality in patients who had LST withdrawn compared to withholding suggests that the decision to withdraw may be at the point when medical futility is recognised.
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Affiliation(s)
- Clare Fong
- FAST and Chronic Programmes, Alexandra Hospital, 378 Alexandra Road, Singapore, 159964, Singapore.
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore.
| | - Wern Lunn Kueh
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Sennen Jin Wen Lew
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Benjamin Choon Heng Ho
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Yu-Lin Wong
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Yie Hui Lau
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Yew Woon Chia
- Cardiac Intensive Care Unit, Department of Cardiology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Hui Ling Tan
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Ying Hao Christopher Seet
- Department of Neurology, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Wen Ting Siow
- FAST and Chronic Programmes, Alexandra Hospital, 378 Alexandra Road, Singapore, 159964, Singapore
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Graeme MacLaren
- Cardiothoracic ICU, Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Rohit Agrawal
- Department of Anaesthesia, National University Hospital, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| | - Tian Jin Lim
- Department of Anaesthesia, National University Hospital, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| | - Shir Lynn Lim
- Department of Cardiology, National University Heart Centre, 1E Kent Ridge Road, Singapore, 119228, Singapore
- Department of Medicine, National University of Singapore, 1E Kent Ridge Road, Singapore, 119228, Singapore
- Pre-Hospital and Emergency Research Center, Duke-NUS Medical School, 8 College Rd, Singapore, 16985, Singapore
| | - Toon Wei Lim
- Department of Cardiology, National University Heart Centre, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Vui Kian Ho
- Department of Intensive Care Medicine, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
- Department of Surgical Intensive Care, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Chai Rick Soh
- Department of Anaesthesiology, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Duu Wen Sewa
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Chian Min Loo
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Faheem Ahmed Khan
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - Chee Keat Tan
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - Roshni Sadashiv Gokhale
- Department of Intensive Care, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore
| | - Chuin Siau
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore
| | - Noelle Louise Siew Hua Lim
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, 2 Simei Street 3, Singapore, 529889, Singapore
| | - Chik-Foo Yim
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Jonathen Venkatachalam
- Department of Respiratory and Critical Care Medicine, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore
| | - Kumaresh Venkatesan
- Department of Anaesthesia, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore
| | - Naville Chi Hock Chia
- Department of Anaesthesia, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore, 768828, Singapore
- Yong Loo Lin School of Medicine, 10 Medical Dr, Singapore, 117597, Singapore
- Lee Kong Chian School of Medicine, 11 Mandalay Rd, Singapore, 308232, Singapore
| | - Mei Fong Liew
- FAST and Chronic Programmes, Alexandra Hospital, 378 Alexandra Road, Singapore, 159964, Singapore
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Guihong Li
- Department of Intensive Care Unit Operations, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Li Li
- Department of Intensive Care Unit Operations, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Su Mon Myat
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Zena Zena
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore
| | - Shuling Zhuo
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - Ling Ling Yueh
- Department of Intensive Care Medicine, Ng Teng Fong General Hospital, 1 Jurong East Street 21, Singapore, 609606, Singapore
| | - Caroline Shu Fang Tan
- Department of Intensive Care Medicine, Sengkang General Hospital, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Jing Ma
- Division of Nursing, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Siew Lian Yeo
- Division of Nursing, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Jason Phua
- FAST and Chronic Programmes, Alexandra Hospital, 378 Alexandra Road, Singapore, 159964, Singapore
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
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Choi HR, Ho MH, Lin CC. Futile life-sustaining treatment in the intensive care unit - nurse and physician experiences: meta-synthesis. BMJ Support Palliat Care 2024; 14:36-46. [PMID: 38050047 DOI: 10.1136/spcare-2023-004640] [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: 10/10/2023] [Accepted: 11/19/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Continuing futile life-sustaining treatment prolongs patients' suffering and family members' and medical staff's psychological distress. Additionally, continuing futile treatment is inefficient in healthcare resource distribution. Although the withdrawal of futile life-sustaining treatment is ideal, the prevalence is variable. OBJECTIVE To synthesise nurses' and physicians' experiences with continuing futile life-sustaining treatment in the intensive care unit. DESIGN This meta-synthesis was conducted following the thematic synthesis. The Preferred Reporting Items for Systematic Review and Meta-Analyses and Enhancing transparency in reporting the synthesis of qualitative research statement were used in reporting the synthesis of qualitative research statements. METHODS AND DATA SOURCES A systematic search was conducted following the inclusion and exclusion criteria in APA PsycINFO, CINAHL Plus, EMBASE, MEDLINE, PubMed and Web of Science in May 2023. Two reviewers independently screened and extracted the data. The extracted data were analysed using thematic analysis of qualitative research. FINDINGS A total of 16 studies were finally included, and 141 quotes were extracted and analysed. The main findings were categorised into four themes: (1) contextual and cultural diversity, (2) perceptions of futile treatment, (3) professional roles and responsibilities, and (4) emotional distress. CONCLUSION The study highlights the influence of culture, religion and family members, as well as perceptions of futile treatment among clinicians, on continuing futile life-sustaining treatment. Also, nurses' awareness of their roles and responsibilities in ensuring patients' comfort at end of life was revealed. This study informs future research to explore the experiences of futile life-sustaining treatment across various contexts.
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Affiliation(s)
- Hye Ri Choi
- School of Nursing, University of Hong Kong, Hong Kong, Hong Kong
| | - Mu-Hsing Ho
- School of Nursing, University of Hong Kong, Hong Kong, Hong Kong
| | - Chia-Chin Lin
- School of Nursing, University of Hong Kong, Hong Kong, Hong Kong
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Guidet B, Vallet H, Flaatten H, Joynt G, Bagshaw SM, Leaver SK, Beil M, Du B, Forte DN, Angus DC, Sviri S, de Lange D, Herridge MS, Jung C. The trajectory of very old critically ill patients. Intensive Care Med 2024; 50:181-194. [PMID: 38236292 DOI: 10.1007/s00134-023-07298-z] [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: 10/02/2023] [Accepted: 11/27/2023] [Indexed: 01/19/2024]
Abstract
The demographic shift, together with financial constraint, justify a re-evaluation of the trajectory of care of very old critically ill patients (VIP), defined as older than 80 years. We must avoid over- as well as under-utilisation of critical care interventions in this patient group and ensure the inclusion of health care professionals, the patient and their caregivers in the decision process. This new integrative approach mobilises expertise at each step of the process beginning prior to intensive care unit (ICU) admission and extending to long-term follow-up. In this review, several international experts have contributed to provide recommendations that can be universally applied. Our aim is to define a minimum core dataset of information to be shared and discussed prior to ICU admission and to facilitate the shared-decision-making process with the patient and their caregivers, throughout the patient journey. Documentation of uncertainty may contribute to a tailored level of care and ultimately to discussions around possible limitations of life sustaining treatments. The goal of ICU care is not only to avoid death, but more importantly to maintain an acceptable quality of life and functional autonomy after hospital discharge. Societal consideration is important to highlight, together with alternatives to ICU admission. We discuss challenges for the future and potential areas of research. In summary, this review provides a state-of-the-art current overview and aims to outline future directions to address the challenges in the treatment of VIP.
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Affiliation(s)
- Bertrand Guidet
- Medical ICU, Assistance Publique, Hôpitaux de Paris, Hôpital Saint-Antoine, Service de Réanimation Médicale, 75012, Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, 75013, Paris, France.
| | - Helene Vallet
- Department of Geriatrics, Sorbonne Université, Institut National de la Santé Et de la Recherche Médicale (INSERM), UMRS 1135, Centre d'immunologie et de Maladies Infectieuses (CIMI), Saint Antoine, Assistance Publique Hôpitaux de Paris (AP-HP), 75012, Paris, France
| | - Hans Flaatten
- Department of Clinical Medicine, Haukeland University Hospital, University of Bergen, Department of Research and Development, Haukeland University Hospital, Bergen, Norway
| | - Gavin Joynt
- Department of Anaesthesia and Intensive Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Canada
| | | | - Michael Beil
- Department of Medical Intensive Care, Faculty of Medicine, Hebrew University and Hadassah University Medical Center, Jerusalem, Israel
| | - Bin Du
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Daniel N Forte
- Departament of Emergency Medicine, Faculdade de Medicina, Universidade de São Paulo, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Derek C Angus
- Critical Care Medicine, UPMC and University of Pittsburgh, Pittsburgh, USA
| | - Sigal Sviri
- Department of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Dylan de Lange
- Department of Intensive Care Medicine, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Margaret S Herridge
- Interdepartmental Division of Critical Care Medicine, Critical Care and Respiratory Medicine, University Health Network, Toronto General Research Institute, Institute of Medical Sciences, University of Toronto, Toronto, Canada
| | - Christian Jung
- Department of Cardiology, Pulmonology and Angiology, University Hospital, Düsseldorf, Germany
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10
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Strandberg G, Lipcsey M. Association of socioeconomic and demographic factors with limitations of life sustaining treatment in the intensive care unit. Intensive Care Med 2023; 49:1249-1250. [PMID: 37580572 DOI: 10.1007/s00134-023-07177-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/24/2023] [Indexed: 08/16/2023]
Affiliation(s)
- Gunnar Strandberg
- Department of Surgical Sciences, Cardiothoracic Surgery and Anesthesiology, Uppsala University, Uppsala, Sweden.
| | - Miklós Lipcsey
- Department of Surgical Sciences, Anesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden
- Department of Surgical Sciences, Hedenstierna Laboratory, Uppsala University, Uppsala, Sweden
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11
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Burns KEA, Cook DJ, Xu K, Dodek P, Villar J, Jones A, Kapadia FN, Gattas DJ, Epstein SK, Pelosi P, Kefala K, Meade MO, Rizvi L. Differences in directives to limit treatment and discontinue mechanical ventilation between elderly and very elderly patients: a substudy of a multinational observational study. Intensive Care Med 2023; 49:1181-1190. [PMID: 37736783 DOI: 10.1007/s00134-023-07188-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 08/01/2023] [Indexed: 09/23/2023]
Abstract
PURPOSE The aim of this study was to characterize differences in directives to limit treatments and discontinue invasive mechanical ventilation (IMV) in elderly (65-80 years) and very elderly (> 80 years) intensive care unit (ICU) patients. METHODS We prospectively described new written orders to limit treatments, IMV discontinuation strategies [direct extubation, direct tracheostomy, spontaneous breathing trial (SBT), noninvasive ventilation (NIV) use], and associations between initial failed SBT and outcomes in 142 ICUs from 6 regions (Canada, India, United Kingdom, Europe, Australia/New Zealand, United States). RESULTS We evaluated 788 (586 elderly; 202 very elderly) patients. Very elderly (vs. elderly) patients had similar withdrawal orders but significantly more withholding orders, especially cardiopulmonary resuscitation and dialysis, after ICU admission [67 (33.2%) vs. 128 (21.9%); p = 0.002]. Orders to withhold reintubation were written sooner in very elderly (vs. elderly) patients [4 (2-8) vs. 7 (4-13) days, p = 0.02]. Very elderly and elderly patients had similar rates of direct extubation [39 (19.3%) vs. 113 (19.3%)], direct tracheostomy [10 (5%) vs. 40 (6.8%)], initial SBT [105 (52%) vs. 302 (51.5%)] and initial successful SBT [84 (80%) vs. 245 (81.1%)]. Very elderly patients experienced similar ICU outcomes (mortality, length of stay, duration of ventilation) but higher hospital mortality [26 (12.9%) vs. 38 (6.5%)]. Direct tracheostomy and initial failed SBT were associated with worse outcomes. Regional differences existed in withholding orders at ICU admission and in withholding and withdrawal orders after ICU admission. CONCLUSIONS Very elderly (vs. elderly) patients had more orders to withhold treatments after ICU admission and higher hospital mortality, but similar ICU outcomes and IMV discontinuation. Significant regional differences existed in withholding and withdrawal practices.
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Affiliation(s)
- Karen E A Burns
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada.
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Unity Health Toronto, St Michael's Hospital, 30 Bond St, Office 4-045 Donnelly Wing, Toronto, ON, M5B 1W8, Canada.
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada.
- Departments of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.
| | - Deborah J Cook
- Departments of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
- Division of Critical Care Medicine, St Joseph's Hospital, Hamilton, Canada
| | - Keying Xu
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
- Applied Health Research Centre, St Michael's Hospital, Toronto, Canada
| | - Peter Dodek
- Division of Critical Care Medicine, Centre for Health Evaluation and Outcome Sciences, St Paul's Hospital, Vancouver, BC, Canada
- University of British Columbia, Vancouver, BC, Canada
| | - Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Multidisciplinary Organ Dysfunction Evaluation Research Network, Research Unit, Hospital Universitario Dr Negrin, Las Palmas de Gran Canaria, Spain
| | - Andrew Jones
- Department of Critical Care Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Farhad N Kapadia
- Department of Intensive Care, Hinduja National Hospital, Bombay, India
| | - David J Gattas
- Intensive Care Unit, Royal Prince Alfred Hospital, University of Sydney, Camperdown, NSW, Australia
- The George Institute for Global Health, Sydney, Australia
| | | | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Kallirroi Kefala
- Anaesthesia, Critical Care and Pain Medicine, Edinburgh Royal Infirmary, Edinburgh, Scotland, UK
| | - Maureen O Meade
- Departments of Medicine and Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Leena Rizvi
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, Unity Health Toronto, St Michael's Hospital, 30 Bond St, Office 4-045 Donnelly Wing, Toronto, ON, M5B 1W8, Canada
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12
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da Silva MDAP, Corradi-Perini C. The Mapping of Influencing Factors in the Decision-Making of End-of-Life Care Patients: A Systematic Scoping Review. Indian J Palliat Care 2023; 29:234-242. [PMID: 37700891 PMCID: PMC10493695 DOI: 10.25259/ijpc_292_2022] [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: 12/08/2022] [Accepted: 01/27/2023] [Indexed: 09/14/2023] Open
Abstract
Decisions in end-of-life care are influenced by several factors, many of which are not identified by the decision maker. These influencing factors modify important decisions in this scenario, such as in decisions to adapt to therapeutic support. This presented scoping review aims to map the factors that influence end-of-life care decisions for adult and older adult patients, by a scoping review. The review was carried out in 19 databases, with the keyword 'clinical decision-making' AND 'terminal care' OR 'end-of-life care' and its analogues, including publications from 2017 to 2022. The study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews. The search resulted in 3474 publications, where the presence of influencing factors in end-of-life decision-making for adults and the elderly was applied as a selection criterion. Fifty-four (54) of them were selected, which means 1.5% of all the results. Among the selected publications, 89 influencing factors were found, distributed in 54 (60.6%) factors related to the health team, 18 (20.2%) to patients, 10 (11.2%) related to family or surrogates and 7 (7.8%) factors related to the decision environment. In conclusion, we note that the decision-making in end-of-life care is complex, mainly because there is an interaction of different characters (health team, patient, family, or surrogates) with a plurality of influencing factors, associated with an environment of uncertainty and that result in a critical outcome, with a great repercussion for the end of life, making it imperative the recognition of these factors for more competent and safe decision-making.
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Affiliation(s)
| | - Carla Corradi-Perini
- Bioethics Graduate Program, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
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13
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Akinosoglou K, Schinas G, Almyroudi MP, Gogos C, Dimopoulos G. The impact of age on intensive care. Ageing Res Rev 2023; 84:101832. [PMID: 36565961 PMCID: PMC9769029 DOI: 10.1016/j.arr.2022.101832] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022]
Abstract
Caring for the elderly has always been challenging for the intensive care unit (ICU) physician. Concerns like frailty, comorbidities, polypharmacy and advanced directives come up even before admission into the unit. The COVID-19 pandemic has put forward a variety of issues concerning elderly populations, making the topic more relevant than ever. Admittance to the ICU, an unequivocally multifactorial decision, requires special consideration from the side of the physician when caring for an elderly person. Patients' wishes are to be respected and thus given priority. Triage assessment must also account for age-related physiological alterations and functional status. Once in the ICU, special attention should be given to age-related specificities, such as therapeutic interventions' controversial role, infection susceptibility, and post-operative care, that could potentially alter the course of hospitalization and affect outcomes. Following ICU discharge, ensuring proper rehabilitation for both survivors and their caregivers can improve long-term outcomes and subsequent quality of life. The pandemic and its implications may limit the standard of care for the elderly requiring ICU support. Socioeconomic factors that further perplex the situation must be addressed. Elderly patients currently represent a vast expanding population in ICU. Tailoring safe treatment plans to match patients' wishes, and personalized needs will guide critical care for the elderly from this time forward.
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Affiliation(s)
- Karolina Akinosoglou
- Department of Internal Medicine and Infectious Diseases, Medical School University of Patras, Greece.
| | - Georgios Schinas
- Department of Internal Medicine, Medical School University of Patras, Greece
| | - Maria Panagiota Almyroudi
- Department of Emergency Medicine, University Hospital ATTIKON, Medical School, National and Kapodistrian University of Athens, Greece
| | - Charalambos Gogos
- Department of Internal Medicine and Infectious Diseases, Medical School University of Patras, Greece
| | - George Dimopoulos
- 3rd Department of Critical Care, EVGENIDIO Hospital, National and Kapodistrian University of Athens, Medical School, Greece
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14
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Beil M, van Heerden PV, de Lange DW, Szczeklik W, Leaver S, Guidet B, Flaatten H, Jung C, Sviri S, Joskowicz L. Contribution of information about acute and geriatric characteristics to decisions about life-sustaining treatment for old patients in intensive care. BMC Med Inform Decis Mak 2023; 23:1. [PMID: 36609257 PMCID: PMC9818057 DOI: 10.1186/s12911-022-02094-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 12/23/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Life-sustaining treatment (LST) in the intensive care unit (ICU) is withheld or withdrawn when there is no reasonable expectation of beneficial outcome. This is especially relevant in old patients where further functional decline might be detrimental for the self-perceived quality of life. However, there still is substantial uncertainty involved in decisions about LST. We used the framework of information theory to assess that uncertainty by measuring information processed during decision-making. METHODS Datasets from two multicentre studies (VIP1, VIP2) with a total of 7488 ICU patients aged 80 years or older were analysed concerning the contribution of information about the acute illness, age, gender, frailty and other geriatric characteristics to decisions about LST. The role of these characteristics in the decision-making process was quantified by the entropy of likelihood distributions and the Kullback-Leibler divergence with regard to withholding or withdrawing decisions. RESULTS Decisions to withhold or withdraw LST were made in 2186 and 1110 patients, respectively. Both in VIP1 and VIP2, information about the acute illness had the lowest entropy and largest Kullback-Leibler divergence with respect to decisions about withdrawing LST. Age, gender and geriatric characteristics contributed to that decision only to a smaller degree. CONCLUSIONS Information about the severity of the acute illness and, thereby, short-term prognosis dominated decisions about LST in old ICU patients. The smaller contribution of geriatric features suggests persistent uncertainty about the importance of functional outcome. There still remains a gap to fully explain decision-making about LST and further research involving contextual information is required. TRIAL REGISTRATION VIP1 study: NCT03134807 (1 May 2017), VIP2 study: NCT03370692 (12 December 2017).
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Affiliation(s)
- Michael Beil
- grid.9619.70000 0004 1937 0538Department of Medical Intensive Care, Hadassah Medical Centre and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - P. Vernon van Heerden
- grid.9619.70000 0004 1937 0538Department of Anaesthesia, Intensive Care and Pain Medicine, Hadassah Medical Centre and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Dylan W. de Lange
- grid.7692.a0000000090126352Department of Intensive Care Medicine, University Medical Centre, University Utrecht, Utrecht, The Netherlands
| | - Wojciech Szczeklik
- grid.5522.00000 0001 2162 9631Department of Intensive Care, Jagiellonian University Medical College, Kraków, Poland
| | - Susannah Leaver
- grid.451349.eIntensive Care, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Bertrand Guidet
- grid.50550.350000 0001 2175 4109Service de Réanimation Médicale, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Hans Flaatten
- grid.412008.f0000 0000 9753 1393Intensive Care, Department of Clinical Medicine, Haukeland Universitetssjukehus, Bergen, Norway
| | - Christian Jung
- grid.411327.20000 0001 2176 9917Department of Cardiology, Pulmonology and Vascular Medicine, Faculty of Medicine, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Sigal Sviri
- grid.9619.70000 0004 1937 0538Department of Medical Intensive Care, Hadassah Medical Centre and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Leo Joskowicz
- grid.9619.70000 0004 1937 0538School of Computer Science and Engineering, The Hebrew University of Jerusalem, Jerusalem, Israel
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Giabicani M, Arditty L, Mamzer MF, Fournel I, Ecarnot F, Meunier-Beillard N, Bruneel F, Weiss E, Spranzi M, Rigaud JP, Quenot JP. Team-family conflicts over end-of-life decisions in ICU: A survey of French physicians' beliefs. PLoS One 2023; 18:e0284756. [PMID: 37098023 PMCID: PMC10128920 DOI: 10.1371/journal.pone.0284756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/08/2023] [Indexed: 04/26/2023] Open
Abstract
INTRODUCTION Conflicts between relatives and physicians may arise when decisions are being made about limiting life-sustaining therapies (LST). The aim of this study was to describe the motives for, and management of team-family conflicts surrounding LST limitation decisions in French adult ICUs. METHODS Between June and October 2021, French ICU physicians were invited to answer a questionnaire. The development of the questionnaire followed a validated methodology with the collaboration of consultants in clinical ethics, a sociologist, a statistician and ICU clinicians. RESULTS Among 186 physicians contacted, 160 (86%) answered all the questions. Conflicts over LST limitation decisions were mainly related to requests by relatives to continue treatments considered to be unreasonably obstinate by ICU physicians. The absence of advance directives, a lack of communication, a multitude of relatives, and religious or cultural issues were frequently mentioned as factors contributing to conflicts. Iterative interviews with relatives and proposal of psychological support were the most widely used tools in attempting to resolve conflict, while the intervention of a palliative care team, a local ethics resource or the hospital mediator were rarely solicited. In most cases, the decision was suspended at least temporarily. Possible consequences include stress and psychological exhaustion among caregivers. Improving communication and anticipation by knowing the patient's wishes would help avoid these conflicts. CONCLUSION Team-family conflicts during LST limitation decisions are mainly related to requests from relatives to continue treatments deemed unreasonable by physicians. Reflection on the role of relatives in the decision-making process seems essential for the future.
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Affiliation(s)
- Mikhael Giabicani
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, and Université Paris Cité, Paris, France
- Centre de Recherche des Cordeliers, Sorbonne Université, Université Paris Cité, Inserm, Laboratoire ETREs, Paris, France
| | - Laure Arditty
- Service de Réanimation, Centre Hospitalier Intercommunal des Alpes du Sud, Gap, France
| | - Marie-France Mamzer
- Centre de Recherche des Cordeliers, Sorbonne Université, Université Paris Cité, Inserm, Laboratoire ETREs, Paris, France
- Unité Fonctionnelle d'Ethique Médicale, Hôpital Necker-Enfants Malades, AP-HP, Paris, France
| | - Isabelle Fournel
- CHU Dijon Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
| | - Fiona Ecarnot
- Department of Cardiology, University Hospital Besançon, Besançon, France
- EA3920, Université de Bourgogne-Franche Comté, Besançon, France
| | - Nicolas Meunier-Beillard
- CHU Dijon Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
- DRCI, USMR, CHU Dijon Bourgogne, Dijon, France
| | - Fabrice Bruneel
- Intensive Care Unit, Versailles Hospital Center, Le Chesnay, France
| | - Emmanuel Weiss
- Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP Nord, and Université Paris Cité, Paris, France
| | - Marta Spranzi
- Center for Clinical Ethics, AP-HP, Paris and Université de Versailles Saint-Quentin en Yvelines, Versailles, France
| | - Jean-Philippe Rigaud
- Service de Médecine Intensive Réanimation, CH de Dieppe, Dieppe, France
- Espace de Réflexion Éthique de Normandie, CHU de Caen, Caen, France
| | - Jean-Pierre Quenot
- CHU Dijon Bourgogne, INSERM, Université de Bourgogne, CIC 1432, Module Épidémiologie Clinique, Dijon, France
- Service de Médecine Intensive-Réanimation, CHU Dijon-Bourgogne, Dijon, France
- Equipe Lipness, Centre de Recherche INSERM UMR1231 et LabEx LipSTIC, Université de Bourgogne-Franche Comté, Dijon, France
- Espace de Réflexion Éthique Bourgogne Franche-Comté (EREBFC), Dijon, France
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16
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Burghi G, Metaxa V, Pickkers P, Soares M, Rello J, Bauer PR, van de Louw A, Taccone FS, Loeches IM, Schellongowski P, Rusinova K, Antonelli M, Kouatchet A, Barratt-Due A, Valkonen M, Pène F, Mokart D, Jaber S, Azoulay E, De Jong A. End of life decisions in immunocompromised patients with acute respiratory failure. J Crit Care 2022; 72:154152. [PMID: 36137351 DOI: 10.1016/j.jcrc.2022.154152] [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: 07/29/2022] [Revised: 08/23/2022] [Accepted: 09/05/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE To identify patient, disease and organizational factors associated with decisions to forgo life-sustaining therapies (DFLSTs) in critically ill immunocompromised patients admitted to the intensive care unit (ICU) for acute respiratory failure. MATERIAL AND METHODS We performed a secondary analysis of the international EFRAIM prospective study, which enrolled 1611 immunocompromised patients with acute respiratory failure admitted to 68 ICUs in 16 countries between October 2015 and June 2016. Multivariate logistic analysis was performed to identify independent predictors of DFLSTs. RESULTS The main causes of immunosuppression were hematological malignancies (50%) and solid tumor (38%). Patients had a median age of 63 yo (54-71). A pulmonologist was involved in the patient management in 38% of cases. DFLSTs had been implemented in 28% of the patients. The following variables were independently associated with DFLSTs: 1) patient-related: older age (OR 1.02 per one year increase, 95% confidence interval(CI) 1.01-1.03,P < 0.001), poor performance status (OR 2.79, 95% CI 1.98-3.93, P < 0.001); 2) disease-related: shock (OR 2.00, 95% CI 1.45-2.75, P < 0.001), liver failure (OR 1.59, 95% CI 1.14-2.21, P = 0.006), invasive mechanical ventilation (OR 1.79, 95% CI 1.31-2.46, P < 0.001); 3) organizational: having a pulmonologist involved in patient management (OR 1.85, 95% CI 1.36-2.52, P < 0.001), and the presence of a critical care outreach services (OR 1.63, 95% CI 1.11-2.38, P = 0.012). CONCLUSIONS A DFLST is made in one in four immunocompromised patient admitted to the ICU for acute respiratory failure. Involving a pulmonologist in patient's management is associated with less non beneficial care.
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Affiliation(s)
- Gaston Burghi
- Terapia Intensiva, Hospital Maciel - Montevideo, Uruguay
| | | | - Peter Pickkers
- The Department of Intensive Care Medicine (710), Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Marcio Soares
- Terapia Intensiva, Hospital Maciel - Montevideo, Uruguay
| | - Jordi Rello
- CIBERES, Universitat Autonòma de Barcelona, European Study Group of Infections in Critically Ill Patients (ESGCIP), Barcelona, Spain
| | - Philippe R Bauer
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Andry van de Louw
- Penn State University College of Medicine, Division of Pulmonary and Critical Care, Hershey, PA, USA
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Ignacio Martin Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland
| | | | - Katerina Rusinova
- Department of Anesthesiology and Intensive Care Medicine and Institute for Medical Humanities, 1st Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Massimo Antonelli
- Agostino Gemelli University Hospital, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Achille Kouatchet
- Department of Medical Intensive Care Medicine, University Hospital of Angers, France
| | - Andreas Barratt-Due
- Department of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Miia Valkonen
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki 00014, Finland
| | - Frédéric Pène
- Medical ICU, Cochin Hospital, Assistance Publique-Hôpitaux de Paris and University Paris Descartes, Paris, France
| | - Djamel Mokart
- Réanimation Polyvalente et Département d'Anesthésie et de Réanimation, Institut Paoli-Calmettes, Marseille, France
| | - Samir Jaber
- Department of Anesthesia and Intensive Care unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, Phymedexp, Université de Montpellier, Inserm, CNRS, CHRU de Montpellier, Montpellier, France
| | - Elie Azoulay
- Medical Intensive Care Unit, Hôpital Saint-Louis and Paris Diderot Sorbonne University, 1 avenue Claude Vellefaux, cedex 10 75475, Paris
| | - Audrey De Jong
- Department of Anesthesia and Intensive Care unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, Phymedexp, Université de Montpellier, Inserm, CNRS, CHRU de Montpellier, Montpellier, France.
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17
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Huang J, Qi H, Zhu Y, Zhang M. Factors Influencing the Initiative Behavior of Intensive Care Unit Nurses toward End-of-Life Decision Making: A Cross-Sectional Study. J Palliat Med 2022; 25:1802-1809. [PMID: 35749724 DOI: 10.1089/jpm.2021.0640] [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] [Indexed: 01/04/2023] Open
Abstract
Background: Although the importance of intensive care unit (ICU) nurse initiative in end-of-life (EOL) decision making has been confirmed, there are few studies on the nurses' initiative in EOL situations. Objectives: To explore the role and mechanism of facilitators/barriers and perceived stress on the behavior of ICU nurses that initiate EOL decision making (i.e., initiative behavior). Design: This research adopted a cross-sectional descriptive design. Setting/Participants: A questionnaire composed of demographics, facilitators/barriers scale, perceived stress scale, and initiative behavior for EOL decision-making scale was used for registered ICU nurses in five tertiary general hospitals in Zhejiang Province, China. Results: The average score of the EOL decision initiative behavior was 5.54 on a range of 2-10. The results of correlation analysis indicated that the facilitators promote the initiative behavior, whereas the barriers interfere with initiative behavior. Facilitators/barriers in the EOL decision-making process significantly predicted the initiative behavior of ICU nurses in decision making (β = 0.698, p < 0.001). Facilitators/barriers had a significant indirect effect on the initiative behavior of ICU nurses through perceived stress. The 95% confidence interval was (-0.327 to -0.031), and the mediating effect of perceived stress accounted for 6.31% of the total effect. Conclusion: In the EOL context, the decision initiative of ICU nurses was at a medium level. Medical managers should implement intervention strategies based on the path that affects the initiative behavior of ICU nurses to reduce barriers and stress level in the decision-making process. That is, they should improve inter-team collaboration, nurse-patient communication, clarity of role responsibilities, and emotional support in dying situations to increase initiative and participation of ICU nurses in decision making.
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Affiliation(s)
- Jingying Huang
- Postanesthesia Care Unit, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
| | - Haiou Qi
- Nursing Department, and Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
| | - Yiting Zhu
- Postanesthesia Care Unit, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
| | - Minyan Zhang
- Intensive Care Unit, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
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18
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What do we know about experiencing end-of-life in burn intensive care units? A scoping review. Palliat Support Care 2022:1-17. [PMID: 36254708 DOI: 10.1017/s1478951522001389] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES The aim of this article is to review and synthesize the evidence on end-of-life in burn intensive care units. METHODS Systematic scoping review: Preferred Reporting Items for Systemic Reviews extension for Scoping Reviews was used as a reporting guideline. Searches were performed in 3 databases, with no time restriction and up to September 2021. RESULTS A total of 16,287 documents were identified; 18 were selected for analysis and synthesis. Three key themes emerged: (i) characteristics of the end-of-life in burn intensive care units, including end-of-life decisions, decision-making processes, causes, and trajectories of death; (ii) symptom control at the end-of-life in burn intensive care units focusing on patients' comfort; and (iii) concepts, models, and designs of the care provided to burned patients at the end-of-life, mainly care approaches, provision of care, and palliative care. SIGNIFICANCE OF RESULTS End-of-life care is a major step in the care provided to critically ill burned patients. Dying and death in burn intensive care units are often preceded by end-of-life decisions, namely forgoing treatment and do-not-attempt to resuscitate. Different dying trajectories were described, suggesting the possibility to develop further studies to identify triggers for palliative care referral. Symptom control was not described in detail. Palliative care was rarely involved in end-of-life care for these patients. This review highlights the need for early and high-quality palliative and end-of-life care in the trajectories of critically ill burned patients, leading to an improved perception of end-of-life in burn intensive care units. Further research is needed to study the best way to provide optimal end-of-life care and foster integrated palliative care in burn intensive care units.
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19
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Lobo SM, Creutzfeldt CJ, Maia IS, Town JA, Amorim E, Kross EK, Çoruh B, Patel PV, Jannotta GE, Lewis A, Greer DM, Curtis JR, Sharma M, Wahlster S. Perceptions of Critical Care Shortages, Resource Use, and Provider Well-being During the COVID-19 Pandemic: A Survey of 1,985 Health Care Providers in Brazil. Chest 2022; 161:1526-1542. [PMID: 35150658 PMCID: PMC8828383 DOI: 10.1016/j.chest.2022.01.057] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 01/18/2022] [Accepted: 01/31/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Brazil has been disproportionately affected by COVID-19, placing a high burden on ICUs. RESEARCH QUESTION Are perceptions of ICU resource availability associated with end-of-life decisions and burnout among health care providers (HCPs) during COVID-19 surges in Brazil? STUDY DESIGN AND METHODS We electronically administered a survey to multidisciplinary ICU HCPs during two 2-week periods (in June 2020 and March 2021) coinciding with COVID-19 surges. We examined responses across geographical regions and performed multivariate regressions to explore factors associated with reports of: (1) families being allowed less input in decisions about maintaining life-sustaining treatments for patients with COVID-19 and (2) emotional distress and burnout. RESULTS We included 1,985 respondents (57% physicians, 14% nurses, 12% respiratory therapists, 16% other HCPs). More respondents reported shortages during the second surge compared with the first (P < .05 for all comparisons), including lower availability of intensivists (66% vs 42%), ICU nurses (53% vs 36%), ICU beds (68% vs 22%), and ventilators for patients with COVID-19 (80% vs 70%); shortages were highest in the North. One-quarter of HCPs reported that families were allowed less input in decisions about maintaining life-sustaining treatments for patients with COVID-19, which was associated with lack of intensivists (adjusted relative risk [aRR], 1.37; 95% CI, 1.05-1.80) and ICU beds (aRR, 1.71; 95% CI, 1.16-2.62) during the first surge and lack of N95 masks (aRR, 1.43; 95% CI, 1.10-1.85), noninvasive positive pressure ventilation (aRR, 1.56; 95% CI, 1.18-2.07), and oxygen concentrators (aRR, 1.50; 95% CI, 1.13-2.00) during the second surge. Burnout was higher during the second surge (60% vs 71%; P < .001), associated with witnessing colleagues at one's hospital contract COVID-19 during both surges (aRR, 1.55 [95% CI, 1.25-1.93] and 1.31 [95% CI, 1.11-1.55], respectively), as well as worries about finances (aRR, 1.28; 95% CI, 1.02-1.61) and lack of ICU nurses (aRR, 1.25; 95% CI, 1.02-1.53) during the first surge. INTERPRETATION During the COVID-19 pandemic, ICU HCPs in Brazil experienced substantial resource shortages, health care disparities between regions, changes in end-of-life care associated with resource shortages, and high proportions of burnout.
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Affiliation(s)
- Suzana M Lobo
- Intensive Care Department, Hospital de Base, São José do Rio Preto, São Paulo, Brazil; Associação de Medicina Intensiva Brasileira, Florianópolis, Santa Catarina, Brazil
| | - Claire J Creutzfeldt
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA; Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA
| | - Israel S Maia
- Department of Intensive Care Medicine, Hospital Nereu Ramos, Florianópolis, Santa Catarina, Brazil
| | - James A Town
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Edilberto Amorim
- Department of Neurology, University of California, San Francisco, San Francisco, CA
| | - Erin K Kross
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA; Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Başak Çoruh
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
| | - Pratik V Patel
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Gemi E Jannotta
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA
| | - Ariane Lewis
- Departments of Neurology and Neurosurgery, New York University, New York, NY
| | - David M Greer
- Department of Neurology, Boston University, Boston, MA
| | - J Randall Curtis
- Department of Intensive Care Medicine, Hospital Nereu Ramos, Florianópolis, Santa Catarina, Brazil; Department of Neurology, University of California, San Francisco, San Francisco, CA
| | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, WA
| | - Sarah Wahlster
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA; Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA; Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, WA.
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20
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Global Comparison of Communication of End-of-Life Decisions in the ICU. Chest 2022; 162:1074-1085. [DOI: 10.1016/j.chest.2022.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 03/22/2022] [Accepted: 05/04/2022] [Indexed: 11/20/2022] Open
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21
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Adamski J, Weigl W, Musialowicz T, Lahtinen P, Reinikainen M. Predictors of treatment limitations in Finnish intensive care units. Acta Anaesthesiol Scand 2022; 66:526-538. [PMID: 35118641 DOI: 10.1111/aas.14035] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 01/06/2022] [Accepted: 01/18/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Few studies have examined the factors that predict the limitations of life-sustaining treatment (LST) to patients in intensive care units (ICUs). We aimed to identify variables associated with the decision of withholding of life support (WHLS) at admission, WHLS during ICU stay and the withdrawal of ongoing life support (WDLS). METHODS This retrospective observational study comprised 17,772 adult ICU patients who were included in the nationwide Finnish ICU Registry in 2016. Factors associated with LST limitations were identified using hierarchical logistic regression. RESULTS The decision of WHLS at admission was made for 822 (4.6%) patients, WHLS during ICU stay for 949 (5.3%) patients, and WDLS for 669 (3.8%) patients. Factors strongly predicting WHLS at admission included old age (adjusted odds ratio [OR] for patients aged 90 years or older in reference to those younger than 40 years was 95.6; 95% confidence interval [CI], 47.2-193.5), dependence on help for activities of daily living (OR, 3.55; 95% CI, 3.01-4.2), and metastatic cancer (OR, 4.34; 95% CI, 3.16-5.95). A high severity of illness predicted later decisions to limit LST. Diagnoses strongly associated with WHLS at admission were cardiac arrest, hepatic failure and chronic obstructive pulmonary disease. Later decisions were strongly associated with cardiac arrest, hepatic failure, non-traumatic intracranial hemorrhage, head trauma and stroke. CONCLUSION Early decisions to limit LST were typically associated with old age and chronic poor health whereas later decisions were related to the severity of illness. Limitations are common for certain diagnoses, particularly cardiac arrest and hepatic failure.
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Affiliation(s)
- Jan Adamski
- Department of Anaesthesiology and Intensive Care Faculty of Medical Sciences University of Warmia and Mazury in Olsztyn Olsztyn Poland
| | - Wojciech Weigl
- Anaesthesiology and Intensive Care Department of Surgical Sciences Akademiska Hospital Uppsala University Uppsala Sweden
| | - Tadeusz Musialowicz
- Department of Anaesthesiology and Intensive Care Medicine Kuopio University Hospital Kuopio Finland
| | - Pasi Lahtinen
- Anaesthesiology and Intensive Care Department Central Hospital of South Ostrobothnia Seinäjoki Finland
| | - Matti Reinikainen
- Department of Anaesthesiology and Intensive Care Medicine Kuopio University Hospital Kuopio Finland
- Faculty of Health Sciences School of Medicine Institute of Clinical Medicine University of Eastern Finland Kuopio Finland
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22
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Ćurković M, Brajković L, Jozepović A, Tonković D, Župan Ž, Karanović N, Borovečki A. End-of-Life Decisions in Intensive Care Units in Croatia-Pre COVID-19 Perspectives and Experiences From Nurses and Physicians. JOURNAL OF BIOETHICAL INQUIRY 2021; 18:629-643. [PMID: 34554388 PMCID: PMC8459337 DOI: 10.1007/s11673-021-10128-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 07/16/2021] [Indexed: 06/13/2023]
Abstract
Healthcare professionals working in intensive care units (ICUs) are often involved in end-of-life decision-making. No research has been done so far about these processes taking place in Croatian ICUs. The aim of this study was to investigate the perceptions, experiences, and challenges healthcare professionals face when dealing with end-of-life decisions in ICUs in Croatia. A qualitative study was performed using professionally homogenous focus groups of ICU nurses and physicians (45 in total) of diverse professional and clinical backgrounds at three research sites (Zagreb, Rijeka, Split). In total, six institutions at the tertiary level of healthcare were included. The constant comparative analysis method was used in the analysis of the data. Differences were found between the perceptions and experiences of nurses and physicians in relation to end-of-life decisions. Nurses' perceptions were more focused on the context and features of immediate care, while physicians' perceptions also included the wider sociocultural context. However, the critical issues these specific professional groups face when dealing with end-of-life decisions seem to overlap. A high variability of practices, both between individual practitioners and between different organizational units, was omnipresent. The lack of adequate legal, professional, and clinical guidelines was commonly expressed as one of the most critical source of difficulties.
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Affiliation(s)
- Marko Ćurković
- University Psychiatric Hospital Vrapče, Bolnička cesta 32, 10090, Zagreb, Croatia
- School of Medicine, University of Zagreb, Šalata 2, 10000, Zagreb, Croatia
| | - Lovorka Brajković
- Department for Psychology, Faculty of Croatian Studies, University of Zagreb, Borongajska cesta 83d, 10000, Zagreb, Croatia
| | - Ana Jozepović
- School of Medicine, University of Zagreb, Šalata 2, 10000, Zagreb, Croatia
| | - Dinko Tonković
- School of Medicine, University of Zagreb, Šalata 2, 10000, Zagreb, Croatia
- Department of Anesthesiology, Reanimatology and Intensive care, University Hospital Center Zagreb, Kišpatićeva ulica 12, 10000, Zagreb, Croatia
| | - Željko Župan
- Department of Anesthesiology, University Hospital Center Rijeka, Krešimirova ulica 42, 51000, Rijeka, Croatia
- School of Medicine, University of Rijeka, Ulica Braće Branchetta 20/1, 51000, Rijeka, Croatia
| | - Nenad Karanović
- Department of Anesthesiology, University Hospital Center Split, Spinčićeva ulica 1, 21000, Split, Croatia
- School of Medicine, University of Split, Šoltanska ulica 2, 21000, Split, Croatia
| | - Ana Borovečki
- School of Medicine, University of Zagreb, Šalata 2, 10000, Zagreb, Croatia.
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23
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Catalisano G, Ippolito M, Marino C, Giarratano A, Cortegiani A. Palliative Care Principles and Anesthesiology Clinical Practice: Current Perspectives. J Multidiscip Healthc 2021; 14:2719-2730. [PMID: 34611408 PMCID: PMC8486274 DOI: 10.2147/jmdh.s240563] [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: 05/15/2021] [Accepted: 09/14/2021] [Indexed: 11/24/2022] Open
Abstract
Background Palliative care is a person-centered approach aiming to relieve patient’s health-related suffering and it is often needed when caring for critically ill patients to manage symptoms and identify goals of care. Aim To describe the integration of palliative care principles in anesthesiology clinical practice, within and outside the ICU and to analyze the additional challenges that COVID-19 pandemic is posing in this context. Methods For the purpose of this review, PubMed database was searched for studies concerning palliative care and end of life care, in contexts involving anesthesiologists and intensivists, published in the last 5 years. Results Anesthesiologists and intensivists integrate palliative care within their daily practice providing symptoms management as well as family counseling. High-quality communicational skills are fundamental for anesthesiologists and intensivists especially when interfacing with surrogate decision makers in the ICU or with patients in the preoperative setting while discussing goals of care. Coronavirus disease 2019 (COVID-19) pandemic has challenged many aspects of palliative care delivery: reduced family presence within the ICU, communication with families through phone calls or video calls, patient–physician relationship mediated by bulky personal protective equipment and healthcare workers physical and psychological distress due to the increased workload and limitations in resources are some of the most evident. Conclusion Anesthesiologists and intensivists are increasingly facing challenging clinical situations where principles and practice of palliative care have to be applied. In this sense, increasing knowledge on palliative care and providing specific training would allow to deliver high-quality symptom management, family counseling and end of life guidance in critical care settings. COVID-19 pandemic sets additional difficulties to palliative care delivery.
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Affiliation(s)
- Giulia Catalisano
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy
| | - Mariachiara Ippolito
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy
| | - Claudia Marino
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy
| | - Antonino Giarratano
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy.,Department of Anesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo, Italy
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy.,Department of Anesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo, Italy
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24
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Nayfeh A, Yarnell CJ, Dale C, Conn LG, Hales B, Gupta TD, Chakraborty A, Pinto R, Taggar R, Fowler R. Evaluating satisfaction with the quality and provision of end-of-life care for patients from diverse ethnocultural backgrounds. BMC Palliat Care 2021; 20:145. [PMID: 34535122 PMCID: PMC8449427 DOI: 10.1186/s12904-021-00841-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/27/2021] [Indexed: 11/14/2022] Open
Abstract
Background Recently immigrated and ethnic minority patients in Ontario, Canada are more likely to receive aggressive life-prolonging treatment at the end of life in comparison to other patients. To explore this finding further, this survey-based observational study aimed to evaluate satisfaction with the quality of end-of-life care for patients from diverse ethnocultural backgrounds. Methods The End-of-Life Satisfaction Survey was used to measure satisfaction with the quality of inpatient end-of-life care from the perspective of next-of-kin of recently deceased patients at Sunnybrook Health Sciences Centre in Toronto, Ontario (between March 2012 to May 2019). The primary outcome was the global rating of satisfaction. Associations with patient ethnicity, patient religion, level of religiosity/spirituality, language/communication barriers, and location of death were assessed using univariable and multivariable modified Poisson regression. Secondary outcomes included differences in satisfaction and rates of dying in intensive care units (ICU) among patient population subgroups, and identification of high priority areas for quality-of-care improvement. Results There were 1,543 respondents. Patient ethnicities included Caucasian (68.2%), Mediterranean (10.5%), East Asian (7.6%), South Asian (3.5%), Southeast Asian (2.1%) and Middle Eastern (2.0%); religious affiliations included Christianity (66.6%), Judaism (12.3%) and Islam (2.1%), among others. Location of death was most commonly in ICU (38.4%), hospital wards (37.0%) or long-term care (20.0%). The mean(SD) rating of satisfaction score was 8.30(2.09) of 10. After adjusting for other covariates, satisfaction with quality of end-of-life care was higher among patients dying in ICU versus other locations (relative risk [RR] 1.51, 95%CI 1.05-2.19, p=0.028), lower among those who experienced language/communication barriers (RR 0.49 95%CI 0.23-1.06, p=0.069), and lower for Muslim patients versus other religious affiliations (RR 0.46, 95%CI 0.21-1.02, p=0.056). Survey items identified as highest priority areas for quality-of-care improvement included communication and information giving; illness management; and healthcare provider characteristics such as emotional support, doctor availability and time spent with patient/family. Conclusion Satisfaction with quality-of-care at the end of life was higher among patients dying in ICU and lower among Muslim patients or when there were communication barriers between families and healthcare providers. These findings highlight the importance of measuring and improving end-of-life care across the ethnocultural spectrum. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-021-00841-z.
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Affiliation(s)
- Ayah Nayfeh
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Room 500, Toronto, Ontario, M5T 3M7, Canada.
| | - Christopher J Yarnell
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Room 500, Toronto, Ontario, M5T 3M7, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Sinai, Health Systems, Toronto, ON, Canada
| | - Craig Dale
- Sunnybrook Research Institute, Toronto, ON, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Lesley Gotlib Conn
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Room 500, Toronto, Ontario, M5T 3M7, Canada.,Sunnybrook Research Institute, Toronto, ON, Canada
| | | | | | | | | | - Ru Taggar
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Robert Fowler
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,H. Barrie Fairley Professorship of Critical Care at the University Health Network, Toronto, ON, Canada
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25
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Avidan A, Sprung CL, Schefold JC, Ricou B, Hartog CS, Nates JL, Jaschinski U, Lobo SM, Joynt GM, Lesieur O, Weiss M, Antonelli M, Bülow HH, Bocci MG, Robertsen A, Anstey MH, Estébanez-Montiel B, Lautrette A, Gruber A, Estella A, Mullick S, Sreedharan R, Michalsen A, Feldman C, Tisljar K, Posch M, Ovu S, Tamowicz B, Demoule A, DeKeyser Ganz F, Pargger H, Noto A, Metnitz P, Zubek L, de la Guardia V, Danbury CM, Szűcs O, Protti A, Filipe M, Simpson SQ, Green C, Giannini AM, Soliman IW, Piras C, Caser EB, Hache-Marliere M, Mentzelopoulos SD. Variations in end-of-life practices in intensive care units worldwide (Ethicus-2): a prospective observational study. THE LANCET RESPIRATORY MEDICINE 2021; 9:1101-1110. [PMID: 34364537 DOI: 10.1016/s2213-2600(21)00261-7] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 05/20/2021] [Accepted: 05/25/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND End-of-life practices vary among intensive care units (ICUs) worldwide. Differences can result in variable use of disproportionate or non-beneficial life-sustaining interventions across diverse world regions. This study investigated global disparities in end-of-life practices. METHODS In this prospective, multinational, observational study, consecutive adult ICU patients who died or had a limitation of life-sustaining treatment (withholding or withdrawing life-sustaining therapy and active shortening of the dying process) during a 6-month period between Sept 1, 2015, and Sept 30, 2016, were recruited from 199 ICUs in 36 countries. The primary outcome was the end-of-life practice as defined by the end-of-life categories: withholding or withdrawing life-sustaining therapy, active shortening of the dying process, or failed cardiopulmonary resuscitation (CPR). Patients with brain death were included in a separate predefined end-of-life category. Data collection included patient characteristics, diagnoses, end-of-life decisions and their timing related to admission and discharge, or death, with comparisons across different regions. Patients were studied until death or 2 months from the first limitation decision. FINDINGS Of 87 951 patients admitted to ICU, 12 850 (14·6%) were included in the study population. The number of patients categorised into each of the different end-of-life categories were significantly different for each region (p<0·001). Limitation of life-sustaining treatment occurred in 10 401 patients (11·8% of 87 951 ICU admissions and 80·9% of 12 850 in the study population). The most common limitation was withholding life-sustaining treatment (5661 [44·1%]), followed by withdrawing life-sustaining treatment (4680 [36·4%]). More treatment withdrawing was observed in Northern Europe (1217 [52·8%] of 2305) and Australia/New Zealand (247 [45·7%] of 541) than in Latin America (33 [5·8%] of 571) and Africa (21 [13·0%] of 162). Shortening of the dying process was uncommon across all regions (60 [0·5%]). One in five patients with treatment limitations survived hospitalisation. Death due to failed CPR occurred in 1799 (14%) of the study population, and brain death occurred in 650 (5·1%). Failure of CPR occurred less frequently in Northern Europe (85 [3·7%] of 2305), Australia/New Zealand (23 [4·3%] of 541), and North America (78 [8·5%] of 918) than in Africa (106 [65·4%] of 162), Latin America (160 [28·0%] of 571), and Southern Europe (590 [22·5%] of 2622). Factors associated with treatment limitations were region, age, and diagnoses (acute and chronic), and country end-of-life legislation. INTERPRETATION Limitation of life-sustaining therapies is common worldwide with regional variability. Withholding treatment is more common than withdrawing treatment. Variations in type, frequency, and timing of end-of-life decisions were observed. Recognising regional differences and the reasons behind these differences might help improve end-of-life care worldwide. FUNDING None.
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Affiliation(s)
- Alexander Avidan
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Charles L Sprung
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Joerg C Schefold
- Inselspital, Department of Intensive Care Medicine, University of Bern, Bern, Switzerland
| | - Bara Ricou
- Department of Anesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | - Christiane S Hartog
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany, and Klinik Bavaria, Kreischa, Germany
| | - Joseph L Nates
- Critical Care Department, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ulrich Jaschinski
- Department of Anesthesiology and Critical Care Medicine, University Hospital Augsburg, Augsburg, Germany
| | - Suzana M Lobo
- Intensive Care Division, São José do Rio Preto School of Medicine, São Jose do Rio Preto, São Paulo, Brazil
| | - Gavin M Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong
| | - Olivier Lesieur
- Intensive Care Unit, Saint Louis General Hospital, La Rochelle, France
| | - Manfred Weiss
- Clinic of Anaesthesiology and Intensive Care Medicine, University Hospital Medical School, Ulm, Germany
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Hans-Henrik Bülow
- Department of Anesthesiology and Intensive Care, Holbaek University Hospital, Zealand Region, Denmark
| | - Maria G Bocci
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Annette Robertsen
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | | | | | - Alexandre Lautrette
- Medical Intensive Care Unit, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Anastasiia Gruber
- Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Angel Estella
- Intensive Care Department, University Hospital SAS of Jerez, Jerez de la Frontera, Spain
| | | | - Roshni Sreedharan
- Department of General Anesthesiology, Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Andrej Michalsen
- Department of Anesthesiology and Critical Care, Medizin Campus Bodensee-Tettnang Hospital, Tettnang, Germany
| | - Charles Feldman
- Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kai Tisljar
- Intensive Care Unit, University Hospital and University of Basel, Basel, Switzerland
| | - Martin Posch
- Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Steven Ovu
- Critical Care Department, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Barbara Tamowicz
- Faculty of Health Sciences, Poznan University of Medical Sciences, Poznań, Poland
| | - Alexandre Demoule
- Service de Médecine intensive- Réanimation, AP-HP Sorbonne Université, Site Pitié-Salpêtrière, and UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, INSERM, Paris, France
| | - Freda DeKeyser Ganz
- Hadassah Hebrew University School of Nursing and Jerusalem College of Technology, Faculty of Life and Health Sciences, Jerusalem, Israel
| | - Hans Pargger
- Intensive Care Unit, University Hospital and University of Basel, Basel, Switzerland
| | - Alberto Noto
- Department of Human Pathology of the Adult and Evolutive Age "Gaetano Barresi", Division of Anesthesia and Intensive Care, University of Messina, Messina, Italy
| | - Philipp Metnitz
- Department of General Anaesthesiology, Emergency and Intensive Care Medicine, LKH-University Hospital of Graz, Graz, Austria
| | - Laszlo Zubek
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Veronica de la Guardia
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Orsolya Szűcs
- 1st Department of Surgery and Interventional Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Alessandro Protti
- Department of Anesthesia, Intensive Care, and Emergency Medicine, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Mario Filipe
- Department of Anesthesiology and Critical Care Medicine, DPC Hospital Budapest, Semmelweis University, Budapest, Hungary
| | - Steven Q Simpson
- Department of Internal Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Kansas, Kansas City, KS, USA
| | - Cameron Green
- Department of Intensive Care, Peninsula Health, Melbourne, VIC, Australia
| | - Alberto M Giannini
- Division of Pediatric Anesthesia and Intensive Care, ASST-Spedali Civili, Brescia, Italy
| | - Ivo W Soliman
- Department of Intensive Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Eliana B Caser
- Department of Internal Medicine, University Federal do Espírito Santo, Espírito Santo, Brazil
| | - Manuel Hache-Marliere
- Department of Critical Care Medicine, CEDIMAT, Santo Domingo, Dominican Republic, and Department of Internal Medicine, Jacobi Medical Center-AECOM, Bronx, NY, USA
| | - Spyros D Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelsimos General Hospital, Athens, Greece
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Lim A, Kim S. Nurses' ethical decision-making during end of life care in South Korea: a cross-sectional descriptive survey. BMC Med Ethics 2021; 22:94. [PMID: 34271891 PMCID: PMC8285824 DOI: 10.1186/s12910-021-00665-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 07/09/2021] [Indexed: 11/11/2022] Open
Abstract
Background Although nurses are crucial to ensure patients’ peaceful death in hospitals, many nurses experience various ethical conflicts during end-of-life care. Therefore, research on nurses’ entire ethical decision-making process is required to improve nurses’ ethical decision-making in end-of-life care. This study aimed to identify Korean nurses’ ethical decision-making process based on their moral sensitivity to end-of-life patients. Methods In total, 171 nurses caring for terminal patients responded to the survey questionnaire. To measure the participants’ moral sensitivity and ethical decision-making process, we used the Korean version of the Moral Sensitivity Questionnaire and Nurses’ Ethical Decision-Making around End of Life Care Scale. Finally, multiple linear regression analysis was used to investigate the effect of moral sensitivity on nurses’ ethical decision-making. Results The mean of moral sensitivity was 4.8 ± 0.5 (out of 7), and that of ethical decision-making was 4.6 ± 0.5 (out of 6). Among the sub-dimensions of ethical decision-making, the highest score was in perceived professional accountability (5.2 ± 0.5), and the lowest in moral reasoning and moral agency (3.9 ± 0.6); the score of moral practice was 4.4 ± 0.7. In the multiple linear regression model, moral sensitivity (β = 0.852, p < .001), clinical department (β = − 7.018, p = .035), ethics education (β = 20.450, p < .001), job satisfaction (β = 5.273, p < .001), and ethical conflict (β = − 2.260, p = 0.031) were influential ethical decision-making factors. Conclusions This study revealed a gap between nurses’ thoughts and practices through the ethical decision-making process. They failed to lead their thought to moral practice. It also implies that moral sensitivity could positively affect nurses’ ethical decision-making. To make nurses morally sensitive, exposing them to various clinical cases would be helpful. Additionally, ethics education and clinical ethics supporting services are valuable for improving nurses’ ethical decision-making. If nurses improved their ethical decision-making regarding end-of-life care, their patients could experience a better quality of death.
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Affiliation(s)
- Arum Lim
- Department of Nursing, Graduate School, Yonsei University, Seoul, Korea
| | - Sanghee Kim
- College of Nursing and, Mo-Im Kim Nursing Research Institute, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea.
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Lin Y, Long-Sutehall T, Myall M. Transferring home to die from critical care units: A scoping review of international practices. J Crit Care 2021; 65:205-215. [PMID: 34243069 DOI: 10.1016/j.jcrc.2021.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/17/2021] [Accepted: 06/18/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE To identify and characterise the international practices of transferring a dying patient home to die from critical care units. MATERIALS AND METHODS A systematic scoping review following the Joanne Briggs Institute methodology was applied searching fifteen data sources to identify papers published in English and Chinese from 1970 to 2019. RESULTS Of the 28 papers meeting eligibility criteria 19 were published in the West and seven in China. The number of patients being transferred home to die was larger in China (74/184-96/159) than in the West (1-7). Clinical characteristics of patients transferred included: consciousness, with or without intubation and ventilation, and clinical stability. Reported key barriers to transfer included: Lack of evidence guiding transfer practice, the CCU environment and culture, Practical and logistical factors and Family members expectations and reactions. Key facilitators of transfer were reported as: Engagement with the multidisciplinary team and Personal patient and family wishes. CONCLUSIONS Transferring patients home to die from critical care is a complex practice varying significantly across countries. Further research to address current knowledge gaps is important to inform policy and practice.
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Affiliation(s)
- Yanxia Lin
- School of Health Sciences, University of Southampton, Highfield, Southampton SO17 1BJ, UK.
| | - Tracy Long-Sutehall
- School of Health Sciences, University of Southampton, Highfield, Southampton SO17 1BJ, UK
| | - Michelle Myall
- School of Health Sciences, University of Southampton, Highfield, Southampton SO17 1BJ, UK
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Rosenwohl-Mack S, Dohan D, Matthews T, Batten JN, Dzeng E. Understanding Experiences of Moral Distress in End-of-Life Care Among US and UK Physician Trainees: a Comparative Qualitative Study. J Gen Intern Med 2021; 36:1890-1897. [PMID: 33111237 PMCID: PMC7592132 DOI: 10.1007/s11606-020-06314-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 10/12/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Moral distress is a state in which a clinician cannot act in accordance with their ethical beliefs because of external constraints. Physician trainees, who work within rigid hierarchies and who lack clinical experience, are particularly vulnerable to moral distress. We examined the dynamics of physician trainee moral distress in end-of-life care by comparing experiences in two different national cultures and healthcare systems. OBJECTIVE We investigated cultural factors in the US and the UK that may produce moral distress within their respective healthcare systems, as well as how these factors shape experiences of moral distress among physician trainees. DESIGN Semi-structured in-depth qualitative interviews about experiences of end-of-life care and moral distress. PARTICIPANTS Sixteen internal medicine residents in the US and fourteen junior doctors in the UK. APPROACH The work was analyzed using thematic analysis. KEY RESULTS Some drivers of moral distress were similar among US and UK trainees, including delivery of potentially inappropriate treatments, a poorly defined care trajectory, and involvement of multiple teams creating different care expectations. For UK trainees, healthcare team hierarchy was common, whereas for US trainees, pressure from families, a lack of guidelines for withholding inappropriate treatments, and distress around physically harming patients were frequently cited. US trainees described how patient autonomy and a fear of lawsuits contributed to moral distress, whereas UK trainees described how societal expectations around resource allocation mitigated it. CONCLUSION This research highlights how the differing experiences of moral distress among US and UK physician trainees are influenced by their countries' healthcare cultures. This research illustrates how experiences of moral distress reflect the broader culture in which it occurs and suggests how trainees may be particularly vulnerable to it. Clinicians and healthcare leaders in both countries can learn from each other about policies and practices that might decrease the moral distress trainees experience.
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Affiliation(s)
- Sarah Rosenwohl-Mack
- Department of Family Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Daniel Dohan
- Institute of Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA
| | - Thea Matthews
- Institute of Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA
| | | | - Elizabeth Dzeng
- Institute of Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA.
- Department of Medicine, Division of Hospital Medicine, University of California, San Francisco, San Francisco, CA, USA.
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Jensen HI, Halvorsen K, Jerpseth H, Fridh I, Lind R. Practice Recommendations for End-of-Life Care in the Intensive Care Unit. Crit Care Nurse 2021; 40:14-22. [PMID: 32476029 DOI: 10.4037/ccn2020834] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
TOPIC A substantial number of patients die in the intensive care unit, so high-quality end-of-life care is an important part of intensive care unit work. However, end-of-life care varies because of lack of knowledge of best practices. CLINICAL RELEVANCE Research shows that high-quality end-of-life care is possible in an intensive care unit. This article encourages nurses to be imaginative and take an individual approach to provide the best possible end-of-life care for patients and their family members. PURPOSE OF PAPER To provide recommendations for high-quality end-of-life care for patients and family members. CONTENT COVERED This article touches on the following domains: end-of-life decision-making, place to die, patient comfort, family presence in the intensive care unit, visiting children, family needs, preparing the family, staff presence, when the patient dies, after-death care of the family, and caring for staff.
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Affiliation(s)
- Hanne Irene Jensen
- Hanne Irene Jensen is an associate professor at the Department of Anaesthesiology and Intensive Care, Vejle and Middelfart Hospitals, Vejle, Denmark, and the University of Southern Denmark, Odense, Denmark
| | - Kristin Halvorsen
- Kristin Halvorsen is a professor and researcher and Heidi Jerpseth is an associate professor and researcher at Oslo Metropolitan University, Faculty of Health Sciences, Oslo, Norway
| | - Heidi Jerpseth
- Kristin Halvorsen is a professor and researcher and Heidi Jerpseth is an associate professor and researcher at Oslo Metropolitan University, Faculty of Health Sciences, Oslo, Norway
| | - Isabell Fridh
- Isabell Fridh is an associate professor at the Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Sweden
| | - Ranveig Lind
- Ranveig Lind is an associate professor at UiT, the Arctic University of Norway, and a research nurse in the intensive care unit at University Hospital of North Norway, Tromsø, Norway
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Sprung CL, Jennerich AL, Joynt GM, Michalsen A, Curtis JR, Efferen LS, Leonard S, Metnitz B, Mikstacki A, Patil N, McDermid RC, Metnitz P, Mularski RA, Bulpa P, Avidan A. The Influence of Geography, Religion, Religiosity and Institutional Factors on Worldwide End-of-Life Care for the Critically Ill: The WELPICUS Study. J Palliat Care 2021:8258597211002308. [PMID: 33818159 DOI: 10.1177/08258597211002308] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To evaluate the association between provider religion and religiosity and consensus about end-of-life care and explore if geographical and institutional factors contribute to variability in practice. MATERIALS AND METHODS Using a modified Delphi method 22 end-of-life issues consisting of 35 definitions and 46 statements were evaluated in 32 countries in North America, South America, Eastern Europe, Western Europe, Asia, Australia and South Africa. A multidisciplinary, expert group from specialties treating patients at the end-of-life within each participating institution assessed the association between 7 key statements and geography, religion, religiosity and institutional factors likely influencing the development of consensus. RESULTS Of 3049 participants, 1366 (45%) responded. Mean age of respondents was 45 ± 9 years and 55% were females. Following 2 Delphi rounds, consensus was obtained for 77 (95%) of 81 definitions and statements. There was a significant difference in responses across geographical regions. South African and North American respondents were more likely to encourage patients to write advance directives. Fewer Eastern European and Asian respondents agreed with withdrawing life-sustaining treatments without consent of patients or surrogates. While respondent's religion, years in practice or institution did not affect their agreement, religiosity, physician specialty and responsibility for end-of-life decisions did. CONCLUSIONS Variability in agreement with key consensus statements about end-of-life care is related primarily to differences among providers, with provider-level variations related to differences in religiosity and specialty. Geography also plays a role in influencing some end-of-life practices. This information may help understanding ethical dilemmas and developing culturally sensitive end-of-life care strategies.
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Affiliation(s)
- Charles L Sprung
- Department of Anesthesiology, Critical Care Medicine, and Pain Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ann L Jennerich
- Division of Pulmonary, Critical Care and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Gavin M Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Andrej Michalsen
- Department of Anaesthesiology and Critical Care Medicine, Tettnang Hospital, Tettnang, Germany
| | - J Randall Curtis
- Division of Pulmonary, Critical Care and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Linda S Efferen
- Department of Medicine, Stony Brook Medicine, Stony Brook, NY, USA
| | - Sara Leonard
- Department of Anaesthesia and Critical Care, King's College Hospital, London, UK
| | - Barbara Metnitz
- Austrian Centre for Documentation and Quality Assurance in Intensive Care Medicine, Vienna, Austria
| | - Adam Mikstacki
- Faculty of Health Sciences, Poznan University of Medical Sciences, Poznan, Poland
| | - Namrata Patil
- Division of Thoracic Surgery and Division of Trauma, Burn and Critical Care, Department of Surgery, Brigham & Women's Hospital, Boston, MA, USA
| | - Robert C McDermid
- Division of Critical Care, University of Alberta, Edmonton, Alberta, Canada
| | - Philipp Metnitz
- Clinical Department of General Anaesthesiology, Emergency and Intensive Care Medicine, LKH-University Hospital of Graz, Medical University of Graz, Graz, Austria
| | - Richard A Mularski
- The Center for Health Research Kaiser Permanente Northwest, Portland, OR, USA
| | - Pierre Bulpa
- Intensive Care Unit of Mont-Godinne University Hospital, CHU UCL Namur, Université Catholique de Louvain, Yvoir, Belgium
| | - Alexander Avidan
- Department of Anesthesiology, Critical Care Medicine, and Pain Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
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Bloomer MJ, Bouchoucha S. Australian College of Critical Care Nurses and Australasian College for Infection Prevention and Control position statement on facilitating next-of-kin presence for patients dying from coronavirus disease 2019 (COVID-19) in the intensive care unit. Aust Crit Care 2021; 34:132-134. [PMID: 32826150 PMCID: PMC7365101 DOI: 10.1016/j.aucc.2020.07.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/06/2020] [Accepted: 07/10/2020] [Indexed: 12/17/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic is challenging healthcare systems worldwide, none more so than critical and intensive care settings. Significant attention has been paid to the capacity of Australian intensive care unit (ICUs) to respond to a COVID-19 surge, particularly in relation to beds, ventilators, staffing, personal protective equipment, and unparalleled increase in deaths in ICUs associated with COVID-19 seen internationally. While death is not uncommon in critical care, the international experience demonstrates that restrictions to family presence at the end of life result in significant distress for families and clinicians. As a result, the Australian College of Critical Care Nurses and the Australasian College for Infection Prevention and Control supported the development of a position statement to provide critical care nurses with specific guidance and recommendations for practice for this emerging priority area. Where possible, position statements are founded on high-quality evidence. However, the short time period since the first recognition of a cluster of pneumonia-like cases in China in January, 2020, meant that an integrative approach was required to expedite timely development of this position statement in preparation for a COVID-19 surge in Australia. This position statement is intended to provide practical guidance to critical care nurses in facilitating next-of-kin presence for patients dying from COVID-19 in the ICU.
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Affiliation(s)
- Melissa J Bloomer
- School of Nursing and Midwifery, Deakin University, 1 Gheringhap Street, Geelong, Victoria, 3220, Australia; Centre for Quality and Patient Safety Research, Deakin University, 1 Gheringhap Street, Geelong, Victoria, 3220, Australia; Institute for Health Transformation, Deakin University, 1 Gheringhap Street, Geelong, Victoria, 3220, Australia; Research Advisory Panel, Australian College of Critical Care Nurses, Surrey Hills, Victoria, 3127, Australia.
| | - Stéphane Bouchoucha
- School of Nursing and Midwifery, Deakin University, 1 Gheringhap Street, Geelong, Victoria, 3220, Australia; Centre for Quality and Patient Safety Research, Deakin University, 1 Gheringhap Street, Geelong, Victoria, 3220, Australia; Institute for Health Transformation, Deakin University, 1 Gheringhap Street, Geelong, Victoria, 3220, Australia; Australasian College for Infection Prevention and Control, 228 Liverpool Street, Hobart, Tasmania, 7000, Australia
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Abstract
Supplemental Digital Content is available in the text. Objectives: The determinants of decisions to limit life support (withholding or withdrawal) in ventilated stroke patients have been evaluated mainly for patients with intracranial hemorrhages. We aimed to evaluate the frequency of life support limitations in ventilated ischemic and hemorrhagic stroke patients compared with a nonbrain-injured population and to determine factors associated with such decisions. Design: Multicenter prospective French observational study. Setting: Fourteen ICUs of the French OutcomeRea network. PATIENTS: From 2005 to 2016, we included stroke patients and nonbrain-injured patients requiring invasive ventilation within 24 hours of ICU admission. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: We identified 373 stroke patients (ischemic, n = 167 [45%]; hemorrhagic, n = 206 [55%]) and 5,683 nonbrain-injured patients. Decisions to limit life support were taken in 41% of ischemic stroke cases (vs nonbrain-injured patients, subdistribution hazard ratio, 3.59 [95% CI, 2.78–4.65]) and in 33% of hemorrhagic stroke cases (vs nonbrain-injured patients, subdistribution hazard ratio, 3.9 [95% CI, 2.97–5.11]). Time from ICU admission to the first limitation was longer in ischemic than in hemorrhagic stroke (5 [3–9] vs 2 d [1–6] d; p < 0.01). Limitation of life support preceded ICU death in 70% of ischemic strokes and 45% of hemorrhagic strokes (p < 0.01). Life support limitations in ischemic stroke were increased by a vertebrobasilar location (vs anterior circulation, subdistribution hazard ratio, 1.61 [95% CI, 1.01–2.59]) and a prestroke modified Rankin score greater than 2 (2.38 [1.27–4.55]). In hemorrhagic stroke, an age greater than 70 years (2.29 [1.43–3.69]) and a Glasgow Coma Scale score less than 8 (2.15 [1.08–4.3]) were associated with an increased risk of limitation, whereas a higher nonneurologic admission Sequential Organ Failure Assessment score was associated with a reduced risk (per point, 0.89 [0.82–0.97]). Conclusions: In ventilated stroke patients, decisions to limit life support are more than three times more frequent than in nonbrain-injured patients, with different timing and associated risk factors between ischemic and hemorrhagic strokes.
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Robin S, Labarriere C, Sechaud G, Dessertaine G, Bosson JL, Payen JF. Information Pamphlet Given to Relatives During the End-of-Life Decision in the ICU: An Assessor-Blinded, Randomized Controlled Trial. Chest 2021; 159:2301-2308. [PMID: 33549600 DOI: 10.1016/j.chest.2021.01.072] [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: 09/12/2020] [Revised: 12/15/2020] [Accepted: 01/23/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Symptoms of posttraumatic stress disorder (PTSD) are common in family members of patients who have died in the ICU. RESEARCH QUESTION Could a pamphlet describing the role of relatives in the end-of-life decision decrease their risk of developing PTSD-related symptoms? STUDY DESIGN AND METHODS In this assessor-blinded, randomized controlled trial, 90 relatives of adult patients for whom an end-of-life decision was anticipated were enrolled. Relatives were randomly assigned to receive oral information as well as an information pamphlet explaining that the end-of-life decision is made by physicians (Group 1; n = 45) or oral information alone (Group 2; n = 45). PTSD-related symptoms were blindly assessed at 90 days following the patient's death by using the Impact of Event Scale (scores range from 0 [indicating no symptoms] to 75 [indicating severe symptoms]). Anxiety and depression symptoms were assessed by using the Hospital Anxiety and Depression Scale score (range, 0-21 [higher scores indicate worse symptoms]). RESULTS On day 90, the number of relatives with PTSD-related symptoms was significantly lower in Group 1 than in Group 2: 18 of 45 vs 33 of 45 (P = .001). The risk ratio of having PTSD-related symptoms in Group 2 compared with Group 1 was 1.8 (95% CI, 1.2-2.7). The mean Impact of Event Scale and Hospital Anxiety and Depression Scale scores were significantly reduced in Group 1 compared with Group 2: 28 ± 10 vs 38 ± 14 (P < .001) and 13 ± 5 vs 17 ± 8 (P = .023), respectively. INTERPRETATION An information pamphlet describing the relatives' role during end-of-life decisions significantly reduced their risk of developing PTSD-related symptoms. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT02329418; URL: www.clinicaltrials.gov).
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Affiliation(s)
- Sylvaine Robin
- Department of Anesthesia and Critical Care, France Université Grenoble Alpes, CHU Grenoble Alpes, Grenoble, France
| | - Cyrielle Labarriere
- Department of Anesthesia and Critical Care, Annecy Genevois Hospital, Annecy, France
| | - Guillaume Sechaud
- Department of Anesthesia and Critical Care, France Université Grenoble Alpes, CHU Grenoble Alpes, Grenoble, France
| | - Geraldine Dessertaine
- Department of Anesthesia and Critical Care, France Université Grenoble Alpes, CHU Grenoble Alpes, Grenoble, France
| | - Jean-Luc Bosson
- Department of Public Health, France Université Grenoble Alpes, CHU Grenoble Alpes, Grenoble, France
| | - Jean-Francois Payen
- Department of Anesthesia and Critical Care, France Université Grenoble Alpes, CHU Grenoble Alpes, Grenoble, France.
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Zhu Y, Zhu X, Xu L, Deng M. Clinical Factors Influencing End-of-Life Care in a Chinese Pediatric Intensive Care Unit: A Retrospective, post-hoc Study. Front Pediatr 2021; 9:601782. [PMID: 33898354 PMCID: PMC8058173 DOI: 10.3389/fped.2021.601782] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 03/15/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: End-of-life(EOL) care decision-making for infants and children is a painful experience. The study aimed to explore the clinical factors influencing the EOL care to withhold/withdraw life-sustaining treatment (WLST) in Chinese pediatric intensive care unit (PICU). Methods: A 14-year retrospective study (2006-2019) for pediatric patients who died in PICU was conducted. Based on the mode of death, patients were classified into WLST group (death after WLST) and fCPR group (death after full intervention, including cardiopulmonary resuscitation). Intergroup differences in the epidemiological and clinical factors were determined. Results: There were 715 patients enrolled in this study. Of these patients, 442 (61.8%) died after WLST and 273 (38.2%) died after fCPR. Patients with previous hospitalizations or those who had been transferred from other hospitals more frequently chose WLST than fCPR (both P < 0.01), and the mean PICU stay duration was significantly longer in the WLST group (P < 0.05). WLST patients were more frequently complicated with chronic underlying disease, especially tumor (P < 0.01). Sepsis, diarrhea, and cardiac attack (all P < 0.05) were more frequent causes of death in the fCPR group, whereas tumor as a direct cause of death was more frequently seen in the WLST group. Logistic regression analysis demonstrated that previous hospitalization and underlying diseases diagnosed before admission were strongly associated with EOL care with WLST decision (OR: 1.6; P < 0.05 and OR: 1.6; P < 0.01, respectively). Conclusions: Pediatric patients with previous hospitalization and underlying diseases diagnosed before admission were associated with the EOL care to WLST.
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Affiliation(s)
- Yueniu Zhu
- Department of Pediatric Critical Care Medicine, Xinhua Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiaodong Zhu
- Department of Pediatric Critical Care Medicine, Xinhua Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lili Xu
- Department of Pediatric Critical Care Medicine, Xinhua Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Mengyan Deng
- Department of Pediatric Critical Care Medicine, Xinhua Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
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Foti G, Giannini A, Bottino N, Castelli GP, Cecconi M, Grasselli G, Guatteri L, Latronico N, Langer T, Monti G, Muttini S, Pesenti A, Radrizzani D, Ranucci M, Russotto V, Fumagalli R. Management of critically ill patients with COVID-19: suggestions and instructions from the coordination of intensive care units of Lombardy. Minerva Anestesiol 2020; 86:1234-1245. [PMID: 33228329 DOI: 10.23736/s0375-9393.20.14762-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
With 63,098 confirmed cases on 17 April 2020 and 11,384 deaths, Lombardy has been the most affected region in Italy by coronavirus disease 2019 (COVID-19). To cope with this emergency, the COVID-19 Lombardy intensive care units (ICU) network was created. The network identified the need of defining a list of clinical recommendations to standardize treatment of patients with COVID-19 admitted to Intensive Care Unit (ICU). Three core topics were identified: 1) rational use of intensive care resources; 2) ventilation strategies; 3) non-ventilatory interventions. Identification of patients who may benefit from ICU treatment is challenging. Clinicians should consider baseline performance and frailty status and they should adopt disease-specific staging tools. Continuous positive airway pressure, mainly delivered through a helmet as elective method, should be considered as initial treatment for all patients with respiratory failure associated with COVID-19. In case of persisting dyspnea and/or desaturation despite 4-6 hours of noninvasive ventilation, endotracheal intubation and invasive mechanical ventilation should be considered. In the early phase, muscle relaxant use and volume-controlled ventilation is recommended. Prone position should be performed in patients with PaO<inf>2</inf>/FiO<inf>2</inf>≤100 mmHg. For patients admitted to ICU with COVID-19 interstitial pneumonia, we do not recommend empiric antibiotic therapy for community-acquired pneumonia. Consultation of an infectious disease specialist is suggested before start of any antiviral therapy. In conclusion, the COVID-19 Lombardy ICU Network identified a list of best practice statements supported by the available evidence and clinical experience or identified as panel members expert opinions for the management of critically ill patients with COVID-19.
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Affiliation(s)
- Giuseppe Foti
- Department of Emergency and Intensive Care, San Gerardo University Hospital, Monza, Italy.,School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Alberto Giannini
- Unit of Pediatric Anesthesiology and Intensive Care, Children's Hospital, ASST Spedali Civili Hospital, Brescia, Italy
| | - Nicola Bottino
- Department of Anesthesiology, Reanimation and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gian Paolo Castelli
- Department of Anesthesiology and Intensive Care, ASST Mantua, Carlo Poma Hospital, Mantua, Italy
| | - Maurizio Cecconi
- Department of Anesthesiology and Intensive Care Medicine, IRCCS Humanitas Clinic, Rozzano, Milan, Italy.,Humanitas University, Pieve Emanuele, Milan, Italy
| | - Giacomo Grasselli
- Department of Anesthesiology, Reanimation and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Luca Guatteri
- Department of Anesthesiology and Intensive Care, Sacra Famiglia Fatebenefratelli Hospital, Erba, Como, Italy
| | - Nicola Latronico
- Unit of Pediatric Anesthesiology and Intensive Care, Children's Hospital, ASST Spedali Civili Hospital, Brescia, Italy.,Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy.,Department of Anesthesiology, Critical Care and Emergency, ASST Spedali Civili, Brescia, Italy
| | - Thomas Langer
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Department of Anesthesiology and Intensive Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giacomo Monti
- Department of Anesthesiology and Intensive Care, IRCCS San Raffaele Hospital, Milan, Italy
| | - Stefano Muttini
- Department of Anesthesiology and Intensive Care, ASST Santi Paolo e Carlo, San Carlo Hospital, Milan, Italy
| | - Antonio Pesenti
- Department of Anesthesiology, Reanimation and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Danilo Radrizzani
- Department of Anesthesiology and Intensive Care, ASST Ovest Milanese, Hospital of Legnano, Legnano, Milan, Italy
| | - Marco Ranucci
- Department of Anesthesiology and Intensive Care, IRCCS San Donato Hospital, Milan, Italy
| | - Vincenzo Russotto
- Department of Emergency and Intensive Care, San Gerardo University Hospital, Monza, Italy - .,School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Roberto Fumagalli
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Department of Anesthesiology and Intensive Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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Smirdec M, Jourdain M, Guastella V, Lambert C, Richard JC, Argaud L, Jaber S, Klouche K, Medard A, Reignier J, Rigaud JP, Doise JM, Chabanne R, Souweine B, Bourenne J, Delmas J, Bertrand PM, Verdier P, Quenot JP, Aubron C, Eisenmann N, Asfar P, Fratani A, Dellamonica J, Terzi N, Constantin JM, Van Lander A, Guerin R, Pereira B, Lautrette A. Impact of advance directives on the variability between intensivists in the decisions to forgo life-sustaining treatment. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:672. [PMID: 33267904 PMCID: PMC7709386 DOI: 10.1186/s13054-020-03402-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 11/20/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND There is wide variability between intensivists in the decisions to forgo life-sustaining treatment (DFLST). Advance directives (ADs) allow patients to communicate their end-of-life wishes to physicians. We assessed whether ADs reduced variability in DFLSTs between intensivists. METHODS We conducted a multicenter, prospective, simulation study. Eight patients expressed their wishes in ADs after being informed about DFLSTs by an intensivist-investigator. The participating intensivists answered ten questions about the DFLSTs of each patient in two scenarios, referring to patients' characteristics without ADs (round 1) and then with (round 2). DFLST score ranged from 0 (no-DFLST) to 10 (DFLST for all questions). The main outcome was variability in DFLSTs between intensivists, expressed as relative standard deviation (RSD). RESULTS A total of 19,680 decisions made by 123 intensivists from 27 ICUs were analyzed. The DFLST score was higher with ADs than without (6.02 95% CI [5.85; 6.19] vs 4.92 95% CI [4.75; 5.10], p < 0.001). High inter-intensivist variability did not change with ADs (RSD: 0.56 (round 1) vs 0.46 (round 2), p = 0.84). Inter-intensivist agreement on DFLSTs was weak with ADs (intra-class correlation coefficient: 0.28). No factor associated with DFLSTs was identified. A qualitative analysis of ADs showed focus on end-of-life wills, unwanted things and fear of pain. CONCLUSIONS ADs increased the DFLST rate but did not reduce variability between the intensivists. In the decision-making process using ADs, the intensivist's decision took priority. Further research is needed to improve the matching of the physicians' decision with the patient's wishes. Trial registration ClinicalTrials.gov Identifier: NCT03013530. Registered 6 January 2017; https://clinicaltrials.gov/ct2/show/NCT03013530 .
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Affiliation(s)
- Margot Smirdec
- Department of Anaesthesiology and Critical Care Medicine, Estaing Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Mercé Jourdain
- INSERM U1190, CHU Lille, Department of Critical Care Medicine, Roger Salengro Hospital, Univ. Lille, 59000, Lille, France
| | - Virginie Guastella
- Palliative Care Unit, Louise Michel Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Céline Lambert
- Biostatistics Unit (DRCI), University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Jean-Christophe Richard
- Medical Intensive Care Unit, La Croix Rousse Hospital, University Hospital of Lyon, Lyon, France
| | - Laurent Argaud
- Medical Intensive Care Unit, Edouard Herriot Hospital, University Hospital of Lyon, Lyon, France
| | - Samir Jaber
- Department of Anaesthesiology and Critical Care Medicine, Saint Eloi Hospital, University Hospital of Montpellier, Montpellier, France
| | - Kada Klouche
- Medical Intensive Care Unit, Lapeyronnie Hospital, University Hospital of Montpellier, Montpellier, France
| | - Anne Medard
- Cardiac Surgery Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, Montpied Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Jean Reignier
- Medical Intensive Care Unit, Hotel-Dieu Hospital, University Hospital of Nantes, Nantes, France
| | | | - Jean-Marc Doise
- Intensive Care Unit, Morey Hospital, Hospital of Chalon-Sur-Saône, Chalon-sur-Saône, France
| | - Russell Chabanne
- Neurocritical Care Unit, Department of Anaesthesiology and Critical Care Medicine, Montpied Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Bertrand Souweine
- Medical Intensive Care Unit, Montpied Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Jeremy Bourenne
- Emergency Intensive Care Unit, La Timone Hospital, University Hospital of Marseille, Marseille, France
| | - Julie Delmas
- Intensive Care Unit, Puel Hospital, Hospital of Rodez, Rodez, France
| | | | | | - Jean-Pierre Quenot
- Medical Intensive Care Unit, Mitterrand Hospital, University Hospital of Dijon, Dijon, France
| | - Cecile Aubron
- Medical Intensive Care Unit, Centre Hospitalier Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | - Nathanael Eisenmann
- Intensive Care Unit, Centre Jean Perrin, 54 Rue Montalembert, BP69, 63003, Clermont-Ferrand, Cedex 1, France
| | - Pierre Asfar
- Medical Intensive Care Unit, Larrey Hospital, University Hospital of Angers, Angers, France
| | - Alexandre Fratani
- Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, Saint-Louis Hospital, Assistance Publique Hopitaux de Paris, Paris, France
| | - Jean Dellamonica
- Medical Intensive Care Unit, l'Archet Hospital, University Hospital of Nice, Nice, France
| | - Nicolas Terzi
- Medical Intensive Care Unit, Michallon Hospital, University Hospital of Grenoble, Grenoble, France
| | - Jean-Michel Constantin
- GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Axelle Van Lander
- UPU ACCePPt, Université Clermont Auvergne, Clermont-Ferrand, France.,EA-481, Laboratoire de Neurosciences, UBFC, Besançon, France
| | - Renaud Guerin
- Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, Estaing Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics Unit (DRCI), University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Alexandre Lautrette
- Intensive Care Unit, Centre Jean Perrin, 54 Rue Montalembert, BP69, 63003, Clermont-Ferrand, Cedex 1, France. .,LMGE «Laboratoire Micro-Organismes: Génome Et Environnement», UMR CNRS 6023, Clermont-Auvergne University, Clermont-Ferrand, France. .,Intensive Care Medicine, Montpied Teaching Hospital, 54 Rue Montalembert, BP69, 63003, Clermont-Ferrand, Cedex 1, France.
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Lo ML, Huang CC, Hu TH, Chou WC, Chuang LP, Chiang MC, Wen FH, Tang ST. Quality Assessments of End-of-Life Care by Medical Record Review for Patients Dying in Intensive Care Units in Taiwan. J Pain Symptom Manage 2020; 60:1092-1099.e1. [PMID: 32650138 DOI: 10.1016/j.jpainsymman.2020.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/28/2020] [Accepted: 07/01/2020] [Indexed: 12/14/2022]
Abstract
CONTEXT/OBJECTIVE Essential indicators of high-quality end-of-life care in intensive care units (ICUs) have been established but examined inconsistently and predominantly with small samples, mostly from Western countries. Our study goal was to comprehensively measure end-of-life-care quality delivered in ICUs using chart-derived process-based quality measures for a large cohort of critically ill Taiwanese patients. METHODS For this observational study, patients with APACHE II score ≥20 or goal of palliative care and with ICU stay exceeding three days (N = 326) were consecutively recruited and followed until death. RESULTS Documentation of process-based indicators for Taiwanese patients dying in ICUs was variable (8.9%-96.3%), but high for physician communication of the patient's poor prognosis to his/her family members (93.0%), providing specialty palliative-care consultations (73.3%), a do-not-resuscitate order in place at death (96.3%), death without cardiopulmonary resuscitation (93.5%), and family presence at patient death (76.1%). Documentation was infrequent for social-worker involvement (8.9%) and interdisciplinary family meetings to discuss goals of care (22.4%). Patients predominantly (79.8%) continued life-sustaining treatments (LSTs) until death and died with full life support, with 88.3% and 58.9% of patients dying with mechanical ventilation support and vasopressors, respectively. CONCLUSIONS Taiwanese patients dying in ICUs heavily used LSTs until death despite high prevalences of documented prognostic communication, providing specialty palliative-care consultations, having a do-not-resuscitate order in place, and death without cardiopulmonary resuscitation. Family meetings should be actively promoted to facilitate appropriate end-of-life-care decisions to avoid unnecessary suffering from potentially inappropriate LSTs during the last days of life.
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Affiliation(s)
- Mei-Ling Lo
- Department of Nursing, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, R.O.C; School of Nursing, Medical College, Chang Gung University, Tao-Yuan, Taiwan, R.O.C
| | - Chung-Chi Huang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, R.O.C; Department of Respiratory Therapy, Chang Gung University, Tao-Yuan, Taiwan, R.O.C
| | - Tsung-Hui Hu
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, R.O.C
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, R.O.C; College of Medicine, Chang Gung University, Tao-Yuan, Taiwan, R.O.C
| | - Li-Pang Chuang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, R.O.C
| | - Ming Chu Chiang
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, R.O.C
| | - Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan, R.O.C
| | - Siew Tzuh Tang
- School of Nursing, Medical College, Chang Gung University, Tao-Yuan, Taiwan, R.O.C; Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, R.O.C; Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, R.O.C.
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Kotsopoulos AM, Jansen NE, Vos P, Witjes M, Volbeda M, Epker JL, Sonneveld HPC, Simons KS, Bronkhorst EM, van der Hoeven HG, Abdo WF. Determining the impact of timing and of clinical factors during end-of-life decision-making in potential controlled donation after circulatory death donors. Am J Transplant 2020; 20:3574-3581. [PMID: 32506559 PMCID: PMC7754148 DOI: 10.1111/ajt.16104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 05/05/2020] [Accepted: 05/23/2020] [Indexed: 01/25/2023]
Abstract
Controlled donation after circulatory death (cDCD) occurs after a decision to withdraw life-sustaining treatment and subsequent family approach and approval for donation. We currently lack data on factors that impact the decision-making process on withdraw life-sustaining treatment and whether time from admission to family approach, influences family consent rates. Such insights could be important in improving the clinical practice of potential cDCD donors. In a prospective multicenter observational study, we evaluated the impact of timing and of the clinical factors during the end-of-life decision-making process in potential cDCD donors. Characteristics and medication use of 409 potential cDCD donors admitted to the intensive care units (ICUs) were assessed. End-of-life decision-making was made after a mean time of 97 hours after ICU admission and mostly during the day. Intracranial hemorrhage or ischemic stroke and a high APACHE IV score were associated with a short decision-making process. Preserved brainstem reflexes, high Glasgow Coma Scale scores, or cerebral infections were associated with longer time to decision-making. Our data also suggest that the organ donation request could be made shortly after the decision to stop active treatment and consent rates were not influenced by daytime or nighttime or by the duration of the ICU stay.
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Affiliation(s)
- Angela M. Kotsopoulos
- Department of Intensive Care MedicineRadboud University Medical CenterNijmegenThe Netherlands
| | | | - Piet Vos
- Department of Intensive CareElisabeth TweeSteden HospitalTilburgThe Netherlands
| | - Marloes Witjes
- Department of Intensive Care MedicineRadboud University Medical CenterNijmegenThe Netherlands
| | - Meint Volbeda
- Department of Intensive Care MedicineUMCG University Medical CenterGroningenThe Netherlands
| | - Jelle L. Epker
- Department of Intensive Care MedicineErasmus University Medical CenterRotterdamThe Netherlands
| | | | - Koen S. Simons
- Department of Intensive Care MedicineJeroen Bosch HospitalDen BoschThe Netherlands
| | - Ewald M. Bronkhorst
- Department of Health EvidenceRadboud University Medical CenterNijmegenThe Netherlands
| | - Hans G. van der Hoeven
- Department of Intensive Care MedicineRadboud University Medical CenterNijmegenThe Netherlands
| | - Wilson F. Abdo
- Department of Intensive Care MedicineRadboud University Medical CenterNijmegenThe Netherlands
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Tanaka M, Kodama S, Lee I, Huxtable R, Chung Y. Forgoing life-sustaining treatment - a comparative analysis of regulations in Japan, Korea, Taiwan, and England. BMC Med Ethics 2020; 21:99. [PMID: 33066771 PMCID: PMC7563900 DOI: 10.1186/s12910-020-00535-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 09/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Regulations on forgoing life-sustaining treatment (LST) have developed in Asian countries including Japan, Korea and Taiwan. However, other countries are relatively unaware of these due to the language barrier. This article aims to describe and compare the relevant regulatory frameworks, using the (more familiar) situation in England as a point of reference. We undertook literature reviews to ascertain the legal and regulatory positions on forgoing LST in Japan, Korea, Taiwan, and England. MAIN TEXT Findings from a literature review are first presented to describe the development of the regulatory frameworks surrounding the option of forgoing LST in each country. Based on the findings from the four countries, we suggest five ethically important points, reflection on which should help to inform the further development of regulatory frameworks concerning end-of-life care in these countries and beyond. There should be reflection on: (1) the definition of - and reasons for defining - the 'terminal stage' and associated criteria for making such judgements; Korea and Taiwan limit forgoing LST to patients in this stage, but there are risks associated with defining this too narrowly or broadly; (2) foregoing LST for patients who are not in this stage, as is allowed in Japan and England, because here too there are areas of controversy, including (in England) whether the law in this area does enough to respect the autonomy of (now) incapacitated patients; (3) whether 'foregoing' LST should encompass withholding and withdrawing treatment; this is also an ethically disputed area, particularly in the Asian countries we examine; (4) the family's role in end-of-life decision-making, particularly as, compared with England, the three Asian countries traditionally place a greater emphasis on families and communities than on individuals; and (5) decision-making with and for those incapacitated patients who lack families, surrogate decision-makers or ADs. CONCLUSION Comparison of, and reflection on, the different legal positions that obtain in Japan, Korea, Taiwan, and England should prove informative and we particularly invite reflection on five areas, in the hope the ensuing discussions will help to establish better end-of-life regulatory frameworks in these countries and elsewhere.
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Affiliation(s)
- Miho Tanaka
- Japan Medical Association Research Institute, 2-28-16 Honkomagome, Bunkyo-ku, Tokyo, 113-8621 Japan
| | - Satoshi Kodama
- Graduate School of Letters, Kyoto University, Yoshida Honmachi, Sakyo-ku, Kyoto, 606-8501 Japan
| | - Ilhak Lee
- College of Medicine, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722 South Korea
| | - Richard Huxtable
- Centre for Ethics in Medicine, Population Health Sciences, Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS UK
| | - Yicheng Chung
- Tokyo Branch of Otani University, Shin Buddhist Comprehensive Research Institute, 2-19-11 Yushima, Bunkyo-ku, Tokyo, 113-0034 Japan
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40
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Severity-Adjusted ICU Mortality Only Tells Half the Truth—The Impact of Treatment Limitation in a Nationwide Database. Crit Care Med 2020; 48:e1242-e1250. [DOI: 10.1097/ccm.0000000000004658] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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41
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Lacerda FH, Checoli PG, Silva CMDD, Brandão CE, Forte DN, Besen BAMP. Mechanical ventilation withdrawal as a palliative procedure in a Brazilian intensive care unit. Rev Bras Ter Intensiva 2020; 32:528-534. [PMID: 33470354 PMCID: PMC7853674 DOI: 10.5935/0103-507x.20200090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 04/19/2020] [Indexed: 11/30/2022] Open
Abstract
Objective To describe the characteristics and outcomes of patients undergoing mechanical ventilation withdrawal and to compare them to mechanically ventilated patients with limitations (withhold or withdrawal) of life-sustaining therapies but who did not undergo mechanical ventilation withdrawal. Methods This was a retrospective cohort study from January 2014 to December 2018 of mechanically ventilated patients with any organ support limitation admitted to a single intensive care unit. We compared patients who underwent mechanical ventilation withdrawal and those who did not regarding intensive care unit and hospital mortality and length of stay in both an unadjusted analysis and a propensity score matched subsample. We also analyzed the time from mechanical ventilation withdrawal to death. Results Out of 282 patients with life-sustaining therapy limitations, 31 (11%) underwent mechanical ventilation withdrawal. There was no baseline difference between groups. Intensive care unit and hospital mortality rates were 71% versus 57% and 93% versus 80%, respectively, among patients who underwent mechanical ventilation withdrawal and those who did not. The median intensive care unit length of stay was 7 versus 8 days (p = 0.6), and the hospital length of stay was 9 versus 15 days (p = 0.015). Hospital mortality was not significantly different (25/31; 81% versus 29/31; 93%; p = 0.26) after matching. The median time from mechanical ventilation withdrawal until death was 2 days [0 - 5], and 10/31 (32%) patients died within 24 hours after mechanical ventilation withdrawal. Conclusion In this Brazilian report, mechanical ventilation withdrawal represented 11% of all patients with treatment limitations and was not associated with increased hospital mortality after propensity score matching on relevant covariates.
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Affiliation(s)
- Fábio Holanda Lacerda
- Unidade de Terapia Intensiva, Hospital da Luz - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva, AC Camargo Cancer Center - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva, Hospital OTOclínica - Fortaleza (CE), Brasil
| | - Pedro Garcia Checoli
- Unidade de Terapia Intensiva, Hospital da Luz - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva, Hospital Sírio-Libanês - São Paulo (SP), Brasil
| | - Carla Marchini Dias da Silva
- Unidade de Terapia Intensiva, Hospital da Luz - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva, AC Camargo Cancer Center - São Paulo (SP), Brasil
| | - Carlos Eduardo Brandão
- Unidade de Terapia Intensiva, Hospital da Luz - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva, AC Camargo Cancer Center - São Paulo (SP), Brasil
| | - Daniel Neves Forte
- Programa de Cuidados Paliativos, Hospital Sírio-Libanês - São Paulo (SP), Brasil
| | - Bruno Adler Maccagnan Pinheiro Besen
- Unidade de Terapia Intensiva, Hospital da Luz - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva, Disciplina de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo, Brasil
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Adamski J, Weigl W, Lahtinen P, Reinikainen M, Kaminski T, Pietiläinen L, Musialowicz T. Intensive care patient survival after limiting life-sustaining treatment-The FINNEOL* national cohort study. Acta Anaesthesiol Scand 2020; 64:1144-1153. [PMID: 32329052 DOI: 10.1111/aas.13612] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 04/11/2020] [Accepted: 04/17/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Few studies have examined survival in intensive care unit (ICU) patients after the restriction of life-sustaining treatment (LST). We aimed to analyse independent factors associated with hospital and 12-month survival rates in ICU patients after treatment restrictions. METHODS This retrospective observational study examined all patients treated in adult ICUs from 1 January 2016 until 31 December 2016 included in the Finnish ICU Registry. Multivariable logistic regression analysis was performed to explain the effect on survival. RESULTS Decisions to limit LST were made for 2444 patients (13.7%; 95% CI 13.2-14.2). ICU, hospital, and 12-month survival rates were 71% (95% CI 69-73), 49% (95% CI 47-51), and 24% (95% CI 22-26), respectively. In patients for whom life support was withheld, increased 12-month survival rates were associated with admission from the operating theatre (OR 1.9, 95% CI 1.1-3.4), good pre-hospital physical fitness (OR 4.7, 95% Cl 1.2-16.8) and being housed at home (OR 2.0, 95% Cl 1.4-2.8). Decreased survival rates were associated with admission from a hospital ward (OR 0.67, 95% Cl 0.5-0.9), higher comorbidity (OR 0.6, 95% Cl 0.4-0.9), cancer (OR 0.4, 95%CI 0.2-0.9), greater illness severity (SAPS II; OR 0.98, 95% Cl 0.98-0.99), and higher care intensity (TISS-76; OR 0.93, 95% Cl 0.92-0.95). CONCLUSION Survival among ICU patients with limited treatment was higher than expected. Advanced age was not associated with higher mortality, potentially because treatment restrictions may be set more easily for older patients.
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Affiliation(s)
- Jan Adamski
- Department of Intensive Care Medicine Satakunta Central Hospital Pori Finland
| | - Wojciech Weigl
- Anaesthesiology and Intensive Care Department of Surgical Sciences Uppsala University Hospital Uppsala Sweden
| | - Pasi Lahtinen
- Department of Anaesthesiology and Intensive Care Medicine Kuopio University Hospital Kuopio Finland
| | - Matti Reinikainen
- Department of Anaesthesiology and Intensive Care Medicine Kuopio University Hospital Kuopio Finland
- Faculty of Health Sciences School of Medicine Institute of Clinical Medicine University of Eastern Finland Kuopio Finland
| | - Tadeusz Kaminski
- Department of Intensive Care Medicine Central Hospital of Middle Ostrobothnia Kokkola Finland
| | - Laura Pietiläinen
- Department of Anaesthesiology and Intensive Care Medicine Kuopio University Hospital Kuopio Finland
| | - Tadeusz Musialowicz
- Department of Anaesthesiology and Intensive Care Medicine Kuopio University Hospital Kuopio Finland
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El Jawiche R, Hallit S, Tarabey L, Abou-Mrad F. Withholding and withdrawal of life-sustaining treatments in intensive care units in Lebanon: a cross-sectional survey of intensivists and interviews of professional societies, legal and religious leaders. BMC Med Ethics 2020; 21:80. [PMID: 32859185 PMCID: PMC7456082 DOI: 10.1186/s12910-020-00525-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 08/24/2020] [Indexed: 11/23/2022] Open
Abstract
Background Little is known about the attitudes and practices of intensivists working in Lebanon regarding withholding and withdrawing life-sustaining treatments (LSTs). The objectives of the study were to assess the points of view and practices of intensivists in Lebanon along with the opinions of medical, legal and religious leaders regarding withholding withdrawal of life-sustaining treatments in Lebanese intensive care units (ICU). Methods A web-based survey was conducted among intensivists working in Lebanese adult ICUs. Interviews were also done with Lebanese medical, legal and religious leaders. Results Of the 229 survey recipients, 83 intensivists completed it, i.e. a response rate of (36.3%). Most respondents were between 30 and 49 years old (72%), Catholic Christians (60%), anesthesiologists (63%), working in Beirut (47%). Ninety-two percent of them were familiar with the withholding and withdrawal concepts and 80% applied them. Poor prognosis of the acute and chronic disease and futile therapy were the main reasons to consider withholding and withdrawal of treatments. Ninety-five percent of intensivists agreed with the “Principle of Double Effect” (i.e. adding analgesia and or sedation to patients after the withholding/withdrawal decisions in order to prevent their suffering and allow their comfort, even though it might hasten the dying process). The main withheld therapies were vasopressors, respiratory assistance and CPR. Most of the respondents reported the decision was often to always multidisciplinary (92%), involving the family (68%), and the patient (65%), or his advance directives (77%) or his surrogate (81%) and the nurses (78%). The interviewees agreed there was a law governing withholding and withdrawal decisions/practices in Lebanon. Christians and Muslim Sunni leaders declared accepting those practices (withholding or withdrawing LSTs from patients when appropriate). Conclusion Withholding and withdrawal of LSTs in the ICU are known concepts among intensivists working in Lebanon and are being practiced. Our results could be used to inform and optimize therapeutic limitation in ICUs in the country.
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Affiliation(s)
- Rita El Jawiche
- Anesthesia Department, Bahman Hospital, Haret Hreik, near Masjed El Hassanein, Beirut, Lebanon.
| | - Souheil Hallit
- Faculty of Medicine and Medical Sciences, Holy Spirit University of Kaslik (USEK), Jounieh, Lebanon. .,INSPECT-LB: Institut National de Santé Publique, Epidemiologie Clinique et Toxicologie- Liban, Beirut, Lebanon.
| | - Lubna Tarabey
- Institute of Social Sciences and Medical School, Lebanese University, Hadath, Lebanon
| | - Fadi Abou-Mrad
- Neurology Division and Memory Clinic, Saint Charles Hospital, Baabda, Lebanon.,Division of Medical Ethics & Forensic Medicine, Lebanese University, Hadath, Lebanon
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Abstract
Critical care clinicians strive to reverse the disease process and are frequently faced with difficult end-of-life (EoL) situations, which include transitions from curative to palliative care, avoidance of disproportionate care, withholding or withdrawing therapy, responding to advance treatment directives, as well as requests for assistance in dying. This article presents a summary of the most common issues encountered by intensivists caring for patients around the end of their life. Topics explored are the practices around limitations of life-sustaining treatment, with specific mention to the thorny subject of assisted dying and euthanasia, as well as the difficulties encountered regarding the adoption of advance care directives in clinical practice and the importance of integrating palliative care in the everyday practice of critical-care physicians. The aim of this article is to enhance understanding around the complexity of EoL decisions, highlight the intricate cultural, religious, and social dimensions around death and dying, and identify areas of potential improvement for individual practice.
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Affiliation(s)
- Victoria Metaxa
- Critical Care Department, King's College Hospital NHS Foundation Trust, London, United Kingdom
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Factors affecting the attitudes and opinions of ICU physicians regarding end-of-life decisions for their patients and themselves: A survey study from Turkey. PLoS One 2020; 15:e0232743. [PMID: 32433670 PMCID: PMC7239490 DOI: 10.1371/journal.pone.0232743] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 04/21/2020] [Indexed: 01/05/2023] Open
Abstract
Introduction Turkey is constitutionally secular with a Muslim majority. There is no legal basis for limiting life-support at the end-of-life (EOL) in Turkey. We aimed to investigate the opinions and attitudes of intensive care unit (ICU) physicians regarding EOL decisions, for both their patients and themselves, and to evaluate if the physicians’ demographic and professional variables predicted the attitudes of physicians toward EOL decisions. Methods An online survey was distributed to national critical care societies’ members. Physicians’ opinions were sought concerning legalization of EOL decisions for terminally ill patients or by patient-request regardless of prognosis. Participants physicians’ views on who should make EOL decisions and when they should occur were determined. Participants were also asked if they would prefer cardiopulmonary resuscitation (CPR) and/or intubation/mechanical ventilation (MV) personally if they had terminal cancer. Results A total of 613 physicians responded. Religious beliefs had no effect on the physicians’ acceptance of do-not-resuscitate (DNR) / do-not-intubate (DNI) orders for terminally ill patients, but atheism, was found to be an independent predictor of approval of DNR/DNI in cases of patient request (p<0.05). While medical experience (≥6 years in the ICU) was the independent predictor for the physicians’ approval of DNI decisions on patient demand, the volume of terminal patients in ICUs (between 10–50% per year) where they worked was an independent predictor of physicians’ approval of DNI for terminal patients. When asked to choose personal options in an EOL scenario (including full code, only DNR, only DNI, both DNR and DNI, and undecided), younger physicians (30–39 years) were more likely to prefer the "only DNR" option compared with physicians aged 40–49 years (p<0.05) for themselves and age 30–39 was an independent predictor of individual preference for "only DNR” at the hypothetical EOL. Physicians from an ICU with <10% terminally ill patients were less likely to prefer "DNR" or "DNR and DNI" options for themselves at EOL compared with physicians who worked in ICUs with a higher (>50%) terminally ill patient ratio (p<0.05). Conclusion Most ICU physicians did not want legalization of DNR and DNI orders, based solely on patient request. Even if EOL decision-making were legal in Turkey, this attitude may conflict with patient autonomy. The proportion of terminally ill patients in the ICU appears to affect physicians’ attitudes to EOL decisions, both for their patients and by personal preference, an association which has not been previously reported.
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The Disappearing Dichotomy Between Critical Care and Palliative Care: Integration Will Enhance Patient Outcomes. Crit Care Med 2020; 47:1667-1668. [PMID: 31609267 DOI: 10.1097/ccm.0000000000003994] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sprung CL, Ricou B, Hartog CS, Maia P, Mentzelopoulos SD, Weiss M, Levin PD, Galarza L, de la Guardia V, Schefold JC, Baras M, Joynt GM, Bülow HH, Nakos G, Cerny V, Marsch S, Girbes AR, Ingels C, Miskolci O, Ledoux D, Mullick S, Bocci MG, Gjedsted J, Estébanez B, Nates JL, Lesieur O, Sreedharan R, Giannini AM, Fuciños LC, Danbury CM, Michalsen A, Soliman IW, Estella A, Avidan A. Changes in End-of-Life Practices in European Intensive Care Units From 1999 to 2016. JAMA 2019; 322:1692-1704. [PMID: 31577037 PMCID: PMC6777263 DOI: 10.1001/jama.2019.14608] [Citation(s) in RCA: 115] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
IMPORTANCE End-of-life decisions occur daily in intensive care units (ICUs) around the world, and these practices could change over time. OBJECTIVE To determine the changes in end-of-life practices in European ICUs after 16 years. DESIGN, SETTING, AND PARTICIPANTS Ethicus-2 was a prospective observational study of 22 European ICUs previously included in the Ethicus-1 study (1999-2000). During a self-selected continuous 6-month period at each ICU, consecutive patients who died or had any limitation of life-sustaining therapy from September 2015 until October 2016 were included. Patients were followed up until death or until 2 months after the first treatment limitation decision. EXPOSURES Comparison between the 1999-2000 cohort vs 2015-2016 cohort. MAIN OUTCOMES AND MEASURES End-of-life outcomes were classified into 5 mutually exclusive categories (withholding of life-prolonging therapy, withdrawing of life-prolonging therapy, active shortening of the dying process, failed cardiopulmonary resuscitation [CPR], brain death). The primary outcome was whether patients received any treatment limitations (withholding or withdrawing of life-prolonging therapy or shortening of the dying process). Outcomes were determined by senior intensivists. RESULTS Of 13 625 patients admitted to participating ICUs during the 2015-2016 study period, 1785 (13.1%) died or had limitations of life-prolonging therapies and were included in the study. Compared with the patients included in the 1999-2000 cohort (n = 2807), the patients in 2015-2016 cohort were significantly older (median age, 70 years [interquartile range {IQR}, 59-79] vs 67 years [IQR, 54-75]; P < .001) and the proportion of female patients was similar (39.6% vs 38.7%; P = .58). Significantly more treatment limitations occurred in the 2015-2016 cohort compared with the 1999-2000 cohort (1601 [89.7%] vs 1918 [68.3%]; difference, 21.4% [95% CI, 19.2% to 23.6%]; P < .001), with more withholding of life-prolonging therapy (892 [50.0%] vs 1143 [40.7%]; difference, 9.3% [95% CI, 6.4% to 12.3%]; P < .001), more withdrawing of life-prolonging therapy (692 [38.8%] vs 695 [24.8%]; difference, 14.0% [95% CI, 11.2% to 16.8%]; P < .001), less failed CPR (110 [6.2%] vs 628 [22.4%]; difference, -16.2% [95% CI, -18.1% to -14.3%]; P < .001), less brain death (74 [4.1%] vs 261 [9.3%]; difference, -5.2% [95% CI, -6.6% to -3.8%]; P < .001) and less active shortening of the dying process (17 [1.0%] vs 80 [2.9%]; difference, -1.9% [95% CI, -2.7% to -1.1%]; P < .001). CONCLUSIONS AND RELEVANCE Among patients who had treatment limitations or died in 22 European ICUs in 2015-2016, compared with data reported from the same ICUs in 1999-2000, limitations in life-prolonging therapies occurred significantly more frequently and death without limitations in life-prolonging therapies occurred significantly less frequently. These findings suggest a shift in end-of-life practices in European ICUs, but the study is limited in that it excluded patients who survived ICU hospitalization without treatment limitations.
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Affiliation(s)
- Charles L. Sprung
- Department of Anesthesiology, Critical Care Medicine, and Pain Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Bara Ricou
- Department of Anesthesiology, Pharmacology, and Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | - Christiane S. Hartog
- Department of Anesthesiology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin and Klinik Bavaria, Kreischa, Germany
| | - Paulo Maia
- Intensive Care Department, Hospital S. Antonio, Centro Hospitalar do Porto, Porto, Portugal
| | - Spyros D. Mentzelopoulos
- First Department of Intensive Care Medicine, University of Athens Medical School, Evaggelsimos General Hospital, Athens, Greece
| | - Manfred Weiss
- Clinic of Anaesthesiology, University Hospital Medical School, Ulm, Germany
| | - Phillip D. Levin
- General Intensive Care Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Laura Galarza
- Intensive Care Unit, Hospital General Universitario de Castellón, Castellón de la Plana, Spain
| | - Veronica de la Guardia
- Department of Anesthesiology, Critical Care Medicine, and Pain Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Joerg C. Schefold
- Inselspital, Department of Intensive Care Medicine, University of Bern, Switzerland
| | - Mario Baras
- The Hebrew University—Hadassah School of Public Health, Jerusalem, Israel
| | - Gavin M. Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Hans-Henrik Bülow
- Department of Anesthesiology and Intensive Care, Holbaek University Hospital, Zealand Region, Denmark
| | - Georgios Nakos
- Department of Intensive Care Medicine, University of Ioannina, Ioannina, Greece
| | - Vladimir Cerny
- Department of Anesthesiology, Perioperative Medicine, and Intensive Care, J.E. Purkinje University, Masaryk Hospital Usti nad Labem, Czech Republic
| | - Stephan Marsch
- Medical Intensive Care, University of Basel Hospital, Basel, Switzerland
| | - Armand R. Girbes
- Department of Intensive Care Medicine, VU Medical Center, Amsterdam, the Netherlands
| | - Catherine Ingels
- Intensive Care Medicine, University Hospitals K.U. Leuven, Leuven Belgium
| | - Orsolya Miskolci
- Mater Misericordiae University Hospital, Intensive Care Unit, Dublin, Ireland
| | - Didier Ledoux
- Department of Anesthesiology and Intensive Care Medicine, University of Liege, Liege, Belgium
| | | | - Maria G. Bocci
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Jakob Gjedsted
- Department of Anesthesia and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Belén Estébanez
- Intensive Care Unit, Hospital Universitario La Paz, Madrid, Spain
| | - Joseph L. Nates
- Critical Care Department, The University of Texas MD Anderson Cancer Center, Houston
| | - Olivier Lesieur
- Intensive Care Unit, Saint Louis General Hospital, La Rochelle, France
| | - Roshni Sreedharan
- Department of General Anesthesiology, Center for Critical Care Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Alberto M. Giannini
- Division of Pediatric Anesthesia and Intensive Care, ASST Spedali Civili, Brescia, Italy
| | | | | | - Andrej Michalsen
- Department of Anesthesiology and Critical Care, Medizin Campus Bodensee-Tettnang Hospital, Tettnang, Germany
| | - Ivo W. Soliman
- Department of Intensive Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Angel Estella
- Intensive Care Department, University Hospital SAS of Jerez, Jerez de la Frontera, Spain
| | - Alexander Avidan
- Department of Anesthesiology, Critical Care Medicine, and Pain Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
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Estimating the Impact of Words Used by Physicians in Advance Care Planning Discussions: The "Do You Want Everything Done?" Effect. Crit Care Explor 2019; 1:e0052. [PMID: 32166233 PMCID: PMC7063893 DOI: 10.1097/cce.0000000000000052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. To estimate the probability of a substitute decision maker choosing to withdraw life-sustaining therapy after hearing an affirmative patient response to the phrase “Do you want everything done?”
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Update and recommendations in decision making referred to limitation of advanced life support treatment. Med Intensiva 2019; 44:101-112. [PMID: 31472947 DOI: 10.1016/j.medin.2019.07.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 06/16/2019] [Accepted: 07/14/2019] [Indexed: 12/18/2022]
Abstract
The Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) Bioethics Working Group has developed recommendations on the Limitation of Advanced Life Support Treatment (LLST) decisions, with the aim of reducing variability in clinical practice and of improving end of life care in critically ill patients. The conceptual framework of LLST and futility are explained. Recommendations referred to new forms of LLST encompassing also the adequacy of other treatments and diagnostic methods are developed. In addition, planning of the possible clinical courses following the decision of LLST is commented. The importance of advanced care planning in decision-making is emphasized, and intensive care oriented towards organ donation at end of life in the critically ill patient is described. The integration of palliative care in the critical patient treatment is promoted in end of life stages in the Intensive Care Unit.
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Abstract
PURPOSE OF REVIEW The burden of critical illness in low-income and middle-income countries (LMICs) is substantial. A better understanding of critical care outcomes is essential for improving critical care delivery in resource-limited settings. In this review, we provide an overview of recent literature reporting on critical care outcomes in LMICs. We discuss several barriers and potential solutions for a better understanding of critical care outcomes in LMICs. RECENT FINDINGS Epidemiologic studies show higher in-hospital mortality rates for critically ill patients in LMICs as compared with patients in high-income countries (HICs). Recent findings suggest that critical care interventions that are effective in HICs may not be effective and may even be harmful in LMICs. Little data on long-term and morbidity outcomes exist. Better outcomes measurement is beginning to emerge in LMICs through decision support tools that report process outcome measures, studies employing mobile health technologies with community health workers and the development of context-specific severity of illness scores. SUMMARY Outcomes from HICs cannot be reliably extrapolated to LMICs, so it is important to study outcomes for critically ill patients in LMICs. Specific challenges to achieving meaningful outcomes studies in LMICs include defining the critically ill population when few ICU beds exist, the resource-intensiveness of long-term follow-up, and the need for reliable severity of illness scores to interpret outcomes. Although much work remains to be done, examples of studies overcoming these challenges are beginning to emerge.
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