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Javed U, Podury S, Kwon S, Liu M, Kim D, Fallah Zadeh A, Li Y, Khan A, Francois F, Schwartz T, Zeig-Owens R, Grunig G, Veerappan A, Zhou J, Crowley G, Prezant D, Nolan A. Biomarkers of Airway Disease, Barrett's and Underdiagnosed Reflux Noninvasively (BAD-BURN): a Case-Control Observational Study Protocol. RESEARCH SQUARE 2024:rs.3.rs-4355584. [PMID: 38798396 PMCID: PMC11118699 DOI: 10.21203/rs.3.rs-4355584/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
BACKGROUND Particulate matter exposure (PM) is a cause of aerodigestive disease globally. The destruction of the World Trade Center (WTC) exposed fifirst responders and inhabitants of New York City to WTC-PM and caused obstructive airways disease (OAD), gastroesophageal Refux disease (GERD) and Barrett's Esophagus (BE). GERD not only diminishes health-related quality of life but also gives rise to complications that extend beyond the scope of BE. GERD can incite or exacerbate allergies, sinusitis, bronchitis, and asthma. Disease features of the aerodigestive axis can overlap, often necessitating more invasive diagnostic testing and treatment modalities. This presents a need to develop novel non-invasive biomarkers of GERD, BE, airway hyperreactivity (AHR), treatment efficacy, and severity of symptoms. METHODS Our observational case-cohort study will leverage the longitudinally phenotyped Fire Department of New York (FDNY)-WTC exposed cohort to identify Biomarkers of Airway Disease, Barrett's and Underdiagnosed Refux Noninvasively (BAD-BURN). Our study population consists of n = 4,192 individuals from which we have randomly selected a sub-cohort control group (n = 837). We will then recruit subgroups of i. AHR only ii. GERD only iii. BE iv. GERD/BE and AHR overlap or v. No GERD or AHR, from the sub-cohort control group. We will then phenotype and examine non-invasive biomarkers of these subgroups to identify under-diagnosis and/or treatment efficacy. The findings may further contribute to the development of future biologically plausible therapies, ultimately enhance patient care and quality of life. DISCUSSION Although many studies have suggested interdependence between airway and digestive diseases, the causative factors and specific mechanisms remain unclear. The detection of the disease is further complicated by the invasiveness of conventional GERD diagnosis procedures and the limited availability of disease-specific biomarkers. The management of Refux is important, as it directly increases risk of cancer and negatively impacts quality of life. Therefore, it is vital to develop novel noninvasive disease markers that can effectively phenotype, facilitate early diagnosis of premalignant disease and identify potential therapeutic targets to improve patient care. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05216133; January 18, 2022.
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Affiliation(s)
- Urooj Javed
- New York University Grossman School of Medicine (NYUGSoM)
| | - Sanjiti Podury
- New York University Grossman School of Medicine (NYUGSoM)
| | - Sophia Kwon
- New York University Grossman School of Medicine (NYUGSoM)
| | - Mengling Liu
- New York University Grossman School of Medicine (NYUGSoM)
| | - Daniel Kim
- New York University Grossman School of Medicine (NYUGSoM)
| | | | - Yiwei Li
- New York University Grossman School of Medicine (NYUGSoM)
| | - Abraham Khan
- New York University Grossman School of Medicine (NYUGSoM)
| | - Fritz Francois
- New York University Grossman School of Medicine (NYUGSoM)
| | | | | | | | - Arul Veerappan
- New York University Grossman School of Medicine (NYUGSoM)
| | - Joanna Zhou
- New York University Grossman School of Medicine (NYUGSoM)
| | - George Crowley
- New York University Grossman School of Medicine (NYUGSoM)
| | - David Prezant
- New York University Grossman School of Medicine (NYUGSoM)
| | - Anna Nolan
- New York University Grossman School of Medicine (NYUGSoM)
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Cohen MG, Althouse AD, Arnold RM, Bulls HW, White DB, Chu E, Rosenzweig MQ, Smith KJ, Schenker Y. Hope and advance care planning in advanced cancer: Is there a relationship? Cancer 2022; 128:1339-1345. [PMID: 34787930 PMCID: PMC8882158 DOI: 10.1002/cncr.34034] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/07/2021] [Accepted: 09/10/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Clinicians often cite a fear of giving up hope as a reason they defer advance care planning (ACP) among patients with advanced cancer. The objective of this study was to determine whether engagement in ACP affects hope in these patients. METHODS This was a secondary analysis of a randomized controlled trial of primary palliative care in advanced cancer. Patients who had not completed ACP at baseline were included in the analysis. ACP was assessed in the forms of an end-of-life (EOL) conversation with one's oncologist and completion of a living will or advance directive (AD). Measurements were obtained at baseline and at 3 months. Hope was measured using the Herth Hope Index (HHI) (range, 12-48; higher scores indicate higher hope). Multivariate regression was performed to assess associations between ACP and hope, controlling for baseline HHI score, study randomization, patient age, religious importance, education, marital status, socioeconomic status, time since cancer diagnosis, pain/symptom burden (Edmonton Symptom Assessment System), and anxiety/depression score (Hospital Anxiety and Depression Scale)-all variables known to be associated with ACP and/or hope. RESULTS In total, 672 patients with advanced cancer were enrolled in the overall study. The mean age was 69 ± 10 years, and the most common cancer types were lung cancer (36%), gastrointestinal cancer (20%) and breast/gynecologic cancers (16%). In this group, 378 patients (56%) had not had an EOL conversation at baseline, of whom 111 of 378 (29%) reported having an EOL conversation by 3 months. Hope was not different between patients who did or did not have an EOL conversation over the study period (mean ± standard deviation ∆HHI, 0.20 ± 5.32 vs -0.53 ± 3.80, respectively; P = .136). After multivariable adjustment, hope was significantly increased in patients who had engaged in an EOL conversation (adjusted mean difference in ∆HHI, 0.95; 95% CI, 0.08-1.82; P = .032). Similarly, of 216 patients (32%) without an AD at baseline, 67 (31%) had subsequently completed an AD. Unadjusted hope was not different between those who did and did not complete an AD (∆HHI, 0.20 ± 3.89 vs -0.91 ± 4.50, respectively; P = .085). After adjustment, hope was significantly higher in those who completed an AD (adjusted mean difference in ∆HHI, 1.31; 95% CI, 0.13-2.49; P = .030). CONCLUSIONS The current results demonstrate that hope is not decreased after engagement in ACP and indeed may be increased. These findings may provide reassurance to clinicians who are apprehensive about having these important and difficult conversations. LAY SUMMARY Many oncologists defer advance care planning (ACP) out of concern for giving up hope. This study demonstrates that hope is not decreased in patients who have engaged in ACP either as a conversation with their oncologists or by completing an advance directive. With this information, providers may feel more comfortable having these important conversations with their patients.
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Affiliation(s)
- Michael G Cohen
- Division of Gynecologic Oncology, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Andrew D Althouse
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, Palliative Research Center and Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Hailey W Bulls
- Section of Palliative Care and Medical Ethics, Palliative Research Center and Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Douglas B White
- Program on Ethics and Decision Making in Critical Illness, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Edward Chu
- Albert Einstein Cancer Center, Albert Einstein College of Medicine, Bronx, New York
| | | | - Kenneth J Smith
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics, Palliative Research Center and Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Briedé S, van Goor HMR, de Hond TAP, van Roeden SE, Staats JM, Oosterheert JJ, van den Bos F, Kaasjager KAH. Code status documentation at admission in COVID-19 patients: a descriptive cohort study. BMJ Open 2021; 11:e050268. [PMID: 34758991 PMCID: PMC8587534 DOI: 10.1136/bmjopen-2021-050268] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 10/26/2021] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES The COVID-19 pandemic pressurised healthcare with increased shortage of care. This resulted in an increase of awareness for code status documentation (ie, whether limitations to specific life-sustaining treatments are in place), both in the medical field and in public media. However, it is unknown whether the increased awareness changed the prevalence and content of code status documentation for COVID-19 patients. We aim to describe differences in code status documentation between infectious patients before the pandemic and COVID-19 patients. SETTING University Medical Centre of Utrecht, a tertiary care teaching academic hospital in the Netherlands. PARTICIPANTS A total of 1715 patients were included, 129 in the COVID-19 cohort (a cohort of COVID-19 patients, admitted from March 2020 to June 2020) and 1586 in the pre-COVID-19 cohort (a cohort of patients with (suspected) infections admitted between September 2016 to September 2018). PRIMARY AND SECONDARY OUTCOME MEASURES We described frequency of code status documentation, frequency of discussion of this code status with patient and/or family, and content of code status. RESULTS Frequencies of code status documentation (69.8% vs 72.7%, respectively) and discussion (75.6% vs 73.3%, respectively) were similar in both cohorts. More patients in the COVID-19 cohort than in the before COVID-19 cohort had any treatment limitation as opposed to full code (40% vs 25%). Within the treatment limitations, 'no intensive care admission' (81% vs 51%) and 'no intubation' (69% vs 40%) were more frequently documented in the COVID-19 cohort. A smaller difference was seen in 'other limitation' (17% vs 9%), while 'no resuscitation' (96% vs 92%) was comparable between both periods. CONCLUSION We observed no difference in the frequency of code status documentation or discussion in COVID-19 patients opposed to a pre-COVID-19 cohort. However, treatment limitations were more prevalent in patients with COVID-19, especially 'no intubation' and 'no intensive care admission'.
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Affiliation(s)
- Saskia Briedé
- Internal Medicine and Dermatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Harriet M R van Goor
- Internal Medicine and Dermatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Titus A P de Hond
- Internal Medicine and Dermatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Sonja E van Roeden
- Internal Medicine and Dermatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Judith M Staats
- Internal Medicine and Dermatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jan Jelrik Oosterheert
- Internal Medicine and Dermatology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Frederiek van den Bos
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Karin A H Kaasjager
- Internal Medicine and Dermatology, University Medical Centre Utrecht, Utrecht, The Netherlands
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Jiang T, Ma Y, Zheng J, Wang C, Cheng K, Li C, Xu F, Chen Y. Prevalence and related factors of do-not-resuscitate orders among in-hospital cardiac arrest patients. Heart Lung 2021; 51:9-13. [PMID: 34731700 DOI: 10.1016/j.hrtlng.2021.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 08/01/2021] [Accepted: 08/03/2021] [Indexed: 12/21/2022]
Abstract
PURPOSE Studies concerning do-not-resuscitate (DNR) orders in mainland China are rather scarce. We explored the prevalence and related factors of DNR orders among in-hospital cardiac arrest (IHCA) patients at a general tertiary hospital in mainland China. MATERIALS AND METHODS We identified all IHCA patients hospital-wide between July 2019 and September 2020. Data regarding DNR status were collected from medical records. We investigated the frequency of DNR orders and explored the determinant factors of DNR establishment using logistic regression. RESULTS A total of 1154 IHCA patients were included, 535 (46.4%) of whom established DNR orders. The following variables were independently associated with a higher DNR rate: female (OR 1.491; 95% CI 1.130-1.965), older age (OR 1.016; 95% CI 1.008-1.024), being a local resident (OR 1.790; 95% CI 1.344-2.383), pulmonary infection (OR 1.398; 95% CI 1052-1.859), respiratory insufficiency (OR 1.356; 95% CI 1.009-1.823), shock (OR 1.735; 95% CI 1.301-2.313), acute stroke (OR 1.821; 95% CI 1.235-2.686),neurological dysfunction (OR 1.527; 95% CI 1.149-2.028) and cancer (OR 3.316; 95% CI 2.461-4.468). Counterintuitively, patients with new-onset coronary artery disease (OR 0.592; 95% CI 0.419-0.837) were less likely to create DNR orders. CONCLUSION In mainland China, the DNR order signing rate is low, and the establishment of a DNR order is associated with demographics and comorbidity characteristics.
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Affiliation(s)
- Tangxing Jiang
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China
| | - Yanyan Ma
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China
| | - Jiaqi Zheng
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China
| | - Chunyi Wang
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China
| | - Kai Cheng
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China
| | - Chuanbao Li
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China
| | - Feng Xu
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China.
| | - Yuguo Chen
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China.
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Garg A, Soto AL, Knies AK, Kolenikov S, Schalk M, Hammer H, White DB, Holloway RG, Sheth KN, Fraenkel L, Hwang DY. Predictors of Surrogate Decision Makers Selecting Life-Sustaining Therapy for Severe Acute Brain Injury Patients: An Analysis of US Population Survey Data. Neurocrit Care 2021; 35:468-479. [PMID: 33619667 PMCID: PMC8380750 DOI: 10.1007/s12028-021-01200-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/29/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Patients with a severe acute brain injury admitted to the intensive care unit often have a poor neurological prognosis. In these situations, a clinician is responsible for conducting a goals-of-care conversation with the patient's surrogate decision makers. The diversity in thought and background of surrogate decision makers can present challenges during these conversations. For this reason, our study aimed to identify predictive characteristics of US surrogate decision makers' favoring life-sustaining treatment (LST) over comfort measures only for patients with severe acute brain injury. METHODS We analyzed data from a cross-sectional survey study that had recruited 1588 subjects from an online probability-based US population sample. Seven hundred and ninety-two subjects had randomly received a hypothetical scenario regarding a relative intubated with severe acute brain injury with a prognosis of severe disability but with the potential to regain some consciousness. Seven hundred and ninety-six subjects had been randomized to a similar scenario in which the relative was projected to remain vegetative. For each scenario, we conducted univariate analyses and binary logistic regressions to determine predictors of LST selection among available respondent characteristics. RESULTS 15.0% of subjects selected LST for the severe disability scenario compared to 11.4% for the vegetative state scenario (p = 0.07), with those selecting LST in both groups expressing less decisional certainty. For the severe disability scenario, independent predictors of LST included having less than a high school education (adjusted OR = 2.87, 95% CI = 1.23-6.76), concern regarding prognostic accuracy (7.64, 3.61-16.15), and concern regarding the cost of care (4.07, 1.80-9.18). For the vegetative scenario, predictors included the youngest age group (30-44 years, 3.33, 1.02-10.86), male gender (3.26, 1.75-6.06), English as a second language (2.94, 1.09-7.89), Evangelical Protestant (3.72, 1.28-10.84) and Catholic (4.01, 1.72-9.36) affiliations, and low income (< $25 K). CONCLUSION Several demographic and decisional characteristics of US surrogate decision makers predict LST selection for patients with severe brain injury with varying degrees of poor prognosis. Surrogates concerned about the cost of medical care may nevertheless be inclined to select LST, albeit with high levels of decisional uncertainty, for patients projected to have severe disabilities.
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Affiliation(s)
- Anisha Garg
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Alexandria L Soto
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, PO Box 208018, New Haven, CT, 06520, USA
| | - Andrea K Knies
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | | | | | - Douglas B White
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert G Holloway
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Kevin N Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, PO Box 208018, New Haven, CT, 06520, USA
- Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT, USA
| | - Liana Fraenkel
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Section of Rheumatology, Yale School of Medicine, New Haven, CT, USA
| | - David Y Hwang
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, PO Box 208018, New Haven, CT, 06520, USA.
- Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT, USA.
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Budweiser S, Baş Ş, Jörres RA, Engelhardt S, von Delius S, Lenherr K, Deerberg-Wittram J, Bauer A. Patients' treatment limitations as predictive factor for mortality in COVID-19: results from hospitalized patients of a hotspot region for SARS-CoV-2 infections. Respir Res 2021; 22:168. [PMID: 34098967 PMCID: PMC8182347 DOI: 10.1186/s12931-021-01756-2] [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: 10/15/2020] [Accepted: 05/18/2021] [Indexed: 12/12/2022] Open
Abstract
Background In hospitalized patients with SARS-CoV-2 infection, outcomes markedly differ between locations, regions and countries. One possible cause for these variations in outcomes could be differences in patient treatment limitations (PTL) in different locations. We thus studied their role as predictor for mortality in a population of hospitalized patients with COVID-19. Methods In a region with high incidence of SARS-CoV-2 infection, adult hospitalized patients with PCR-confirmed SARS-CoV-2 infection were prospectively registered and characterized regarding sex, age, vital signs, symptoms, comorbidities (including Charlson comorbidity index (CCI)), transcutaneous pulse oximetry (SpO2) and laboratory values upon admission, as well as ICU-stay including respiratory support, discharge, transfer to another hospital and death. PTL assessed by routine clinical procedures comprised the acceptance of ICU-therapy, orotracheal intubation and/or cardiopulmonary resuscitation. Results Among 526 patients included (median [quartiles] age 73 [57; 82] years, 47% female), 226 (43%) had at least one treatment limitation. Each limitation was associated with age, dementia and eGFR (p < 0.05 each), that regarding resuscitation additionally with Charlson comorbidity index (CCI) and cardiac disease. Overall mortality was 27% and lower (p < 0.001) in patients without treatment limitation (12%) compared to those with any limitation (47%). In univariate analyses, age and comorbidities (diabetes, cardiac, cerebrovascular, renal, hepatic, malignant disease, dementia), SpO2, hemoglobin, leucocyte numbers, estimated glomerular filtration rate (eGFR), C-reactive protein (CRP), Interleukin-6 and LDH were predictive for death (p < 0.05 each). In multivariate analyses, the presence of any treatment limitation was an independent predictor of death (OR 4.34, 95%-CI 2.10–12.30; p = 0.001), in addition to CCI, eGFR < 55 ml/min, neutrophil number > 5 G/l, CRP > 7 mg/l and SpO2 < 93% (p < 0.05 each). Conclusion In hospitalized patients with SARS-CoV-2, the percentage of patients with treatment limitations was high. PTL were linked to age, comorbidities and eGFR assessed upon admission and strong, independent risk factors for mortality. These findings might be useful for further understanding of COVID-19 mortality and its regional variations. Clinical trial registration ClinicalTrials.gov Identifier: NCT04344171 Supplementary Information The online version contains supplementary material available at 10.1186/s12931-021-01756-2.
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Affiliation(s)
- Stephan Budweiser
- Department of Internal Medicine III, Division of Pulmonary and Respiratory Medicine, RoMed Hospital Rosenheim, Pettenkoferstrasse 10, 83022, Rosenheim, Germany.
| | - Şevki Baş
- Department of Internal Medicine III, Division of Pulmonary and Respiratory Medicine, RoMed Hospital Rosenheim, Pettenkoferstrasse 10, 83022, Rosenheim, Germany
| | - Rudolf A Jörres
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, Ludwig-Maximilians-University, Munich, Germany
| | | | - Stefan von Delius
- Department of Internal Medicine II, RoMed Hospital Rosenheim, Rosenheim, Germany
| | - Katharina Lenherr
- Internal Intensive Care Medicine Unit, RoMed Hospital Rosenheim, Rosenheim, Germany
| | | | - Andreas Bauer
- Institute for Anesthesiology and Surgical Intensive Care Medicine, RoMed Hospital Rosenheim, Rosenheim, Germany
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7
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Mentzelopoulos SD, Couper K, Van de Voorde P, Druwé P, Blom M, Perkins GD, Lulic I, Djakow J, Raffay V, Lilja G, Bossaert L. [Ethics of resuscitation and end of life decisions]. Notf Rett Med 2021; 24:720-749. [PMID: 34093076 PMCID: PMC8170633 DOI: 10.1007/s10049-021-00888-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/14/2022]
Abstract
These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.
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Affiliation(s)
- Spyros D. Mentzelopoulos
- Evaggelismos Allgemeines Krankenhaus, Abteilung für Intensivmedizin, Medizinische Fakultät der Nationalen und Kapodistrischen Universität Athen, 45–47 Ipsilandou Street, 10675 Athen, Griechenland
| | - Keith Couper
- Universitätskliniken Birmingham NHS Foundation Trust, UK Critical Care Unit, Birmingham, Großbritannien
- Medizinische Fakultät Warwick, Universität Warwick, Coventry, Großbritannien
| | - Patrick Van de Voorde
- Universitätsklinikum und Universität Gent, Gent, Belgien
- staatliches Gesundheitsministerium, Brüssel, Belgien
| | - Patrick Druwé
- Abteilung für Intensivmedizin, Universitätsklinikum Gent, Gent, Belgien
| | - Marieke Blom
- Medizinisches Zentrum der Universität Amsterdam, Amsterdam, Niederlande
| | - Gavin D. Perkins
- Medizinische Fakultät Warwick, Universität Warwick, Coventry, Großbritannien
| | | | - Jana Djakow
- Intensivstation für Kinder, NH Hospital, Hořovice, Tschechien
- Abteilung für Kinderanästhesiologie und Intensivmedizin, Universitätsklinikum und Medizinische Fakultät der Masaryk-Universität, Brno, Tschechien
| | - Violetta Raffay
- School of Medicine, Europäische Universität Zypern, Nikosia, Zypern
- Serbischer Wiederbelebungsrat, Novi Sad, Serbien
| | - Gisela Lilja
- Universitätsklinikum Skane, Abteilung für klinische Wissenschaften Lund, Neurologie, Universität Lund, Lund, Schweden
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Mentzelopoulos SD, Couper K, Voorde PVD, Druwé P, Blom M, Perkins GD, Lulic I, Djakow J, Raffay V, Lilja G, Bossaert L. European Resuscitation Council Guidelines 2021: Ethics of resuscitation and end of life decisions. Resuscitation 2021; 161:408-432. [PMID: 33773832 DOI: 10.1016/j.resuscitation.2021.02.017] [Citation(s) in RCA: 106] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
These European Resuscitation Council Ethics guidelines provide evidence-based recommendations for the ethical, routine practice of resuscitation and end-of-life care of adults and children. The guideline primarily focus on major ethical practice interventions (i.e. advance directives, advance care planning, and shared decision making), decision making regarding resuscitation, education, and research. These areas are tightly related to the application of the principles of bioethics in the practice of resuscitation and end-of-life care.
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Affiliation(s)
| | - Keith Couper
- UK Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Warwick Medical School, University of Warwick, Coventry, UK
| | - Patrick Van de Voorde
- University Hospital and University Ghent, Belgium; Federal Department Health, Belgium
| | - Patrick Druwé
- Ghent University Hospital, Department of Intensive Care Medicine, Ghent, Belgium
| | - Marieke Blom
- Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Gavin D Perkins
- UK Critical Care Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Czech Republic; Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital and Medical Faculty of Masaryk University, Brno, Czech Republic
| | - Violetta Raffay
- European University Cyprus, School of Medicine, Nicosia, Cyprus; Serbian Resuscitation Council, Novi Sad, Serbia
| | - Gisela Lilja
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
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Ding CQ, Zhang YP, Wang YW, Yang MF, Wang S, Cui NQ, Jin JF. Death and do-not-resuscitate order in the emergency department: A single-center three-year retrospective study in the Chinese mainland. World J Emerg Med 2020; 11:231-237. [PMID: 33014219 DOI: 10.5847/wjem.j.1920-8642.2020.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Consenting to do-not-resuscitate (DNR) orders is an important and complex medical decision-making process in the treatment of patients at the end-of-life in emergency departments (EDs). The DNR decision in EDs has not been extensively studied, especially in the Chinese mainland. METHODS This retrospective chart study of all deceased patients in the ED of a university hospital was conducted from January 2017 to December 2019. The patients with out-of-hospital cardiac arrest were excluded. RESULTS There were 214 patients' deaths in the ED in the three years. Among them, 132 patients were included in this study, whereas 82 with out-of-hospital cardiac arrest were excluded. There were 99 (75.0%) patients' deaths after a DNR order medical decision, 64 (64.6%) patients signed the orders within 24 hours of the ED admission, 68 (68.7%) patients died within 24 hours after signing it, and 97 (98.0%) patients had DNR signed by the family surrogates. Multivariate analysis showed that four independent factors influenced the family surrogates' decisions to sign the DNR orders: lack of referral (odds ratio [OR] 0.157, 95% confidence interval [CI] 0.047-0.529, P=0.003), ED length of stay (ED LOS) ≥72 hours (OR 5.889, 95% CI 1.290-26.885, P=0.022), acute myocardial infarction (AMI) (OR 0.017, 95% CI 0.001-0.279, P=0.004), and tracheal intubation (OR 0.028, 95% CI 0.007-0.120, P<0.001). CONCLUSIONS In the Chinese mainland, the proportion of patients consenting for DNR order is lower than that of developed countries. The decision to sign DNR orders is mainly affected by referral, ED LOS, AMI, and trachea intubation.
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Affiliation(s)
- Chuan-Qi Ding
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yu-Ping Zhang
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yu-Wei Wang
- Department of Emergency Medicine, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Min-Fei Yang
- Department of Emergency Medicine, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Sa Wang
- Department of Emergency Medicine, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Nian-Qi Cui
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Jing-Fen Jin
- Department of Nursing, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
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Cui P, Ping Z, Wang P, Bie W, Yeh CH, Gao X, Chen Y, Dong S, Chen C. Timing of do-not-resuscitate orders and health care utilization near the end of life in cancer patients: a retrospective cohort study. Support Care Cancer 2020; 29:1893-1902. [PMID: 32803724 DOI: 10.1007/s00520-020-05672-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 08/03/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE The objectives are to explore the prevalence of DNR orders, the factors influencing them, and the association between DNR signing and health care utilization among advanced cancer patients. METHODS This was a retrospective cohort study. Data from cancer decedents in three hospitals in China from January 2016 to December 2017 during their last hospitalization before death were obtained from the electronic medical records system. RESULTS In total, 427 cancer patients were included; 59.0% had a DNR order. Patients who had solid tumors, lived in urban areas, had more than one comorbidity, and had more than five symptoms were more likely to have DNR orders. The cut-off of the timing of obtaining a DNR order was 3 days, as determined by the median number of days from the signing of a DNR order to patient death. Patients with early DNR orders (more than 3 days before death) were less likely to be transferred to the intensive care unit and undergo cardiopulmonary resuscitation, tracheal intubation, and ventilation, while they were more likely to be given morphine and psychological support compared with those with late (within 3 days before death) and no orders. CONCLUSIONS Advanced cancer patients with solid tumors living in urban areas with more symptoms and comorbidities are relatively more likely to have DNR orders. Early DNR orders are associated with less aggressive procedures and more comfort measures. However, these orders are always signed late. Future studies are needed to better understand the timing of DNR orders.
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Affiliation(s)
- Panpan Cui
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China.,The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China.,Academy of Medical Sciences, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Zhiguang Ping
- College of Public Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Panpan Wang
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Wenqian Bie
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Chao Hsing Yeh
- Johns Hopkins School of Nursing, 525 N. Wolfe Street, Baltimore, USA
| | - Xinyi Gao
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Yiyang Chen
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Shiqi Dong
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Changying Chen
- School of Nursing and Health, Zhengzhou University, Zhengzhou, Henan Province, China. .,The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China.
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11
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van der Zee EN, Epker JL, Bakker J, Benoit DD, Kompanje EJO. Treatment Limitation Decisions in Critically Ill Patients With a Malignancy on the Intensive Care Unit. J Intensive Care Med 2020; 36:42-50. [PMID: 32787659 PMCID: PMC7705645 DOI: 10.1177/0885066620948453] [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] [Indexed: 12/04/2022]
Abstract
Background: Treatment limitation decisions (TLDs) on the ICU can be challenging, especially in patients with a malignancy. Up-to-date literature regarding TLDs in critically ill patients with a malignancy admitted to the ICU is scarce. The aim was to compare the incidence of written TLDs between patients with an active malignancy, patients with a malignancy in their medical history (complete remission, CR) and patients without a malignancy admitted unplanned to the ICU. Methods: We conducted a retrospective cohort study in a large university hospital in the Netherlands. We identified all unplanned admissions to the ICU in 2017 and categorized the patients in 3 groups: patients with an active malignancy (study population), with CR and without a malignancy. A TLD was defined as a written instruction not to perform life-saving treatments, such as CPR in case of cardiac arrest. A multivariate binary logistic regression analysis was used to identify whether having a malignancy was associated with TLDs. Results: Of the 1046 unplanned admissions, 125 patients (12%) had an active malignancy and 76 (7.3%) patients had CR. The incidence of written TLDs in these subgroups were 37 (29.6%) and 20 (26.3%). Age (OR 1.03; 95% CI 1.01 -1.04), SOFA score at ICU admission (OR 1.11; 95% CI 1.05 -1.18) and having an active malignancy (OR 1.75; 95% CI 1.04-2.96) compared to no malignancy were independently associated with written TLDs. SOFA scores on the day of the TLD were not significantly different in patients with and without a malignancy. Conclusions: This study shows that the presence of an underlying malignancy is independently associated with written TLDs during ICU stay. Patients with CR were not at risk of more written TLDs. Whether this higher incidence of TLDs in patients with a malignancy is justified, is at least questionable and should be evaluated in future research.
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Affiliation(s)
- Esther N van der Zee
- Department of Intensive Care, 6993Erasmus MC-University Medical Center Rotterdam, the Netherlands
| | - Jelle L Epker
- Department of Intensive Care, 6993Erasmus MC-University Medical Center Rotterdam, the Netherlands
| | - Jan Bakker
- Department of Intensive Care, 6993Erasmus MC-University Medical Center Rotterdam, the Netherlands.,Department of Pulmonology and Critical Care, New York University NYU Langone Medical Center, New York, NY, USA.,Department of Pulmonology and Critical Care, Columbia University Medical Center, New York, NY, USA.,Department of Intensive Care, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Dominique D Benoit
- Department of Intensive Care, 60200Ghent University Hospital, Ghent, Belgium
| | - Erwin J O Kompanje
- Department of Intensive Care, 6993Erasmus MC-University Medical Center Rotterdam, the Netherlands
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12
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Cohen MG, Althouse AD, Arnold RM, Bulls HW, White D, Chu E, Rosenzweig M, Smith K, Schenker Y. Is Advance Care Planning Associated With Decreased Hope in Advanced Cancer? JCO Oncol Pract 2020; 17:e248-e256. [PMID: 32530807 DOI: 10.1200/op.20.00039] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
PURPOSE Providers have cited fear of taking away hope from patients as one of the principal reasons for deferring advance care planning (ACP). However, research is lacking on the relationship between ACP and hope. We sought to investigate the potential association between ACP and hope in advanced cancer. METHODS This is a cross-sectional analysis of baseline data from a primary palliative care intervention trial. All patients had advanced solid cancers. Three domains of ACP were measured using validated questions to assess discussion with oncologists about end-of-life (EOL) planning, selection of a surrogate decision maker, and completion of an advance directive. Hope was measured using the Hearth Hope Index (HHI). Multivariable regression was performed, adjusting for variables associated with hope or ACP. RESULTS A total of 672 patients were included in this analysis. The mean age was 69.3 ± 10.2 years; 54% were female, and 94% were White. Twenty percent of patients (132 of 661) reported having a discussion about EOL planning, 51% (342 of 668) reported completing an advance directive, and 85% (565 of 666) had chosen a surrogate. There was no difference in hope between patients who had and had not had an EOL discussion (adjusted mean difference in HHI, 0.55; P = .181 for adjusted regression), chosen a surrogate (adjusted HHI difference, 0.31; P = .512), or completed an advance directive (adjusted HHI difference, 0.11; P = .752). CONCLUSION In this study, hope was equivalent among patients who had or had not completed 3 important domains of ACP. These findings do not support concerns that ACP is associated with decreased hope for patients with advanced cancer.
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Affiliation(s)
- Michael G Cohen
- Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Gynecologic Oncology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Robert M Arnold
- Palliative Research Center, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, PA
| | - Hailey W Bulls
- Palliative Research Center, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, PA
| | - Douglas White
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Edward Chu
- Division of Hematology-Oncology, Department of Medicine and Cancer Therapeutics Program, UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA
| | | | - Kenneth Smith
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Yael Schenker
- Palliative Research Center, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, PA
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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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Rubins JB. Use of Combined Do-Not-Resuscitate/Do-Not Intubate Orders Without Documentation of Intubation Preferences: A Retrospective Observational Study at an Academic Level 1 Trauma Center Code Status and Intubation Preferences. Chest 2020; 158:292-297. [PMID: 32109445 DOI: 10.1016/j.chest.2020.02.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 02/04/2020] [Accepted: 02/06/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Combining orders for do-not-resuscitate (DNR) for cardiac arrest with do-not-intubate (DNI) orders into a DNR/DNI code status is not evidence-based practice and may violate patient autonomy and informed consent when providers discuss intubation only in the context of CPR. RESEARCH QUESTION How often do providers refer to patients with a DNR order as "DNR/DNI" without documentation of refusal of intubation for non-arrest situations? METHODS Retrospective observational study of adults (18 years of age or older) hospitalized in a Level 1 trauma/academic hospital between July 2017 and June 2018 inclusive with DNR orders placed during hospitalization. RESULTS Of 422 hospitalized adults with DNR orders, 261 (61.9%) had code status written in progress notes as DNR/DNI. Providers' use of the term DNR/DNI in progress notes was significantly (OR, 2.21; 99% CI, 1.12-4.37) more common on medical hospital services (hospitalist, family medicine, internal medicine) than on nonmedical ward services (medical/surgical ICUs, surgery, psychiatry, neurology services). Of 261 "DNR/DNI" patients, providers did not document informed refusal of intubation for nonarrest situations for 68 (26.0%) of patients. By comparison, of 161 patients for whom providers documented code status in progress notes as DNR alone, 69 (42.9%) did have documentation of refusal of intubation for nonarrest events. Therefore, if a DNR/DNI code status was used in a nonarrest emergency to determine whether to intubate a patient, 68 (16.1%) of 422 patients could inappropriately be denied intubation without informed refusal (or despite their informed acceptance), and 69 (16.4%) could inappropriately be intubated despite their documented refusal of intubation. CONCLUSIONS Conflation of DNR and DNI into DNR/DNI does not reliably distinguish patients who refuse or accept intubation for indications other than cardiac arrest, and thus may inappropriately deny desired intubation for those who would accept it, and inappropriately impose intubation on patients who would not.
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Affiliation(s)
- Jeffrey B Rubins
- University of Minnesota, Division of Palliative Care, Department of Medicine, Hennepin Healthcare, Minneapolis, MN.
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Street M, Dunning T, Bucknall T, Hutchinson AM, Rawson H, Hutchinson AF, Botti M, Duke MM, Mohebbi M, Considine J. Resuscitation status and characteristics and outcomes of patients transferred from subacute care to acute care hospitals: A multi-site prospective cohort study. J Clin Nurs 2020; 29:1302-1311. [PMID: 31793121 DOI: 10.1111/jocn.15125] [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: 07/17/2019] [Revised: 11/19/2019] [Accepted: 11/21/2019] [Indexed: 11/26/2022]
Abstract
AIMS AND OBJECTIVES To examine the relationship between resuscitation status and (i) patient characteristics; (ii) transfer characteristics; and (iii) patient outcomes following an emergency inter-hospital transfer from a subacute to an acute care hospital. BACKGROUND Patients who experience emergency inter-hospital transfers from subacute to acute care hospitals have high rates of acute care readmission (81%) and in-hospital mortality (15%). DESIGN This prospective, exploratory cohort study was a subanalysis of data from a larger case-time-control study in five Health Services in Victoria, Australia. There were 603 transfers in 557 patients between August 2015 and October 2016. The study was conducted in accordance with the STrengthening the Reporting of OBservational studies in Epidemiology guidelines. METHODS Data were extracted by medical record audit. Three resuscitation categories (full resuscitation; limitation of medical treatment (LOMT) orders; or not-for-cardiopulmonary resuscitation (CPR) orders) were compared using chi-square or Kruskal-Wallis tests. Stratified multivariable proportional hazard Cox regression models were used to account for health service clustering effect. FINDINGS Resuscitation status was 63.5% full resuscitation; 23.1% LOMT order; and 13.4% not-for-CPR. Compared to patients for full resuscitation, patients with not-for-CPR or LOMT orders were more likely to have rapid response team calls during acute care readmission or to die during hospitalisation. Patients who were not-for-CPR were less likely to be readmitted to acute care and more likely to return to subacute care. CONCLUSIONS Two-thirds of patients in subacute care who experienced an emergency inter-hospital transfer were for full resuscitation. Although the proportion of patients with LOMT and not-for-CPR orders increased after transfer, there were deficiencies in the documentation of resuscitation status and planning for clinical deterioration for subacute care patients. RELEVANCE TO CLINICAL PRACTICE As many subacute care patients experience clinical deterioration, patient preferences for care need to be discussed and documented early in the subacute care admission.
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Affiliation(s)
- Maryann Street
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research - Eastern Health Partnership, Deakin University, Geelong, Australia
| | - Trisha Dunning
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research - Barwon Health Partnership, Deakin University, Geelong, Australia
| | - Tracey Bucknall
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research - Alfred Health Partnership, Deakin University, Geelong, Australia
| | - Alison M Hutchinson
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research - Monash Health Partnership, Deakin University, Geelong, Australia
| | - Helen Rawson
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research - Monash Health Partnership, Deakin University, Geelong, Australia
| | - Anastasia F Hutchinson
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research - Epworth HealthCare Partnership, Deakin University, Geelong, Australia
| | - Mari Botti
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research - Epworth HealthCare Partnership, Deakin University, Geelong, Australia
| | - Maxine M Duke
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research, Deakin University, Geelong, Australia
| | | | - Julie Considine
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research - Eastern Health Partnership, Deakin University, Geelong, Australia
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