Limitación del esfuerzo terapéutico en medicina intensiva

Limitation of life support treatments in Spanish Intensive Care Units: Analysis of the ETHICUS II study

OBJECTIVE

The aim of this study is to describe the results of Spanish ICUs in ETHICUS II study.

DESIGN

Planned substudy of patients from ETHICUS II study.

SETTING

12 Spanish ICU.

PATIENTS OR PARTICIPANTS

Patients admitted to Spanish ICU who died or in whom a limitation of life-sustaining treatment (LLST) was decided during a recruitment period of 6 months.

INTERVENTIONS

Follow-up of patients was performed until discharge from the ICU and 2 months after the decision of LLST or death.

MAIN VARIABLES OF INTEREST

Demographic characteristics, clinical profile, type of decision of LLST, time and form in which it was adopted. Patients were classified into 4 categories according to the ETHICUS II study protocol: withholding or withdrawing life-sustaining therapy, active shortening of the dying process, failed cardiopulmonary resuscitation and patients with brain death.

RESULTS

A total of 795 patients were analyzed; 129 patients died after CPR, 129 developed brain death. LLST was decided in 537 patients, 485 died in the ICU, 90.3%. The mean age was 66.19 years ± 14.36, 63.8% of male patients. In 221 (41%) it was decided to withdraw life-sustaining treatments and in 316 (59%) withholding life-sustaining treatments. Nineteen patients (2.38%) had advance living directives.

CONCLUSIONS

The predominant clinical profile when LTSV was established was male patients over 65 years with mostly cardiovascular comorbidity. We observed that survival was higher in LLST decisions involving withholding of treatments compared to those in which withdrawal was decided. Spain has played a leading role in both patient and ICU recruitment participating in this worldwide multicenter study.

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.

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.

Identification of Senior At Risk scale predicts 30-day mortality among older patients with acute heart failure

OBJECTIVE

To assess the value of frailty screening tool (Identification of Senior at Risk [ISAR]) in predicting 30-day mortality risk in older patients attended in emergency department (ED) for acute heart failure (AHF).

DESIGN

Observational multicenter cohort study.

SETTING

OAK-3 register.

SUBJECTS

Patients aged ≥65 years attended with ADHF in 16 Spanish EDs from January to February 2016.

INTERVENTION

No.

VARIABLES

Variable of study was ISAR scale. The outcome was all-cause 30-day mortality.

RESULTS

We included 1059 patients (mean age 85±5,9 years old). One hundred and sixty (15.1%) cases had 0-1 points, 278 (26.3%) 2 points, 260 (24.6%) 3 points, 209 (19.7%) 4 points, and 152 (14.3%) 5-6 points of ISAR scale. Ninety five (9.0%) patients died within 30 days. The percentage of mortality increased in relation to ISAR category (lineal trend P value <.001). The area under curve of ISAR scale was 0.703 (95%CI 0.655-0.751; P<.001). After adjusting for EFFECT risk categories, we observed a progressive increase in odds ratios of ISAR scale groups compared to reference (0-1 points).

CONCLUSIONS

scale is a brief and easy tool that should be considered for frailty screening during initial assessment of older patients attended with AHF for predicting 30-day mortality.

The role of the nurse at the end of the life of a critically ill patient

OBJECTIVE

Analyze the role of the nurse at the end of the life of a critically ill patient.

METHOD

Bibliographic review from a search of the health science databases such as PubMed, CINAHL, Cuiden, Scopus, Cochrane, as well as specialized platforms, general and thematic browsers. The limits were language (English or Spanish) and publication date (2005-2015).

RESULTS

180 articles met the inclusion criteria, and 16 of them were selected for analysis. The main results were grouped into three categories of analysis: direct patient care, family-focussed care and the nurse's role within the team.

CONCLUSIONS

the described roles place the nurse as a key element in humanising death in the ICU and so nurses can and must lead change, playing an active role in creating strategies that really promote the integration of a palliative care approach in ICU.

[Perspective of intensive care nursing staff on the limitation of life support treatment]

OBJECTIVE

To determine the perspective of intensive care nursing staff on the limitation of life support treatment (LLST) in the Intensive Care Units.

METHOD

An exploratory qualitative study was carried out by applying the theory of Strauss and Corbin as the analysis tool. Constructivist paradigm.

POPULATION

Nursing staff from three Intensive Care Units of Hospital Universitari de Bellvitge. Convenience sampling to reach theoretical saturation of data. Data collection through semi-structured interview recorded prior to informed consent. Rigor and quality criteria (reliability, credibility, transferability), and authenticity criteria: reflexivity. Demographic data was analysed using Excel.

RESULTS

A total of 28 interviews were conducted. The mean age of the nurses was 35.6 years, with a mean seniority of 11.46 years of working in ICU. A minority of nurses (21.46%) had received basic training in bioethics. The large majority (85.7%) believe that LLST is not a common practice due to therapeutic cruelty and poor management with it. There is a correlation with the technical concepts; but among the main ethical problems is the decision to apply LLST. Nurses recognise that the decision on applying LLST depends on medical consensus with relatives, and they believe that their opinion is not considered. Their objective is trying to avoid suffering, and assist in providing a dignified death and support to relatives.

CONCLUSIONS

There is still a paternalistic pattern between the doctor and patient relationship, where the doctor makes the decision and then agrees with the relatives to apply LLST. Organ failure and poor prognosis are the most important criteria for applying LLST. It is necessary to develop a guide for applying LLST, emphasising the involvement of nurses, patients, and their relatives.

[Opinion of professionals in an intensive care unit on the limitations of therapeutic effort]

OBJECTIVE

To determine the opinion held by professionals in an intensive care unit on the limitation of therapeutic effort process at the end-of-life (LTE). To collect this information, and then use it to improve the basic aspects that the LTE have on the quality of care by intensive care unit staff.

MATERIAL AND METHODS

A prospective descriptive study was carried out in the Intensive Care Unit of a third level public university hospital. A questionnaire was prepared that included questions on their demographic profile and others to provide an ethical valuation profile, as well as to find out the knowledge and information that the professional had on the LTE. Descriptive study of the sample and comparative statistics were performed using the chi-squared statistical test.

RESULTS

A total of 65 valid questionnaires were obtained from a convenience sample of 70 professionals. Almost all of them (98%) were in favour of the limitation of therapeutic effort. The LTE was considered as some kind of euthanasia (active or passive) in up to 28% of the replies, valuations by professional categories is shown in. More than three-quarters (77%) had the belief that not to start treatment was not the same as withdrawing an already established treatment. Just over half (52%) of the respondents believe the value that should have more weight when considering LET would be the prognosis of the current illness of the patient, and 46% the future quality of life of the patient. The economic cost of treatment to be applied was not considered in any case.

CONCLUSIONS

The LTE is approved by the majority of professionals in our Intensive Care Unit. Although a non-negligible percentage understood it as a form of euthanasia.

[The suitability of therapeutic effort: An end-of-life strategy]

End-of-life treatment and attention to the needs of relatives are not adequate for several reasons: Society denies or hides the death; it is very difficult to predict it accurately; treatment is frequently fragmented between different specialists, and there is insufficient palliative medicine training, including communication skills. There are frequent conflicts with decisions made at the end of life, particularly the suitability of therapeutic effort. The attitude of professionals on the adequacy of therapeutic effort is not homogenous, and varies depending on the specialty, experience, and beliefs. Many doctors are still afraid of inconveniencing patients. Primary care is in a privileged position to approach the life and values of our patients and their families, and not just the disease, which makes it the right place to guide and advise the patient on the preparation and registration of living wills.

Limitation of life-sustaining treatment in patients with prolonged admission to the ICU. Current situation in Spain as seen from the EPIPUSE Study

OBJECTIVE

Limitation of life-sustaining treatment (LLST) is a recommended practice in certain circumstances. Limitation practices are varied, and their application differs from one center to another. The present study evaluates the current situation of LLST practices in patients with prolonged admission to the ICU who suffer worsening of their condition.

DESIGN

A prospective, observational cohort study was carried out.

SETTING

Seventy-five Spanish ICUs.

PATIENTS

A total of 589 patients suffering 777 complications or adverse events with organ function impairment after day 7 of admission, during a three-month recruitment period.

MAIN VARIABLES OF INTEREST

The timing of limitation, the subject proposing LLST, the degree of agreement within the team, the influence of LLST upon the doctor-patient-family relationship, and the way in which LLST is implemented.

RESULTS

LLST was proposed in 34.3% of the patients presenting prolonged admission to the ICU with severe complications. The incidence was higher in patients with moderate to severe lung disease, cancer, immunosuppressive treatment or dependence for basic activities of daily living. LLST was finally implemented in 97% of the cases in which it was proposed. The decision within the medical team was unanimous in 87.9% of the cases. The doctor-patient-family relationship usually does not change or even improves in this situation.

CONCLUSION

LLST in ICUs is usually carried out under unanimous decision of the medical team, is performed more frequently in patients with severe comorbidity, and usually does not have a negative impact upon the relationship with the patients and their families.

[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.

[Life-sustaining treatment limitation criteria upon admission to the intensive care unit: results of a Spanish national multicenter survey]

OBJECTIVE

To determine the life-sustaining treatment limitation (LSTL) predisposition upon patient admission to the intensive care unit (ICU), the criteria upon which such predisposition is based, and whether these decisions are related to structural factors of the surveyed hospitals.

DESIGN

A descriptive multicenter study was made in 2010, involving the conduction of a survey in 90 hospitals, with a view to documenting the usual practice referred to LSTL upon admission in these centers.

SETTING

Spanish ICUs.

INTERVENTION

Opinion survey.

MAIN VARIABLES OF INTEREST

Type of hospital, number of hospital beds, ICU and semicritical patient beds, usual bed availability in the ICU, use of restrictive admission criteria, use of LSTL criteria upon admission, and type of criterion used to decide LSTL.

RESULTS

A total of 43 (48%) hospitals participated in the study, with LSTL being a common practice in these centers (93%). LSTL was fundamentally decided on the basis of the presence of prior severe chronic disease (95%), observation of previously declared patient will (95%), prior functional limitation (85%), and qualitative futility of care (82%). Frequent ICU bed availability (77% of the hospitals) and the use of restrictive criteria (79% of the hospitals) were also associated to patient admission with LSTL.

CONCLUSIONS

Admission to ICU with LSTL is a generalized practice in Spanish Hospitals. LSTL is decided based on physiological futility from an objective medical point of view, but also in observance of ethical and moral implications based on the qualitative futility of medical care.

[Bioethics limitation of therapeutic effort in pediatrics]

Given that the demand of society has shifted to seek maximum efficiency, maximum help based on the patient autonomy respect and awareness of its necessity, the limitation of therapeutic effort is one of the decisions more complex. Therefore, it should be an institutional objective to know the limitations of practice, assess and encourage improvement and in doubtful cases, resort to Assistive Bioethics Committees to advise on the development of clinical protocols in cases which the professional or the therapeutic team is faced with an ethical dilemma.

[The nursing profession regarding limitation of life support treatment in the intensive care units. Technical and practical features]

The scientific and technical developments in medicine in the recent decades have greatly helped to increase life expectancy and quality of life of many patients. In hospitals, this technological scenario has clearly influenced patient care, for example, in the Intensive Medicine Departments, leading to new clinical perspectives and has made the growing complexity of giving treatment and making decisions more evident. In some cases, it is difficult to predict how beneficial intensive medical care can be when there is no reasonable prospect of improving the patient's health, prolonging their life in situations with poor prognosis or dramatically reducing their quality of life. The clinical diagnosis of irreversibility, through indicators of severity and principles of beneficence, autonomy and justice in the professional conduct are the elements that give rise to the consideration of withholding and withdrawing treatment in the critical patient. However, there are other factors that need to be taken into consideration and that are analyzed by professional ethics and bioethics. It is from this approach that any decision involving withholding and withdrawing treatment should be taken so that these decisions can be considered estimable form an ethical point of view. The nursing professional in intensive care units is expected to actively participate in decision making by contributing with their humanizing vision and care ethics. They should be aware of their contribution in the medical team behaving, representing and encouraging the requirements of bioethics.

[Evacuation plan of an intensive care unit: a new quality indicator?]

The intensive care units must be prepared for a possible disaster, whether internal or external, in case it becomes necessary to evacuate the in-patients. They must have an Emergency and Self-protection Plan that includes the patient evacuation criteria and this must be known by all the personnel who work in the service. For that reason, the patients must be triaged, based on their attention priorities, according to their survival possibilities. Having an evacuation, known by all the personnel and updated by means of the performance of periodic drills, should be included as a quality indicator that must be met, since this would achieve better attention to the patient in case of a disaster situation requiring the evacuation of the ICU.

Advance directives in Spain. Perspectives from a medical bioethicist approach

Spain is one of the most advanced European countries in terms of the legislative and administrative development of ADs. Article 11 of Law 41/2002, concerning Patient Autonomy, regulates 'advance directives' and has prompted various Autonomous Regions to develop legislation in this area. Nevertheless, whilst the variety of legislations in different territories presents advantages, the disparity of criteria also presents problems. Despite significant legislative development, only 23,000 Spanish citizens have filled in an AD. Clearly, AD use is confined to a minority. Several surveys, however, show that the Spanish population views these documents in a positive light. Thus, we must analyse this discrepancy between attitude and practice. A similar situation exists amongst health professionals. Whilst they generally feel that the use of ADs is positive and necessary, they are frequently unwilling to employ them. Bioethical literature and research on ADs has significantly increased in Spain over the last six years. It is likely that this trend will continue in the foreseeable future; but more resources and effort are required if ADs are to become consolidated.

[Limitation of therapeutic effort after ICU admission. Analysis of related factors]

OBJECTIVE

To analyze the limitation of therapeutic effort (LTE) in our Intensive Care Unit (ICU) and the variables associated with that decision.

DESIGN

Prospective cohort study with a follow up of one year after discharge.

SETTING

ICU of a second level hospital.

PATIENTS

Four hundred and nine patients admitted during a two-year period.

MAIN VARIABLES

APACHE II, NEMS, SOFA, quality of life (PAEEC) and mortality.

RESULTS

LTE was performed in 49 (12%) patients. This decision was made by general agreement among the care team in 88% of cases and with the family in 73.5%. It was made on day 8 (4-20) with a SOFA score of 9 (4-13). Mortality in the LTE group was 69.4% in ICU, 92% in hospital, and 96% at 6 and 12 months. A logistic regression model showed that the variables associated with LTE were the following: NEMS score >or=30.7 (OR 12; 95% CI 3.7-39, p < 0.001), NEMS 26.6-30.6 (OR 8; 95% CI 2.5-25.6, p = 0.001), APACHE II > 30 (OR 7.6; 95% CI 2-29, p = 0.003), quality of life >or= 7 (OR 4.2; 95% CI 1.1-15, p = 0.03), age >or= 80 (OR 3.7, 95% CI 1.4-9.5, p = 0.007) and medical patient condition (OR 3.5; 95% CI 1.5-8, p = 0.003).

CONCLUSIONS

LTE is a common practice and is usually performed among the care team and the patient's surrogates. The main variables associated with LSC are those related to the severity of illness, previous quality of life, medical disease and patient's age.

La adjudicación de recursos en los pacientes con mal pronóstico: la necesidad de un debate

OBJECTIVE

Assess the opinion of health care professions on the awarding of resources when the patient has a bad prognosis.

DESIGN

Survey type test where a scenario of a patient with a 6 month life prognosis is posed, differentiating between good and bad quality of life. It is evaluated if the following resources would be indicated if necessary: admission to ICU, hemodialysis, hip prosthesis, transplant, Hospital admission, antibiotics for bacterial infection, permanent pacemaker and surgery. To analyze the possible association between the variables, the Pearson's Chi Square Test or that of linear tendency was used. To determine if each person interviewed was appropriate in a different way based on the patient's quality of life status, the McNemar test was used.

SETTING

University Hospital of 480 beds.

PARTICIPANTS

Sample of 256 volunteers (physicians and nurses) from the Emergency Service, Intensive Care Unit and Operating Room.

INTERVENTIONS

A responsible physician was in charge of personally distributing the survey during a 2-week period and to explain the possible doubts that could arise on it.

RESULTS

A total of 23.8% of those surveyed considered that transplant would be indicated and 79.8% that permanent pacemaker would be indicated if the patient had a good quality of life. If there was bad quality of life, 9.1% would have always indicated hemodialysis (60.5% never), 2.8% hip prosthesis (81.1% never) and 4% complex surgery (78.8% never). There were also significant differences in all the variables studied, depending on whether the patient had good or bad quality of life.

CONCLUSION

There is great variability on the allotment of resources for patients with limited possibilities of survival.

Multicenter study of the multiple organ dysfunction syndrome in intensive care units: the usefulness of Sequential Organ Failure Assessment scores in decision making

OBJECTIVE

This study examined the incidence and mortality of multiple organ dysfunction syndrome (MODS) in intensive care units, evaluated the limitation of life support in these patients, and determined whether daily measurement of the Sequential Organ Failure Assessment (SOFA) is useful for decision making.

DESIGN AND SETTING

Prospective, observational study in 79 intensive care units.

PATIENTS AND PARTICIPANTS

Of the 7,615 patients admitted during a 2-month period we found 1,340 patients to have MODS.

MEASUREMENTS AND RESULTS

We recorded mortality and length of stay in the intensive care unit and the hospital and the maximum and minimum total SOFA scores during MODS. Limitation of life support in MODS patients was also evaluated. Stepwise logistic regression was used to determine the factors predicting mortality. The in-hospital mortality rate in patients with MODS was 44.6%, and some type of limitation of life support was applied in 70.6% of the patients who died. The predictive model maximizing specificity included the following variables: maximum SOFA score, minimum SOFA score, trend of the SOFA for 5 consecutive days, and age over 60 years. The model diagnostic yield was: specificity 100%, sensitivity 7.2%, positive predictive value 100%, and negative predictive value 57.3%; the area under the receiver operating characteristic curve was 0.807.

CONCLUSIONS

This model showed that in our population with MODS those older than 60 years and with SOFA score higher than 9 for at least 5 days were unlikely to survive.