Limitación del esfuerzo terapéutico

Factors associated with limitation of life support: Post-ICU mortality case study of a tertiary hospital

BACKGROUND

Life-sustaining treatment limitation (LSV) is the medical act of withdrawing or not initiating measures that are considered futile in a patient's specific situation. LSV in critically ill patients remains a difficult topic to study, due to the multitude of factors that condition it.

OBJECTIVE

To determine factors related to LSV in ICU in cases of post-ICU in-hospital mortality, as well as factors associated with survival after discharge from ICU.

DESIGN

Retrospective longitudinal study.

AMBIT

Intensive care unit of a tertiary hospital.

PATIENTS

People who died in the hospitalization ward after ICU treatment between January 2014 and December 2019.

INTERVENTIONS

None. This is an observational study.

VARIABLES OF INTEREST

Age, sex, probability of death, type of admission, LSV in ICU, oncological disease, dependence, invasive mechanical ventilation, emergency hemodialysis, transfusion of blood products, nosocomial infection (NI), pre-ICU, intra-ICU and post-ICU stays.

RESULTS

Of 114 patients who died outside the ICU, 49 had LSV registered in the ICU (42.98%). Age and stay prior to ICU admission were positively associated with LSV (OR 1,03 and 1,08, respectively). Patients without LSV had a higher post-ICU stay, while it was lower for male patients.

CONCLUSIONS

Our results support that LSV established within the ICU can avoid complications commonly associated with unnecessary prolongation of stay, such as NI.

[The Death of Children: Ethical dilemmas about the limitation of therapeutic effort]

Ethical dilemmas take importance in current medical practice, especially at the end of life. Limitation of therapeutic effort, understood as not starting or withdrawing life support measures, is an alternative to preserve patient dignity when death approaches. Ethical dilemmas in this context have been widely studied in adults; not in children, in which the big psychological tension experienced by parents and professionals makes difficult to take accepted and consensual ethical decisions. The objective of this work has been to understand the concept of limitation of therapeutic effort and the deontological principles that support them in the pediatric field. The purpose was none other than to establish improvements in dying children whom peculiar life-end makes necessary a different approach of adults and an ethical conceptual clarification which justify LET practice in youngers.

Do internists know what limitation of therapeutic effort means?

OBJECTIVES

To ascertain whether internists know what limitation of therapeutic effort (LTE) means and whether training in palliative care affects this understanding.

METHODS

A survey was administered to Spanish internists on their knowledge of LTE and training in palliative care.

RESULTS

A total of 273 respondents completed the survey (mean age, 42±12 years), 80.2% of whom were associates. Some 23.8% of the respondents identified the complete definition of LTE. The most frecuently selected responses were «not starting an active treatment»(85.0%) and «withdrawing an active treatment» (65.9%). Forty-three percent of the respondents lacked training in palliative care, 73.3% considered their level of understanding to be good or very good, 62.3% stated that they became anxious when addressing planning for end-of-life care with a patient, and 81.3% stated that they had experienced some conflict with their LTE decisions.

CONCLUSIONS

Only 1 of every 4 internists knew the proper definition of LTE, with no association with level of training in palliative care.

Do internists know what limitation of therapeutic effort means?

OBJECTIVES

To ascertain whether internists know what limitation of therapeutic effort (LTE) means and whether training in palliative care affects this understanding.

METHODS

A survey was administered to Spanish internists on their knowledge of LTE and training in palliative care.

RESULTS

A total of 273 respondents completed the survey (mean age, 42±12 years), 80.2% of whom were associates. Some 23.8% of the respondents identified the complete definition of LTE. The most frequently selected responses were "not starting an active treatment" (85.0%) and "withdrawing an active treatment" (65.9%). Forty-three percent of the respondents lacked training in palliative care, 73.3% considered their level of understanding to be good or very good, 62.3% stated that they became anxious when addressing planning for end-of-life care with a patient, and 81.3% stated that they had experienced some conflict with their LTE decisions.

CONCLUSIONS

Only 1 of every 4 internists knew the proper definition of LTE, with no association with the level of training in palliative care.

Evaluación del conocimiento y práctica de la limitación del esfuerzo terapéutico en personal asistencial de una institución prestadora de servicios de salud para pacientes oncológicos de Medellín, 2018

La limitación del esfuerzo terapéutico (LET) es toda acción que implique suspender o no iniciar tratamientos o medidas terapéuticas en pacientes que no se beneficiarán clínicamente. En Latinoamérica, las investigaciones realizadas dejan en evidencia la falta de familiarización y discordancia que hay alrededor del tema y sus prácticas. El presente estudio buscó objetivizar el conocimiento en LET del personal de salud de una institución de Medellín, a partir de una encuesta autoaplicada que permitió el desarrollo de un estudio descriptivo de tipo transversal, con muestreo no probabilístico. Dentro de los resultados se encontró que el 56,5 % de los encuestados refirió conocer el concepto, y el 90 % manifestó aplicarlo. Sin embargo, había discordancias dentro de los conceptos clave de la definición y el ejercicio.

Suitability of therapeutic effort in paediatric intensive care units: Opinion and attitude of professionals

OBJECTIVE

To determine the opinion and describe the attitude of different health professionals on suitability of therapeutic effort.

METHOD

Multi-centre, cross-sectional observational study carried out with nurses and doctors who work in the paediatric intensive care units of four hospitals in the Madrid region. A self-administered questionnaire, previously piloted to assess its viability, was used and a sealed box was set up at the nursing station to hand it in. The analysis was performed using SPSS 21.0 software.

RESULTS

The 98.9% of the respondents were in favour of suitability of therapeutic effort. Doctors consider that the decision is made with the agreement of the multidisciplinary staff and the child's parents (48.8%). Of the nurses, 51.1% believe that the decision is made by agreement with the doctors and parents. Of the nurses, 65.5% state that they are never asked about decision-making for their patients. Of the doctors, 75% are always or almost always asked. Fifty-seven percent of the nurses and 83% of the doctors feel capable of making decisions about suitability of therapeutic effort. Of the professionals, 77.2% believe that suitability is used less often than required.

CONCLUSIONS

There are differences between doctors and nurses both in the perception of the decision-making model and in the way to proceed. Professionals seem not to follow any protocols or circuits in the decision-making process.

The advocacy role of nurses in cardiopulmonary resuscitation

BACKGROUND

The decision whether to initiate cardiopulmonary resuscitation may sometimes be ethically complex. While studies have addressed some of these issues, along with the role of nurses in cardiopulmonary resuscitation, most have not considered the importance of nurses acting as advocates for their patients with respect to cardiopulmonary resuscitation.

RESEARCH OBJECTIVE

To explore what the nurse's advocacy role is in cardiopulmonary resuscitation from the perspective of patients, relatives, and health professionals in the Basque Country (Spain).

RESEARCH DESIGN

An exploratory critical qualitative study was conducted from October 2015 to March 2016. Thematic analysis was used to analyse the data.

PARTICIPANTS

Four discussion groups were held: one with patients and relatives (n = 8), two with nurses (n = 7 and n = 6, respectively), and one with physicians (n = 5).

ETHICAL CONSIDERATIONS

Approval was obtained from the Basque Country Clinical Research Ethics Committee.

FINDINGS

Three significant themes were identified: (a) accompanying patients during end of life in a context of medical dominance, (b) maintaining the pact of silence, and (c) yielding to legal uncertainty and concerns.

DISCUSSION

The values and beliefs of the actors involved, as well as pre-established social and institutional rules reduced nurses' advocacy to that of intermediaries between the physician and the family within the hospital environment. On the contrary, in primary health care, nurses participated more actively within the interdisciplinary team.

CONCLUSION

This study provides key information for the improvement and empowerment for ethical nursing practice in a cardiac arrest, and provides the perspective of patients and relatives, nurses and physicians.

[Limitation of therapeutic effort in patients with bacteremia]

INTRODUCTION

The limitation of therapeutic effort (LTE) depends on medical, ethical and individual factors. We describe the characteristics of patients with bacteremia in which it was decided to limit the therapeutic effort.

METHOD

Prospective study of bacteremia in a community hospital in 2011. We collected information regarding patient variable (age, sex, Barthel index, comorbidities, Charlson Index and exogenous factors) as well as regarding the infectious episode (etiology, focus, place of adquisition, clinical expressivity, LTE and hospital mortality). The group in which LTE was performed was compared to the one that was not.

RESULTS

We collected 233 episodes of bacteremia in 227 patients. We performed LTE in 19 patients (8.2%). Patients with LTE were older (80.7 vs. 72.6 years, p=.014), had more comorbidity (Charlson index 4.6 vs. 2.1, p<.001 and most frequently were severe dependents (57.9% vs. 18.8%, p<.001). We found no association with sex, place of adquisition or clinical expressivity. The commonest clinical focus in patients with LTE was the urinary (42.1%) and there was a predominance of gram positive bacteria (63.2%). The empirical treatment was started early in 73.7% of cases. All patients except one died.

CONCLUSION

LTE is considered in an important number of patients with bacteremia. They usually are older, with more comorbidity and functional dependence, bad functional basal status and important comorbidity. Knowing their differential characteristics allow us to understand this decision.

End-of-life care in a cardiology department: have we improved?

BACKGROUND

End-of-life care is not usually a priority in cardiology departments. We sought to evaluate the changes in end-of-life care after the introduction of a do-not-resuscitate (DNR) order protocol.

METHODS & RESULTS

Retrospective analysis of all deaths in a cardiology department in two periods, before and after the introduction of the protocol. Comparison of demographic characteristics, use of DNR orders, and end-of-life care issues between both periods, according to the presence in the second period of the new DNR sheet (Group A), a conventional DNR order (Group B) or the absence of any DNR order (Group C). The number of deaths was similar in both periods (n = 198 vs. n = 197). The rate of patients dying with a DNR order increased significantly (57.1% vs. 68.5%; P = 0.02). Only 4% of patients in both periods were aware of the decision taken about cardiopulmonary resuscitation. Patients in Group A received the DNR order one day earlier, and 24.5% received it within the first 24 h of admission (vs. 2.6% in the first period; P < 0.001). All patients in Group A with an implantable cardioverter defibrillator (ICD) had shock therapies deactivated (vs. 25.0% in the first period; P = 0.02).

CONCLUSIONS

The introduction of a DNR order protocol may improve end-of-life care in cardiac patients by increasing the use and shortening the time of registration of DNR orders. It may also contribute to increase ICD deactivation in patients with these orders in place. However, the introduction of the sheet in late stages of the disease failed to improve patient participation.

[Improving shared decision-making for hospital patients: Description and evaluation of a treatment intensity assessment tool]

BACKGROUND AND AIM

Shared decision-making between patients and healthcare professionals is crucial to guarantee adequate coherence between patient values and preferences, caring aims and treatment intensity, which is key for the provision of patient-centred healthcare. The assessment of such interventions are essential for caring continuity purposes. To do this, reliable and easy-to-use assessment systems are required. This study describes the results of the implementation of a hospital treatment intensity assessment tool.

MATERIAL AND METHODS

The pre-implementation and post-implementation results were compared between two cohorts of patients assessed for one month.

RESULTS

Some record of care was registered in 6.1% of patients in the pre-implementation group (n=673) compared to 31.6% of patients in the post-implementation group (n=832) (P<.01), with differences between services. Hospital mortality in both cohorts is 1.9%; in the pre-implementation group, 93.75% of deceased patients had treatment intensity assessment.

CONCLUSIONS

In hospital settings, the availability of a specific tool seems to encourage very significantly shared decision-making processes between patients and healthcare professionals -multiplying by more than 5 times the treatment intensity assessment. Moreover, such tools help in the caring continuity processes between different teams and the personalisation of caring interventions to be monitored. More research is needed to continue improving shared decision-making for hospital patients.

[Limitation of therapeutic effort: Approach to a combined view]

Over the past few decades, we have been witnessing that increasing fewer people pass away at home and increasing more do so within the hospital. More specifically, 20% of deaths now occur in an intensive care unit (ICU). However, death in the ICU has become a highly technical process. This sometimes originates excesses because the resources used are not proportionate related to the purposes pursued (futility). It may create situations that do not respect the person's dignity throughout the death process. It is within this context that the situation of the clinical procedure called "limitation of the therapeutic effort" (LTE) is reviewed. This has become a true bridge between Intensive Care and Palliative Care. Its final goal is to guarantee a dignified and painless death for the terminally ill.

Editors' report, 2012

The editors of Revista Clínica Española (Rev Clin Esp) inform on their editorial activity during the last 12 months: a) objectives and attainments; b) editorial activity; and c) objectives for 2013. In 2012 the most relevant modifications concerning the editorial activity have been: a) revision by the responsible editor of all manuscripts sent to peer review, and b) translation into English of five manuscripts with abstract of each issue. From the first January to the 30th September 2012 we handled 457 manuscripts (50 manuscripts per month) a figure 22.5% higher than in 2011 (40.8 manuscripts per month). We have accepted 27.2% of all manuscripts (originals, 13.0%). We asked for 295 revisions to 241 reviewers and we have received 66.1% of the revisions asked for in less than two weeks (mean time to receive a revision, 11.3 days). The mean time to adopt an editorial decision for all manuscripts («accept»/«reject») has been 23.9 days (31.3 days in 2011; 35.4 in 2010). This figure has been 29.4 days for the original manuscripts (9.5 and 12.3 days less than in 2011 and 2010, respectively). The mean time taken since a manuscript is received to publication has dropped from 203 days in 2010, 168 in 2011 and 115 in 2012 (less than 3 months). The collaboration with the working groups has reported 19 published manuscripts in 2012. We hope that in 2013 both the English version and the digitalization of Rev Clin Esp from 1940 to 1999 (the journal is already digitalized since 2000) will become a reality. The renewal of the actual sections (i.e., clinical conference, an image for a diagnosis) pretends, with the collaboration of all, to make our journal, each day, better.