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Grable S, McKeon S, Burns B, Wetshtein A, Rossfeld Z. Observations from Optimizing an Electronic Order Set for Withdrawal of Life-Sustaining Treatment. J Palliat Med 2024; 27:846-853. [PMID: 38416599 DOI: 10.1089/jpm.2023.0380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2024] Open
Abstract
Background: Withdrawal of life-sustaining treatment (WLST) is a process with unique pressure for all involved. The use of an electronic order set can facilitate best care. Objective: To assess utilization of a WLST order set and time to inpatient death before and after optimization. Design: A retrospective chart review for 12-month periods before and after enhancements to a WLST order set. Setting/Subjects: Multicenter study within an American, not-for-profit health care system of inpatient decedents July 2017-June 2018 and April 2021-March 2022 with orders placed via WLST order set. Measurements: Co-primary outcomes included order set utilization and time from activation of orders to patient death. Descriptive post hoc analyses featured demographics, palliative consultation, ordering clinician type/specialty, and COVID-19. Results: A total of 1949 patients had orders placed via the WLST order set and died in-hospital. Compared with the 2017-2018 period, use increased 35.8% in 2021-2022. Time to death after release of orders was significantly longer for the 2021-2022 group (4.4 vs. 3.7 hours). Demographic details included nurse practitioners (39%) as most frequent WLST order set utilizer and palliative consultation in 46% of terminal hospitalizations. Among decedents with consultation, palliative clinicians were the WLST order set utilizer for 47% of cases (i.e., 21% of all WLST order set utilizations). The median time to death was significantly longer when orders were placed by a palliative clinician (4.5 hours) compared with nonpalliative specialists (3.9 hours). COVID-19 was a hospital diagnosis for 29% of decedents in the 2021-2022 group. Conclusions: In the emotionally and cognitively intense process that is WLST, an order set provides a modifiable panel of defaults. Our experience highlights the power in guiding primary palliative care for WLST in the hospital setting and suggests that advanced practice providers and nonpalliative clinicians, as primary utilizers, be integral in the design of a WLST order set.
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Affiliation(s)
- Samantha Grable
- Palliative Medicine, OhioHealth, Columbus, Ohio, USA
- Grant Medical Center, Columbus, Ohio, USA
| | - Scott McKeon
- Palliative Medicine, OhioHealth, Columbus, Ohio, USA
| | - Brianna Burns
- Service Line Analytics, OhioHealth, Columbus, Ohio, USA
| | - Andrea Wetshtein
- Department of Pharmacy, Cleveland Clinic Fairview Hospital, Cleveland, Ohio, USA
| | - Zach Rossfeld
- Division of Palliative Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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2
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Jennerich AL. An Approach to Caring for Patients and Family of Patients Dying in the ICU. Chest 2024; 166:127-135. [PMID: 38354905 DOI: 10.1016/j.chest.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 01/10/2024] [Accepted: 02/07/2024] [Indexed: 02/16/2024] Open
Abstract
TOPIC IMPORTANCE Death is common in the ICU and often occurs after a decision to withhold or withdraw life-sustaining therapies. Care of the dying is a core skill for ICU clinicians, requiring expert communication, primarily with family of critically ill patients. REVIEW FINDINGS Limited high-quality evidence supports specific practices related to the care of dying patients in the ICU; thus, many of the recommendations that exist are based on expert opinion. Value exists in sharing a practical approach to caring for patients during the dying process, including topics to be addressed with family members, rationales for recommended care, and strategies for implementing comfort measures only. Through dedicated preparation and planning, clinicians can help family members navigate this intense experience. SUMMARY After a decision had been made to discontinue life-sustaining therapies, family members need to be given a clear description of comfort measures only and provided with additional detail about what it entails, including therapies or interventions to be discontinued, monitoring during the dying process, and common features of the dying process. Order sets can be a valuable resource for ensuring that adequate analgesia and sedation are available and the care plan is enacted properly. To achieve a good death for patients, a collaborative effort among members of the care team is essential.
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Affiliation(s)
- Ann L Jennerich
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, and the Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA.
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3
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Nicolson C, Burke A, Gardiner D, Harvey D, Munshi L, Shaw M, Tsanas A, Lone N, Puxty K. Predicting time to asystole following withdrawal of life-sustaining treatment: a systematic review. Anaesthesia 2024; 79:638-649. [PMID: 38301032 DOI: 10.1111/anae.16222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2023] [Indexed: 02/03/2024]
Abstract
The planned withdrawal of life-sustaining treatment is a common practice in the intensive care unit for patients where ongoing organ support is recognised to be futile. Predicting the time to asystole following withdrawal of life-sustaining treatment is crucial for setting expectations, resource utilisation and identifying patients suitable for organ donation after circulatory death. This systematic review evaluates the literature for variables associated with, and predictive models for, time to asystole in patients managed on intensive care units. We conducted a comprehensive structured search of the MEDLINE and Embase databases. Studies evaluating patients managed on adult intensive care units undergoing withdrawal of life-sustaining treatment with recorded time to asystole were included. Data extraction and PROBAST quality assessment were performed and a narrative summary of the literature was provided. Twenty-three studies (7387 patients) met the inclusion criteria. Variables associated with imminent asystole (<60 min) included: deteriorating oxygenation; absence of corneal reflexes; absence of a cough reflex; blood pressure; use of vasopressors; and use of comfort medications. We identified a total of 20 unique predictive models using a wide range of variables and techniques. Many of these models also underwent secondary validation in further studies or were adapted to develop new models. This review identifies variables associated with time to asystole following withdrawal of life-sustaining treatment and summarises existing predictive models. Although several predictive models have been developed, their generalisability and performance varied. Further research and validation are needed to improve the accuracy and widespread adoption of predictive models for patients managed in intensive care units who may be eligible to donate organs following their diagnosis of death by circulatory criteria.
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Affiliation(s)
- C Nicolson
- Department of Critical Care, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary, Glasgow, UK
- School of Informatics, University of Edinburgh, Edinburgh, UK
| | - A Burke
- Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
| | - D Gardiner
- Critical Care, Nottingham University Hospitals NHS Trust, Nottingham, UK
- NHS Blood and Transplant, Watford, UK
| | - D Harvey
- Critical Care, Nottingham University Hospitals NHS Trust, Nottingham, UK
- NHS Blood and Transplant, Watford, UK
| | - L Munshi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada
| | - M Shaw
- Department of Clinical Physics & Bioengineering, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary, Glasgow, UK
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
| | - A Tsanas
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - N Lone
- Usher Institute, University of Edinburgh, Edinburgh, UK
- Department of Critical Care, NHS Lothian, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - K Puxty
- Department of Critical Care, NHS Greater Glasgow and Clyde, Glasgow Royal Infirmary, Glasgow, UK
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK
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4
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Tong HH, Creutzfeldt CJ, Hicks KG, Kross EK, Sharma RK, Jennerich AL. Questions From Family Members During the Dying Process And Moral Distress Experienced by ICU Nurses. J Pain Symptom Manage 2024; 67:402-410.e1. [PMID: 38342474 DOI: 10.1016/j.jpainsymman.2024.01.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/25/2024] [Accepted: 01/29/2024] [Indexed: 02/13/2024]
Abstract
BACKGROUND For a hospitalized patient, transitioning to comfort measures only (CMO) involves discontinuation of life-prolonging interventions with a goal of allowing natural death. Nurses play a pivotal role during the provision of CMO, caring for both the dying patient and their family. OBJECTIVE To examine the experiences of ICU nurses caring for patients receiving CMO. METHODS Between October 2020 and June 2021, nurses in the neuro- and medical-cardiac intensive care units at Harborview Medical Center in Seattle, WA, completed surveys about their experiences providing CMO. Surveys addressed involvement in discussions about CMO and questions asked by family members of dying patients. We also assessed nurses' moral distress related to CMO and used ordinal logistic regression to examine predictors of moral distress. RESULTS Surveys were completed by 82 nurses (response rate 44%), with 79 (96%) reporting experience providing CMO in the previous year. Most preferred to be present for discussions between physicians or advanced practice providers and family members about transitioning to CMO (89% most of the time or always); however, only 31% were present most of the time or always. Questions from family about time to death, changes in breathing, and medications to relieve symptoms were common. Most nurses reported moral distress at least some of the time when providing CMO (62%). Feeling well-prepared to answer specific questions from family was associated with less moral distress. CONCLUSION There is discordance between nurses' preferences for inclusion in discussions about the transition to CMO and their actual presence. Moral distress is common for nurses when providing CMO and feeling prepared to answer questions from family members may attenuate distress.
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Affiliation(s)
- Hao H Tong
- University of Pennsylvania, Division of Pulmonary, Allergy and Critical Care (H.H.T.), Philadelphia, Pennsylvania, USA
| | - Claire J Creutzfeldt
- Harborview Medical Center, Department of Neurology (C.J.C.), Seattle, Washington, USA; Cambia Palliative Care Center of Excellence, University of Washington (C.J.C., E.K.K., R.K.S., A.L.J.), Seattle, Washington, USA
| | - Katherine G Hicks
- Baylor College of Medicine, Section of Geriatrics and Palliative Medicine (K.G.H.), Houston, Texas, USA
| | - Erin K Kross
- Cambia Palliative Care Center of Excellence, University of Washington (C.J.C., E.K.K., R.K.S., A.L.J.), Seattle, Washington, USA; Harborview Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington (E.K.K., A.L.J.), Seattle, Washington, USA
| | - Rashmi K Sharma
- Cambia Palliative Care Center of Excellence, University of Washington (C.J.C., E.K.K., R.K.S., A.L.J.), Seattle, Washington, USA; University of Washington, Division of General Internal Medicine (R.K.S.), Seattle, Washington, USA
| | - Ann L Jennerich
- Cambia Palliative Care Center of Excellence, University of Washington (C.J.C., E.K.K., R.K.S., A.L.J.), Seattle, Washington, USA; Harborview Medical Center, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington (E.K.K., A.L.J.), Seattle, Washington, USA.
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5
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Campbell ML, Yarandi HN. Effectiveness of an Algorithmic Approach to Ventilator Withdrawal at the End of Life: A Stepped Wedge Cluster Randomized Trial. J Palliat Med 2024; 27:185-191. [PMID: 37594769 PMCID: PMC10825265 DOI: 10.1089/jpm.2023.0128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2023] [Indexed: 08/19/2023] Open
Abstract
Background: The transition to spontaneous breathing puts patients who are undergoing ventilator withdrawal at high risk for developing respiratory distress. A patient-centered algorithmic approach could standardize this process and meet unique patient needs because a single approach (weaning vs. one-step extubation) does not capture the needs of a heterogenous population undergoing this palliative procedure. Objectives: (1) Demonstrate that the algorithmic approach can be effective to ensure greater patient respiratory comfort compared to usual care; (2) determine differences in opioid or benzodiazepine use; (3) predict factors associated with duration of survival. Design/Settings/Measures: A stepped-wedge cluster randomized design at five sites was used. Sites crossed over to the algorithm in random order after usual care data were obtained. Patient comfort was measured with the Respiratory Distress Observation Scale© (RDOS) at baseline, at ventilator off, and every 15-minutes for an hour. Parenteral morphine and lorazepam equivalents from the onset of the process until patient death were calculated. Results: Usual care data n = 120, algorithm data n = 48. Gender and race were evenly distributed. All patients in the usual care arm underwent a one-step ventilator cessation; 58% of patients in the algorithm arm were weaned over an average of 18 ± 27 minutes as prescribed in the algorithm. Patients had significantly less respiratory distress in the intervention arm (F = 10.41, p = 0.0013, effective size [es] = 0.49). More opioids (t = -2.30, p = 0.023) and benzodiazepines (t = -2.08, p = 0.040) were given in the control arm. Conclusions: The algorithm was effective in ensuring patient respiratory comfort. Surprisingly, more medication was given in the usual care arm; however, less may be needed when distress is objectively measured (RDOS), and treatment is initiated as soon as distress develops as in the algorithm. Clinical Trial Registration number: NCT03121391.
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6
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Tripathi S, Laksana E, McCrory MC, Hsu S, Zhou AX, Burkiewicz K, Ledbetter DR, Aczon MD, Shah S, Siegel L, Fainberg N, Morrow KR, Avesar M, Chandnani HK, Shah J, Pringle C, Winter MC. Analgesia and Sedation at Terminal Extubation: A Secondary Analysis From Death One Hour After Terminal Extubation Study Data. Pediatr Crit Care Med 2023; 24:463-472. [PMID: 36877028 DOI: 10.1097/pcc.0000000000003209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
OBJECTIVES To describe the doses of opioids and benzodiazepines administered around the time of terminal extubation (TE) to children who died within 1 hour of TE and to identify their association with the time to death (TTD). DESIGN Secondary analysis of data collected for the Death One Hour After Terminal Extubation study. SETTING Nine U.S. hospitals. PATIENTS Six hundred eighty patients between 0 and 21 years who died within 1 hour after TE (2010-2021). MEASUREMENTS AND MAIN RESULTS Medications included total doses of opioids and benzodiazepines 24 hours before and 1 hour after TE. Correlations between drug doses and TTD in minutes were calculated, and multivariable linear regression performed to determine their association with TTD after adjusting for age, sex, last recorded oxygen saturation/F io2 ratio and Glasgow Coma Scale score, inotrope requirement in the last 24 hours, and use of muscle relaxants within 1 hour of TE. Median age of the study population was 2.1 years (interquartile range [IQR], 0.4-11.0 yr). The median TTD was 15 minutes (IQR, 8-23 min). Forty percent patients (278/680) received either opioids or benzodiazepines within 1 hour after TE, with the largest proportion receiving opioids only (23%, 159/680). Among patients who received medications, the median IV morphine equivalent within 1 hour after TE was 0.75 mg/kg/hr (IQR, 0.3-1.8 mg/kg/hr) ( n = 263), and median lorazepam equivalent was 0.22 mg/kg/hr (IQR, 0.11-0.44 mg/kg/hr) ( n = 118). The median morphine equivalent and lorazepam equivalent rates after TE were 7.5-fold and 22-fold greater than the median pre-extubation rates, respectively. No significant direct correlation was observed between either opioid or benzodiazepine doses before or after TE and TTD. After adjusting for confounding variables, regression analysis also failed to show any association between drug dose and TTD. CONCLUSIONS Children after TE are often prescribed opioids and benzodiazepines. For patients dying within 1 hour of TE, TTD is not associated with the dose of medication administered as part of comfort care.
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Affiliation(s)
- Sandeep Tripathi
- Pediatric Intensive Care, OSF HealthCare, Children's Hospital of Illinois/University of Illinois College of Medicine, Peoria, IL
| | - Eugene Laksana
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Michael C McCrory
- Departments of Anesthesiology and Pediatrics, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Stephanie Hsu
- Division of Critical Care Medicine, Children's Health Medical Center Dallas, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Alice X Zhou
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Kimberly Burkiewicz
- Pediatric Intensive Care, OSF HealthCare, Children's Hospital of Illinois/University of Illinois College of Medicine, Peoria, IL
| | - David R Ledbetter
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Melissa D Aczon
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Sareen Shah
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Division of Critical Care, Department of Pediatrics, Cohen Children's Medical Center, Long Island, NY
| | - Linda Siegel
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Division of Critical Care, Department of Pediatrics, Cohen Children's Medical Center, Long Island, NY
| | - Nina Fainberg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Katie R Morrow
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Michael Avesar
- Division of Pediatric Critical Care Medicine, Loma Linda University Children's Hospital, Loma Linda, CA
| | - Harsha K Chandnani
- Division of Pediatric Critical Care Medicine, Loma Linda University Children's Hospital, Loma Linda, CA
| | - Jui Shah
- Division of Pediatric Critical Care Medicine, Loma Linda University Children's Hospital, Loma Linda, CA
| | - Charlene Pringle
- Department of Pediatrics, Critical Care Medicine, University of Florida, Gainesville, FL
| | - Meredith C Winter
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
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Zheng YC, Huang YM, Chen PY, Chiu HY, Wu HP, Chu CM, Chen WS, Kao YC, Lai CF, Shih NY, Lai CH. Prediction of survival time after terminal extubation: the balance between critical care unit utilization and hospice medicine in the COVID-19 pandemic era. Eur J Med Res 2023; 28:21. [PMID: 36631882 PMCID: PMC9832251 DOI: 10.1186/s40001-022-00972-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 12/26/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND We established 1-h and 1-day survival models after terminal extubation to optimize ventilator use and achieve a balance between critical care for COVID-19 and hospice medicine. METHODS Data were obtained from patients with end-of-life status at terminal extubation from 2015 to 2020. The associations between APACHE II scores and parameters with survival time were analyzed. Parameters with a p-value ≤ 0.2 in univariate analysis were included in multivariate models. Cox proportional hazards regression analysis was used for the multivariate analysis of survival time at 1 h and 1 day. RESULTS Of the 140 enrolled patients, 76 (54.3%) died within 1 h and 35 (25%) survived beyond 24 h. No spontaneous breathing trial (SBT) within the past 24 h, minute ventilation (MV) ≥ 12 L/min, and APACHE II score ≥ 25 were associated with shorter survival in the 1 h regression model. Lower MV, SpO2 ≥ 96% and SBT were related to longer survival in the 1-day model. Hospice medications did not influence survival time. CONCLUSION An APACHE II score of ≥ 25 at 1 h and SpO2 ≥ 96% at 1 day were strong predictors of disposition of patients to intensivists. These factors can help to objectively tailor pathways for post-extubation transition and rapidly allocate intensive care unit resources without sacrificing the quality of palliative care in the era of COVID-19. Trial registration They study was retrospectively registered. IRB No.: 202101929B0.
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Affiliation(s)
- Yun-Cong Zheng
- grid.413801.f0000 0001 0711 0593Departments of Neurosurgery, Chang Gung Memorial Hospital, Keelung and Linkou & Chang Gung University, Taoyuan, Taiwan ,grid.19188.390000 0004 0546 0241Department of Biomedical Engineering, National Taiwan University, Taipei, Taiwan
| | - Yen-Min Huang
- grid.454209.e0000 0004 0639 2551Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital, No. 222, Maijin Rd., Anle Dist., Keelung, 204 Taiwan ,grid.411641.70000 0004 0532 2041Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Pin-Yuan Chen
- grid.413801.f0000 0001 0711 0593Departments of Neurosurgery, Chang Gung Memorial Hospital, Keelung and Linkou & Chang Gung University, Taoyuan, Taiwan
| | - Hsiao-Yean Chiu
- grid.412896.00000 0000 9337 0481School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan ,grid.412896.00000 0000 9337 0481Research Center of Sleep Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan ,grid.412897.10000 0004 0639 0994Department of Nursing, Taipei Medical University Hospital, Taipei, Taiwan
| | - Huang-Pin Wu
- grid.454209.e0000 0004 0639 2551Division of Pulmonary, Critical Care and Sleep Medicine, Chang Gung Memorial Hospital, Keelung, 20401 Taiwan ,grid.145695.a0000 0004 1798 0922College of Medicine, Chang Gung University, Taoyuan, 33302 Taiwan
| | - Chien-Ming Chu
- grid.454209.e0000 0004 0639 2551Division of Pulmonary, Critical Care and Sleep Medicine, Chang Gung Memorial Hospital, Keelung, 20401 Taiwan
| | - Wei-Siang Chen
- grid.145695.a0000 0004 1798 0922Division of Cardiology Section, Internal Medicine, Chang Gung Memorial Hospital, Keelung & Chang Gung University, Taoyuan, Taiwan
| | - Yu-Cheng Kao
- grid.145695.a0000 0004 1798 0922Division of Cardiology Section, Internal Medicine, Chang Gung Memorial Hospital, Keelung & Chang Gung University, Taoyuan, Taiwan
| | - Ching-Fang Lai
- grid.454209.e0000 0004 0639 2551Department of Social Services, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Ning-Yi Shih
- grid.454209.e0000 0004 0639 2551Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital, No. 222, Maijin Rd., Anle Dist., Keelung, 204 Taiwan
| | - Chien-Hong Lai
- grid.454209.e0000 0004 0639 2551Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital, No. 222, Maijin Rd., Anle Dist., Keelung, 204 Taiwan
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Antonio ACP, Antonio JP. Palliative extubation experience in a community hospital in southern Brazil. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e20230208. [PMID: 37194907 DOI: 10.1590/1806-9282.20230208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 02/23/2023] [Indexed: 05/18/2023]
Affiliation(s)
- Ana Carolina Peçanha Antonio
- Hospital de Clínicas de Porto Alegre - Porto Alegre (RS), Brazil
- Rede de Saúde Divina Providência, Hospital Independência - Porto Alegre (RS), Brazil
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Cullum KG, Madani CA, Cutler ER, Reavis KJ. The Lived Experience of Respiratory Therapists During Withdrawal of Advanced Life-Sustaining Therapies at End of Life in the ICU. Respir Care 2022; 67:1568-1577. [PMID: 35944967 PMCID: PMC9994019 DOI: 10.4187/respcare.09249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The act of withdrawing advanced life-sustaining therapies, more specifically mechanical ventilation, is performed in hospitals all over the world. Success involves coordination of several members of the patient care team, including nurses, providers (physicians nurse practitioners, or physician assistants), and respiratory therapists (RTs). The experiences of RTs surrounding this procedure are not well documented. The aim of this study was to explore the lived experience of RTs who have participated in withdrawal of advanced life-sustaining therapies, utilizing a hermeneutical phenomenological approach. METHODS Individual interviews were conducted with experienced RTs that were audio recorded and transcribed. The data were analyzed by 4 health professionals, and data were triangulated. RESULTS Three themes emerged from the study: (1) impact of power relations surrounding the process, (2) needing tools to provide quality withdrawal of advanced life-sustaining therapies, and (3) emotional involvement/exposure. It was clear from the analysis that RTs desire more education, to be part of the decision-making, and to be appreciated for their role in this emotional process. CONCLUSIONS Through this study, the role of RT in withdrawal of advanced life-sustaining therapies is better understood, which can only lead to improvement in the overall process for health care team, patient, and families.
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Affiliation(s)
| | | | - Eloisa R Cutler
- University of California, San Diego Medical Center, San Diego, California
| | - Karen J Reavis
- San Diego State University, School of Nursing, San Diego, California
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10
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Kaur R, Harmon E, Joseph A, Dhliwayo NL, Kramer N, Chen E. Palliative Ventilator Withdrawal Practices in an Inpatient Hospice Unit. Am J Hosp Palliat Care 2022:10499091221129827. [DOI: 10.1177/10499091221129827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Palliative ventilator withdrawal (PVW) involves removal of mechanical ventilation in patients not expected to survive to allow a peaceful death. This process traditionally occurs in Intensive Care Units (ICU) and recently has evolved to occur in Inpatient Hospice and Palliative Care Units (IPU). Objectives To describe the process and response of patients undergoing PVW in an IPU setting. Methods This is a longitudinal observational cohort study of adult patients who underwent PVW in an IPU from January 2021 through March 2022. Results Among 25 enrolled subjects, median age was 68 (IQR 62.5-76.5) years and 14 (56%) were females. Median time from PVW to death was 16.8 (IQR 2.6-100) hours. A registered nurse and attending physician were present in all the cases, while a respiratory therapist was present in 20 (80%) and chaplain in 9 (36%) of the cases. Before PVW, opioids and benzodiazepines were administered to 24 (96%) patients. Post PVW, respiratory distress was noted among 16 (64%) patients and medication was given to 15 (60%) patients for respiratory distress. There was a significant association between the presence of respiratory distress and administration of medication within 30 minutes after PVW ( P = .009). The rituals performed during PVW were reciting prayers for 11 (44%), playing music for 8 (32%), and observing silence for 6 (24%) of the patients. Conclusion This study describes the PVW practices in an IPU setting where a multidisciplinary team was present during PVW for most of the cases and two-third of the patients undergoing PVW experienced respiratory distress immediately after PVW.
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Affiliation(s)
- Ramandeep Kaur
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL, USA
| | - Elizabeth Harmon
- Department of Internal Medicine, Section of Palliative Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Augustin Joseph
- Department of Internal Medicine, Section of Palliative Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Nyembezi L Dhliwayo
- Department of Internal Medicine, Section of Palliative Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Neha Kramer
- Department of Internal Medicine, Section of Palliative Medicine, Rush University Medical Center, Chicago, IL, USA
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Elaine Chen
- Department of Internal Medicine, Section of Palliative Medicine, Rush University Medical Center, Chicago, IL, USA
- Department of Internal Medicine, Division of Pulmonary and Critical Care, Rush University Medical Center, Chicago, IL, USA
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11
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Predicting Time to Death After Withdrawal of Life-Sustaining Treatment in Children. Crit Care Explor 2022; 4:e0764. [PMID: 36101830 PMCID: PMC9462532 DOI: 10.1097/cce.0000000000000764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Accurately predicting time to death after withdrawal of life-sustaining treatment is valuable for family counseling and for identifying candidates for organ donation after cardiac death. This topic has been well studied in adults, but literature is scant in pediatrics. The purpose of this report is to assess the performance and clinical utility of the available tools for predicting time to death after treatment withdrawal in children.
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Dilemas bioéticos experimentados por el cuidador respiratorio durante el retiro de la ventilación mecánica en adultos al final de la vida. MOVIMIENTO CIENTÍFICO 2022. [DOI: 10.33881/2011-7191.mct.15205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Introducción: sobre el retiro de la ventilación mecánica al final de la vida, la literatura ha documentado brechas conceptuales en los cuidadores respiratorios y los consecuentes dilemas bioéticos a los que se enfrentan estos profesionales. Objetivo: analizar los dilemas bioéticos que experimentan los cuidadores respiratorios durante el retiro de la ventilación mecánica en adultos al final de la vida a partir de una revisión integradora de la literatura publicada entre 2010 y 2021. Metodología: revisión integrativa de la literatura siguiendo los lineamientos de Whittemore & Knafl (2005) y Guirao Goris (2015). Para el análisis de la información se realizó una evaluación crítica de la literatura acopiada para identificar patrones de comportamiento de los cuidadores respiratorios. Resultados: las enfermedades no transmisibles y crónicas fueron identificadas como las principales condiciones clínicas que determinan la toma de decisiones del cuidador respiratorio en el retiro de la ventilación mecánica paliativa; prolongar la vida de forma artificial a pacientes en estado terminal fue el dilema bioético más frecuente. Conclusiones: los profesionales del cuidado respiratorio enfrentan dilemas éticos en el retiro de la ventilación mecánica al final de la vida de pacientes con afecciones oncológicas y no oncológica; la toma de decisiones se realiza principalmente con base en los principios bioéticos clásicos de Respeto por la autonomía, Beneficencia, No maleficencia y Justicia. Se evidencia la carencia de estudios sobre bioética en diálogo con lineamientos de la Declaración Universal sobre Bioética y Derechos humanos.
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Honinx E, Van den Block L, Piers R, Van Kuijk SMJ, Onwuteaka-Philipsen BD, Payne SA, Szczerbińska K, Gambassi GG, Finne-Soveri H, Deliens L, Smets T. Potentially Inappropriate Treatments at the End of Life in Nursing Home Residents: Findings From the PACE Cross-Sectional Study in Six European Countries. J Pain Symptom Manage 2021; 61:732-742.e1. [PMID: 32916262 DOI: 10.1016/j.jpainsymman.2020.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/28/2020] [Accepted: 09/01/2020] [Indexed: 12/15/2022]
Abstract
CONTEXT Certain treatments are potentially inappropriate when administered to nursing homes residents at the end of life and should be carefully considered. An international comparison of potentially inappropriate treatments allows insight into common issues and country-specific challenges of end-of-life care in nursing homes and helps direct health-care policy in this area. OBJECTIVES To estimate the prevalence of potentially inappropriate treatments in the last week of life in nursing home residents and analyze the differences in prevalence between countries. METHODS A cross-sectional study of deceased residents in nursing homes (2015) in six European countries: Belgium (Flanders), England, Finland, Italy, The Netherlands, and Poland. Potentially inappropriate treatments included enteral administration of nutrition, parental administration of nutrition, artificial fluids, resuscitation, artificial ventilation, blood transfusion, chemotherapy/radiotherapy, dialysis, surgery, antibiotics, statins, antidiabetics, new oral anticoagulants. Nurses were questioned about whether these treatments were administered in the last week of life. RESULTS We included 1384 deceased residents from 322 nursing homes. In most countries, potentially inappropriate treatments were rarely used, with a maximum of 18.3% of residents receiving at least one treatment in Poland. Exceptions were antibiotics in all countries (between 11.3% in Belgium and 45% in Poland), artificial nutrition and hydration in Poland (54.3%) and Italy (41%) and antidiabetics in Poland (19.7%). CONCLUSION Although the prevalence of potentially inappropriate treatments in the last week of life was generally low, antibiotics were frequently prescribed in all countries. In Poland and Italy, the prevalence of artificial administration of food/fluids in the last week of life was high, possibly reflecting country differences in legislation, care organization and culture, and the palliative care competences of staff.
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Affiliation(s)
- Elisabeth Honinx
- End-of-Life Care Research Group, Department of Family Medicine & Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.
| | - Lieve Van den Block
- End-of-Life Care Research Group, Department of Family Medicine & Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Ruth Piers
- Clinic of Geriatric Medicine, Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
| | - Sander M J Van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), MUMC, Maastricht, The Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, Vrije Universiteit Amsterdam Medisch Centrum, Amsterdam, The Netherlands
| | - Sheila A Payne
- Faculty of Health And Medicine, Lancaster University, Lancaster, UK
| | - Katarzyna Szczerbińska
- Laboratory for Research on Aging Society, Department of Sociology of Medicine, Epidemiology and Preventive Medicine, Medical Faculty, Jagiellonian University Medical College, Kraków, Poland
| | - Giovanni G Gambassi
- Department of Internal Medicine, Istituto di Medicina Interna e Geriatria, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Harriet Finne-Soveri
- Geriatric Medicine, Department of Welfare, Ageing Disability and Functioning Unit, National Institute for Health and Welfare, Helsinki, Finland
| | - Luc Deliens
- End-of-Life Care Research Group, Department of Family Medicine & Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Tinne Smets
- End-of-Life Care Research Group, Department of Family Medicine & Chronic Care, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
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Winter MC, Day TE, Ledbetter DR, Aczon MD, Newth CJL, Wetzel RC, Ross PA. Machine Learning to Predict Cardiac Death Within 1 Hour After Terminal Extubation. Pediatr Crit Care Med 2021; 22:161-171. [PMID: 33156210 DOI: 10.1097/pcc.0000000000002612] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Accurate prediction of time to death after withdrawal of life-sustaining therapies may improve counseling for families and help identify candidates for organ donation after cardiac death. The study objectives were to: 1) train a long short-term memory model to predict cardiac death within 1 hour after terminal extubation, 2) calculate the positive predictive value of the model and the number needed to alert among potential organ donors, and 3) examine associations between time to cardiac death and the patient's characteristics and physiologic variables using Cox regression. DESIGN Retrospective cohort study. SETTING PICU and cardiothoracic ICU in a tertiary-care academic children's hospital. PATIENTS Patients 0-21 years old who died after terminal extubation from 2011 to 2018 (n = 237). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The median time to death for the cohort was 0.3 hours after terminal extubation (interquartile range, 0.16-1.6 hr); 70% of patients died within 1 hour. The long short-term memory model had an area under the receiver operating characteristic curve of 0.85 and a positive predictive value of 0.81 at a sensitivity of 94% when predicting death within 1 hour of terminal extubation. About 39% of patients who died within 1 hour met organ procurement and transplantation network criteria for liver and kidney donors. The long short-term memory identified 93% of potential organ donors with a number needed to alert of 1.08, meaning that 13 of 14 prepared operating rooms would have yielded a viable organ. A Cox proportional hazard model identified independent predictors of shorter time to death including low Glasgow Coma Score, high Pao2-to-Fio2 ratio, low-pulse oximetry, and low serum bicarbonate. CONCLUSIONS Our long short-term memory model accurately predicted whether a child will die within 1 hour of terminal extubation and may improve counseling for families. Our model can identify potential candidates for donation after cardiac death while minimizing unnecessarily prepared operating rooms.
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Affiliation(s)
- Meredith C Winter
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Travis E Day
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
- Department of Computer Science, University of Southern California Viterbi School of Engineering, Los Angeles, CA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - David R Ledbetter
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
| | - Melissa D Aczon
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
| | - Christopher J L Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Randall C Wetzel
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Patrick A Ross
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
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Efstathiou N, Vanderspank-Wright B, Vandyk A, Al-Janabi M, Daham Z, Sarti A, Delaney JW, Downar J. Terminal withdrawal of mechanical ventilation in adult intensive care units: A systematic review and narrative synthesis of perceptions, experiences and practices. Palliat Med 2020; 34:1140-1164. [PMID: 32597309 DOI: 10.1177/0269216320935002] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND During the terminal withdrawal of life-sustaining measures for intensive care patients, the removal of respiratory support remains an ambiguous practice. Globally, perceptions and experiences of best practice vary due to the limited evidence in this area. AIM To identify, appraise and synthesise the latest evidence around terminal withdrawal of mechanical ventilation in adult intensive care units specific to perceptions, experiences and practices. DESIGN Mixed methods systematic review and narrative synthesis. A review protocol was registered on PROSPERO (CRD42018086495). DATA SOURCES Four electronic databases were systematically searched (Medline, Embase, CENTRAL and CINAHL). Obtained articles published between January 2008 and January 2020 were screened for eligibility. All included papers were appraised using relevant appraisal tools. RESULTS Twenty-five papers were included in the review. Findings from the included papers were synthesised into four themes: 'clinicians' perceptions and practices'; 'time to death and predictors'; 'analgesia and sedation practices'; 'physiological and psychological impact'. CONCLUSIONS Perceptions, experiences and practices of terminal withdrawal of mechanical ventilation vary significantly across the globe. Current knowledge highlights that the time to death after withdrawal of mechanical ventilation is very short. Predictors for shorter duration could be considered by clinicians and guide the choice of pharmacological interventions to address distressing symptoms that patients may experience. Clinicians ought to prepare patients, families and relatives for the withdrawal process and the expected progression and provide them with immediate and long-term support following withdrawal. Further research is needed to improve current evidence and better inform practice guidelines.
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Affiliation(s)
- Nikolaos Efstathiou
- College of Medical and Dental Sciences, Institute of Clinical Sciences, School of Nursing, University of Birmingham, Birmingham, UK
| | | | - Amanda Vandyk
- Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, ON, Canada
| | - Mustafa Al-Janabi
- Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, ON, Canada
| | - Zeinab Daham
- Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, ON, Canada
| | - Aimee Sarti
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - James Downar
- Divisions of Critical Care and Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
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16
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Lacerda FH, Checoli PG, Silva CMDD, Brandão CE, Forte DN, Besen BAMP. Mechanical ventilation withdrawal as a palliative procedure in a Brazilian intensive care unit. Rev Bras Ter Intensiva 2020; 32:528-534. [PMID: 33470354 PMCID: PMC7853674 DOI: 10.5935/0103-507x.20200090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 04/19/2020] [Indexed: 11/30/2022] Open
Abstract
Objective To describe the characteristics and outcomes of patients undergoing mechanical ventilation withdrawal and to compare them to mechanically ventilated patients with limitations (withhold or withdrawal) of life-sustaining therapies but who did not undergo mechanical ventilation withdrawal. Methods This was a retrospective cohort study from January 2014 to December 2018 of mechanically ventilated patients with any organ support limitation admitted to a single intensive care unit. We compared patients who underwent mechanical ventilation withdrawal and those who did not regarding intensive care unit and hospital mortality and length of stay in both an unadjusted analysis and a propensity score matched subsample. We also analyzed the time from mechanical ventilation withdrawal to death. Results Out of 282 patients with life-sustaining therapy limitations, 31 (11%) underwent mechanical ventilation withdrawal. There was no baseline difference between groups. Intensive care unit and hospital mortality rates were 71% versus 57% and 93% versus 80%, respectively, among patients who underwent mechanical ventilation withdrawal and those who did not. The median intensive care unit length of stay was 7 versus 8 days (p = 0.6), and the hospital length of stay was 9 versus 15 days (p = 0.015). Hospital mortality was not significantly different (25/31; 81% versus 29/31; 93%; p = 0.26) after matching. The median time from mechanical ventilation withdrawal until death was 2 days [0 - 5], and 10/31 (32%) patients died within 24 hours after mechanical ventilation withdrawal. Conclusion In this Brazilian report, mechanical ventilation withdrawal represented 11% of all patients with treatment limitations and was not associated with increased hospital mortality after propensity score matching on relevant covariates.
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Affiliation(s)
- Fábio Holanda Lacerda
- Unidade de Terapia Intensiva, Hospital da Luz - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva, AC Camargo Cancer Center - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva, Hospital OTOclínica - Fortaleza (CE), Brasil
| | - Pedro Garcia Checoli
- Unidade de Terapia Intensiva, Hospital da Luz - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva, Hospital Sírio-Libanês - São Paulo (SP), Brasil
| | - Carla Marchini Dias da Silva
- Unidade de Terapia Intensiva, Hospital da Luz - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva, AC Camargo Cancer Center - São Paulo (SP), Brasil
| | - Carlos Eduardo Brandão
- Unidade de Terapia Intensiva, Hospital da Luz - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva, AC Camargo Cancer Center - São Paulo (SP), Brasil
| | - Daniel Neves Forte
- Programa de Cuidados Paliativos, Hospital Sírio-Libanês - São Paulo (SP), Brasil
| | - Bruno Adler Maccagnan Pinheiro Besen
- Unidade de Terapia Intensiva, Hospital da Luz - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva, Disciplina de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo, Brasil
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17
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Affonseca CDA, Carvalho LFAD, Quinet RDPB, Guimarães MCDC, Cury VF, Rotta AT. Palliative extubation: five-year experience in a pediatric hospital. J Pediatr (Rio J) 2020; 96:652-659. [PMID: 31493370 PMCID: PMC9432159 DOI: 10.1016/j.jped.2019.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 07/13/2019] [Accepted: 07/15/2019] [Indexed: 10/31/2022] Open
Abstract
OBJECTIVE To present the characteristics of pediatric patients with chronic and irreversible diseases submitted to palliative extubation. METHOD This is a descriptive analysis of a series of patients admitted to a public pediatric hospital, with chronic and irreversible diseases, permanently dependent on ventilatory support, who underwent palliative extubation between April 2014 and May 2019. The following information was collected from the medical records: demographic data, diagnosis, duration and type of mechanical ventilation; date, time, and place of palliative extubation; medications used; symptoms observed; and hospital outcome. RESULTS A total of 19 patients with a mean age of 2.2 years were submitted to palliative extubation. 68.4% of extubations were performed in the ICU; 11 patients (57.9%) died in the hospital. The time between mechanical ventilation withdrawal and in-hospital death ranged from 15minutes to five days. Thirteen patients used an orotracheal tube and the others used tracheostomy. The main symptoms were dyspnea and pain, and the main drugs used to control symptoms were opioids and benzodiazepines. CONCLUSIONS It was not possible to identify predictors of in-hospital death after ventilatory support withdrawal. Palliative extubation requires specialized care, with the presence and availability of a multidisciplinary team with adequate training in symptom control and palliative care.
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Affiliation(s)
- Carolina de Araújo Affonseca
- Hospital Infantil João Paulo II, Unidade CUIDAR - Cuidado Paliativo e Atenção Domiciliar, Belo Horizonte, MG, Brazil.
| | | | | | | | | | - Alexandre Tellechea Rotta
- Duke University School of Medicine, Division of Pediatric Critical Care Medicine, North Carolina, United States
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18
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de Araújo Affonseca C, de Carvalho LFA, de Pinho Barroso Quinet R, da Cunha Guimarães MC, Cury VF, Rotta AT. Palliative extubation: five‐year experience in a pediatric hospital. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2020. [DOI: 10.1016/j.jpedp.2019.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Kuriakose CK, Chandiraseharan VK, John AO, Bal D, Jeyaseelan V, Sudarsanam TD. End-of-life decisions: A retrospective study in a tertiary care teaching hospital in India. Indian J Med Res 2020; 150:598-605. [PMID: 32048623 PMCID: PMC7038812 DOI: 10.4103/ijmr.ijmr_1409_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background & objectives In developing countries like India, there is a lack of clarity regarding the factors that influence decisions pertaining to life supports at the end-of-life (EOL). The objectives of this study were to assess the factors associated with EOL-care decisions in the Indian context and to raise awareness in this area of healthcare. Methods This retrospectively study included all patients admitted to the medical unit of a tertiary care hospital in southern India, over one year and died. The baseline demographics, economic, physiological, sociological, prognostic and medical treatment-related factors were retrieved from the patient's medical records and analysed. Results Of the 122 decedents included in the study whose characteristics were analyzed, 41 (33.6%) received full life support and 81 (66.4%) had withdrawal or withholding of some life support measure. Amongst those who had withdrawal or withholding of life support, 62 (76.5%) had some support withheld and in 19 (23.5%), it was withdrawn. The documentation of the disease process, prognosis and the mention of imminent death in the medical records was the single most important factor that was associated with the EOL decision (odds ratio - 0.08; 95% confidence interval, 0.01-0.74; P=0.03). Interpretation & conclusions The documentation of poor prognosis was the only factor found to be associated with EOL care decisions in our study. Prospective, multicentric studies need to be done to evaluate the influence of various other factors on the EOL care.
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Affiliation(s)
- Cijoy K Kuriakose
- Department of Medicine, Christian Medical College & Hospital, Vellore, Tamil Nadu, India
| | | | - Ajoy Oommen John
- Department of Medicine, Christian Medical College & Hospital, Vellore, Tamil Nadu, India
| | - Deepti Bal
- Department of Medicine, Christian Medical College & Hospital, Vellore, Tamil Nadu, India
| | - Visalakshi Jeyaseelan
- Department of Biostatistics, Christian Medical College & Hospital, Vellore, Tamil Nadu, India
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20
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Chang HT, Lin MH, Chen CK, Chen TJ, Hwang SJ. Aggressive End-of-Life Care and Symptom Relief Treatments in Terminally Ill Patients Who Had Discussed Withdrawal of Mechanical Ventilation: A Hospital-Based Observational Study. Am J Hosp Palliat Care 2020; 37:897-903. [PMID: 32115985 DOI: 10.1177/1049909120906612] [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] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The aim of this study was to explore the status of aggressive end-of-life care and symptom relief treatments in terminally ill patients who had discussed the withdrawal of mechanical ventilation. METHODS This research is a retrospective observational study based on a chart review. Terminal patients aged ≥20 years, who were intubated with mechanical ventilation support, who underwent hospice-shared care, and who personally, or whose close relatives, had discussed the withdrawal of mechanical ventilation with hospice-shared care team members in a tertiary hospital in Taiwan during 2012 to 2015 were included. Demographics, medical conditions, and aggressive end-of-life care, including hospitalization, use of vasopressors, artificial nutrition, tube feeding, antibiotics, and symptom relief treatments including the use of opioids, steroids, and sedatives, were identified. The modes of care and treatments of patients by the status of withdrawal of mechanical ventilation were compared. RESULTS A total of 141 patients had discussed the withdrawal of mechanical ventilation, and 111 (78.7%) had been withdrawn. Aggressive end-of-life care was noted in all patients regardless of mechanical ventilation status. There were no significant differences in the number and pattern of aggressive end-of-life care measures between patients who had or had not been withdrawn. There were significantly higher rates of symptom relief treatments used in patients who had been withdrawn. CONCLUSIONS Aggressive end-of-life care is common for patients who have discussed the withdrawal of mechanical ventilation. There are significantly higher rates of symptom relief medications administered in patients who have been withdrawn from mechanical ventilation.
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Affiliation(s)
- Hsiao-Ting Chang
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei .,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei
| | - Ming-Hwai Lin
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei .,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei
| | - Chun-Ku Chen
- Department of Radiology, Taipei Veterans General Hospital, Taipei.,Faculty of Medicine, School of Medicine and Institute of Clinical Medicine, National Yang-Ming University, Taipei
| | - Tzeng-Ji Chen
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei .,Faculty of Medicine, School of Medicine and Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei
| | - Shinn-Jang Hwang
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei .,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei
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Nurses' Experiences and Factors Related to Their Attitudes Regarding Discussions with Patients and Family Members about Do-Not-Resuscitate Decisions and Life-Sustaining Treatment Withdrawal: A Hospital-Based Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17020557. [PMID: 31952305 PMCID: PMC7014028 DOI: 10.3390/ijerph17020557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 01/06/2020] [Accepted: 01/11/2020] [Indexed: 11/17/2022]
Abstract
This study aimed to evaluate nurses’ experiences and factors related to their attitudes regarding discussions of do-not-resuscitate (DNR) and withdrawal of life-sustaining treatment (LST) with patients and their families. A cross-sectional survey was conducted in a tertiary hospital in Taiwan. Nurses aged ≥ 20 years who were in charge of acute inpatient care were randomly recruited. A semi-structured questionnaire was used to evaluate participants’ experiences and attitudes regarding discussions of DNR and LST withdrawal for terminal patients. Logistic regression with adjustment for covariates was used to analyze factors related to participants’ attitudes toward discussions about DNR and LST withdrawal with patients and families in the future care of terminal patients. The participants were 132 nurses. They had significantly more discussions about DNR and LST withdrawal with patients’ families than with patients. Regression analysis showed that participants who had past experiences in actively initiating DNR discussions with patients or patients’ families were significantly more likely to discuss DNR with patients in the future care of terminal patients, but participants aged 40.0 to 60.0 years were significantly less likely to have DNR discussions than those aged 20.0 to 29.9 years. Experiences of actively initiated DNR or LST discussions with patients’ families were significantly more likely to discuss DNR with patients’ families, but those aged 40.0 to 60.0 years were also significantly less likely to have DNR discussions than those aged 20.0 to 29.9 years. Experience in actively initiating discussions about LST withdrawal with patients’ families, being male, and possessing an education level higher than university were significantly related to LST withdrawal discussions with terminal patients or their families in the future. In conclusion, there need to be more discussions about DNR and LST withdrawal with patients. To protect patients’ autonomy and their rights to make decisions about their DNR and LST, measures are needed to facilitate DNR and LST discussions with patients to ensure better end-of-life care.
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22
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Yeow ME, Chen E. Ventilator Withdrawal in Anticipation of Death: The Simulation Lab as an Educational Tool in Palliative Medicine. J Pain Symptom Manage 2020; 59:165-171. [PMID: 31610274 DOI: 10.1016/j.jpainsymman.2019.09.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 09/27/2019] [Accepted: 09/30/2019] [Indexed: 11/18/2022]
Abstract
Simulation is a growing model of education in many medical disciplines. Withdrawal of mechanical ventilation is an important skill set for palliative medicine practitioners who must be facile with a variety of end-of-life scenarios and is well suited to the simulation laboratory. We describe a novel approach using high-fidelity simulation to design a curriculum to teach Hospice & Palliative Medicine fellows the practical aspects of managing a compassionate terminal extubation. This simulation session aims to equip palliative fellows with a knowledge base of respiratory physiology and mechanical ventilation as well as the practical experience of performing a terminal extubation. We designed a three-hour simulation session which includes a one-hour didactic followed by two hours of simulation, with four cases that focus on different teaching points regarding symptom management and practical aspects of removing the endotracheal tube. The session was designed as an annual session for Hospice & Palliative Medicine fellows in our region during a collaborative educational conference. Based on feedback, the session is scheduled for the beginning of the academic year and each fellow is given the opportunity to physically remove the endotracheal tube. Simulation can be effectively used to teach practical and complex bedside skills such as withdrawal of mechanical ventilation to palliative medicine trainees. This method of teaching could be expanded to teach other advanced hospice and palliative care skills.
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Affiliation(s)
- Mei-Ean Yeow
- Center for Palliative Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Elaine Chen
- Division of Pulmonary & Critical Care Medicine and Section of Palliative Medicine, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
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Yeh A, Pietras C, Wallenstein D, Hu P. End of Life in the Neurological Intensive Care Unit: Is Extubating to Comfort Care Comfortable? J Pain Symptom Manage 2019; 58:e14-e16. [PMID: 31302260 DOI: 10.1016/j.jpainsymman.2019.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 07/01/2019] [Accepted: 07/03/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Angela Yeh
- UCLA Department of Medicine Division of Hospitalist Medicine Palliative Care Program, Los Angeles, California, USA.
| | - Christopher Pietras
- UCLA Department of Medicine Division of Hospitalist Medicine Palliative Care Program, Los Angeles, California, USA
| | | | - Peifeng Hu
- UCLA Department of Medicine Division of Geriatrics, Los Angeles, California, USA
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Chen YC, Fan HY, Curtis JR, Lee OKS, Liu CK, Huang SJ. The authors reply. Crit Care Med 2019; 45:e1302-e1303. [PMID: 29149004 DOI: 10.1097/ccm.0000000000002740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Yang-Ching Chen
- Taipei City Hospital, ZhongXing Branch, Taipei, Taiwan, and School of Nutrition and Health Sciences, College of Nutrition, Taipei Medical University, Taipei, Taiwan;Taipei City Hospital, ZhongXing Branch, Taipei, Taiwan;Cambia Palliative Care Center of Excellence, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington, Seattle, WA;Taipei City Hospital, Taipei, Taiwan, and Institute of Clinical Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan;Taipei City Hospital, ZhongXing Branch, Taipei, Taiwan, and Department of Medicine and Graduate Institute of Business Administration, Fu-Jen Catholic University, Taipei, Taiwan;Taipei City Hospital, Taipei, Taiwan, and Surgical Department, Medical College, National Taiwan University, Taipei, Taiwan
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McPherson K, Carlos WG, Emmett TW, Slaven JE, Torke AM. Limitation of Life-Sustaining Care in the Critically Ill: A Systematic Review of the Literature. J Hosp Med 2019; 14:303-310. [PMID: 30794145 PMCID: PMC6625435 DOI: 10.12788/jhm.3137] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 12/03/2018] [Indexed: 12/21/2022]
Abstract
When life-sustaining treatments (LST) are no longer effective or consistent with patient preferences, limitations may be set so that LSTs are withdrawn or withheld from the patient. Many studies have examined the frequency of limitations of LST in intensive care unit (ICU) settings in the past 30 years. This systematic review describes variation and patient characteristics associated with limitations of LST in critically ill patients in all types of ICUs in the United States. A comprehensive search of the literature was performed by a medical librarian between December 2014 and April 2017. A total of 1,882 unique titles and abstracts were reviewed, 113 were selected for article review, and 36 studies were fully reviewed. Patient factors associated with an increased likelihood of limiting LST included white race, older age, female sex, poor preadmission functional status, multiple comorbidities, and worse illness severity score. Based on several large, multicenter studies, there was a trend toward a higher frequency of limitation of LST over time. However, there is large variability between ICUs in the proportion of patients with limitations and on the proportion of deaths preceded by a limitation. Increases in the frequency of limitations of LST over time suggests changing attitudes about aggressive end-of-life-care. Limitations are more common for patients with worse premorbid health and greater ICU illness severity. While some differences in the frequency of limitations of LST may be explained by personal factors such as race, there is unexplained wide variability between units.
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Affiliation(s)
- Katie McPherson
- Division of Pulmonary and Critical Care Medicine, University of Colorado, Denver Colorado
| | - W Graham Carlos
- Division of Pulmonary, Critical Care, Sleep, and Occupational Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Thomas W Emmett
- Ruth Lilly Medical Library at Indiana University School of Medicine, Indianapolis, Indiana
| | - James E Slaven
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Alexia M Torke
- Indiana University Center for Aging Research, Indianapolis Indiana
- Daniel F. Evans Center for Spiritual and Religious Values in Healthcare and Fairbanks Center for Medical Ethics, Indiana University Health, Indianapolis, Indiana
- Corresponding Author: Alexia M Torke, MD, MS; E-mail: ; Telephone: 317-274-9221; Twitter: @AlexiaMTorke
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Campbell ML. Ensuring Breathing Comfort at the End of Life: The Integral Role of the Critical Care Nurse. Am J Crit Care 2018; 27:264-269. [PMID: 29961660 DOI: 10.4037/ajcc2018420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
This article describes the author's program of clinical research focused on assessment and treatment of respiratory distress among critically ill patients at the end of life. Dyspnea is a subjective experience of breathing discomfort that occurs in the presence of cardiopulmonary and neuromuscular diseases. Dyspnea is one of the most common and most distressing symptoms experienced by critically ill patients. Many critically ill patients, particularly those not expected to survive, become cognitively impaired or unconscious and lose the ability to report symptoms, although dyspnea can be known only from a patient's report. When self-reporting ability is lost, the critical care nurse must rely on signs indicative of a patient's respiratory distress. The critically ill patient unable to self-report is vulnerable to under-recognition of symptom distress and subsequent over-treatment or undertreatment. When the patient is dying, there is only 1 chance to optimize the assessment and treatment of symptoms.
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Affiliation(s)
- Margaret L. Campbell
- Margaret L. Campbell is a professor, College of Nursing, Wayne State University, Detroit, Michigan
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Coelho CBT, Yankaskas JR. New concepts in palliative care in the intensive care unit. Rev Bras Ter Intensiva 2018; 29:222-230. [PMID: 28977262 PMCID: PMC5496757 DOI: 10.5935/0103-507x.20170031] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Accepted: 09/12/2016] [Indexed: 01/03/2023] Open
Abstract
Some patients admitted to an intensive care unit may face a terminal illness
situation, which usually leads to death. Knowledge of palliative care is
strongly recommended for the health care providers who are taking care of these
patients. In many situations, the patients should be evaluated daily as the
introduction of further treatments may not be beneficial to them. The
discussions among health team members that are related to prognosis and the
goals of care should be carefully evaluated in collaboration with the patients
and their families. The adoption of protocols related to end-of-life patients in
the intensive care unit is fundamental. A multidisciplinary team is important
for determining whether the withdrawal or withholding of advanced care is
required. In addition, patients and families should be informed that palliative
care involves the best possible care for that specific situation, as well as
respect for their wishes and the consideration of social and spiritual
backgrounds. Thus, the aim of this review is to present palliative care as a
reasonable option to support the intensive care unit team in assisting
terminally ill patients. Updates regarding diet, mechanical ventilation, and
dialysis in these patients will be presented. Additionally, the hospice-model
philosophy as an alternative to the intensive care unit/hospital environment
will be discussed.
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Affiliation(s)
| | - James R Yankaskas
- University of North Carolina at Chapel Hill - North Carolina, United States
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Hung YS, Lee SH, Hung CY, Wang CH, Kao CY, Wang HM, Chou WC. Clinical characteristics and survival outcomes of terminally ill patients undergoing withdrawal of mechanical ventilation. J Formos Med Assoc 2017; 117:798-805. [PMID: 29032021 DOI: 10.1016/j.jfma.2017.09.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 09/29/2017] [Accepted: 09/30/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Withdrawal of mechanical ventilation is an important, but rarely explored issue in Asia during end-of-life care. This study aimed to describe the clinical characteristics and survival outcomes of terminally ill patients undergoing withdrawal of mechanical ventilation in Taiwan. METHODS One-hundred-thirty-five terminally ill patients who had mechanical ventilation withdrawn between 2013 and 2016, from a medical center in Taiwan, were enrolled. Patients' clinical characteristics and survival outcomes after withdrawal of mechanical ventilation were analyzed. RESULTS The three most common diagnoses were organic brain lesion, advanced cancer, and newborn sequelae. The initiator of the withdrawal process was family, medical personnel, and patient him/herself. The median survival time was 45 min (95% confidence interval, 33-57 min) after the withdrawal of mechanical ventilation, and 102 patients (75.6%) died within one day after extubation. The median time from diagnosis of disease to receiving life-sustaining treatment and artificial ventilation support, receiving life-sustaining treatment and artificial ventilation support to "Withdrawal meeting," "Withdrawal meeting" to ventilator withdrawn, and ventilator withdrawn to death was 12.1 months, 19 days, 1 day, and 0 days, respectively. Patients with a diagnosis of advanced cancer and withdrawal initiation by the patients themselves had a significantly shorter time interval between receiving life-sustaining treatment and artificial ventilation support to "Withdrawal meeting" compared to those with non-cancer diseases and withdrawal initiation by family or medical personnel. CONCLUSION This study is the first observational study to describe the patients' characteristics and elaborate on the survival outcome of withdrawal of mechanical ventilation in patients who are terminally ill in an Asian population. Understanding the clinical characteristics and survival outcomes of mechanical ventilation withdrawal might help medical personnel provide appropriate end-of-life care and help patients/families decide about the withdrawal process earlier.
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Affiliation(s)
- Yu-Shin Hung
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taiwan
| | - Shu-Hui Lee
- Department of Nursing, Chang Gung Medical Foundation at Linkou, Taiwan
| | - Chia-Yen Hung
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taiwan; Department of Hematology-Oncology, Division of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Chao-Hui Wang
- Department of Nursing, Chang Gung Medical Foundation at Linkou, Taiwan
| | - Chen-Yi Kao
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taiwan
| | - Hung-Ming Wang
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taiwan
| | - Wen-Chi Chou
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taiwan.
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Development and Testing of the End-of-Life Transfer Tool. J Hosp Palliat Nurs 2017. [DOI: 10.1097/njh.0000000000000357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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How Long Does (S)He Have? Retrospective Analysis of Outcomes After Palliative Extubation in Elderly, Chronically Critically Ill Patients. Crit Care Med 2017; 44:1138-44. [PMID: 26958748 DOI: 10.1097/ccm.0000000000001642] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE For chronically critically ill elderly patients on mechanical ventilation, prognosis for significant recovery may be minimal. These individuals, or their surrogates, may decide for "palliative extubation." A common prognostic question arises: "How long does she/he have?" This study describes demographics, mortality, time to death, and factors associated with death after palliative extubation. DESIGN, SETTING, AND PATIENTS Retrospective 3-year study in community hospital with ethnically diverse elderly population. Chronically critically ill patients followed from palliative extubation to death or survival to discharge. MEASURES Mortality/survival following palliative extubation, time to death or discharge, factors associated with death. RESULTS Hundred and forty-eight subjects underwent palliative extubation. Mean age: 78 years, 60% female, ethnically diverse with 46% white, and 54% others. Top diagnostic categories: sepsis (47%) and respiratory failure (22%). After extubation, 114 patients (77%) died in hospital and 34 (23%) were discharged. Of those who died, median time to death 8.9 hours (range, 4 min to 7 d). Mortality proportion was 56% at 24 hours and increased with time. Factors associated with early death: Systolic blood pressure less than 90 (p = 0.002) and Charlson Comorbidity Index that is above 6 or 0 (p = 0.002). CONCLUSIONS Palliative extubation at end of life was an option selected by an ethnically diverse elderly population. Approximately three-fourths of subjects died in hospital, and one-fourth was discharged alive. Over 50% who died did so within 24 hours, making this useful information for counseling and anticipatory planning. Subjects with systolic blood pressure less than 90 and Charlson Comorbidity Index that is very low or very high had higher mortality.
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Turgeon AF, Lauzier F, Zarychanski R, Fergusson DA, Léger C, McIntyre LA, Bernard F, Rigamonti A, Burns K, Griesdale DE, Green R, Scales DC, Meade MO, Savard M, Shemilt M, Paquet J, Gariépy JL, Lavoie A, Reddy K, Jichici D, Pagliarello G, Zygun D, Moore L. Prognostication in critically ill patients with severe traumatic brain injury: the TBI-Prognosis multicentre feasibility study. BMJ Open 2017; 7:e013779. [PMID: 28416497 PMCID: PMC5775467 DOI: 10.1136/bmjopen-2016-013779] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Severe traumatic brain injury is a significant cause of morbidity and mortality in young adults. Assessing long-term neurological outcome after such injury is difficult and often characterised by uncertainty. The objective of this feasibility study was to establish the feasibility of conducting a large, multicentre prospective study to develop a prognostic model of long-term neurological outcome in critically ill patients with severe traumatic brain injury. DESIGN A prospective cohort study. SETTING 9 Canadian intensive care units enrolled patients suffering from acute severe traumatic brain injury. Clinical, biological, radiological and electrophysiological data were systematically collected during the first week in the intensive care unit. Mortality and functional outcome (Glasgow Outcome Scale extended) were assessed on hospital discharge, and then 3, 6 and 12 months following injury. OUTCOMES The compliance to protocolised test procedures was the primary outcome. Secondary outcomes were enrolment rate and compliance to follow-up. RESULTS We successfully enrolled 50 patients over a 12-month period. Most patients were male (80%), with a median age of 45 years (IQR 29.0-60.0), a median Injury Severity Score of 38 (IQR 25-50) and a Glasgow Coma Scale of 6 (IQR 3-7). Mortality was 38% (19/50) and most deaths occurred following a decision to withdraw life-sustaining therapies (18/19). The main reasons for non-enrolment were the time window for inclusion being after regular working hours (35%, n=23) and oversight (24%, n=16). Compliance with protocolised test procedures ranged from 92% to 100% and enrolment rate was 43%. No patients were lost to follow-up at 6 months and 2 were at 12 months. CONCLUSIONS In this multicentre prospective feasibility study, we achieved feasibility objectives pertaining to compliance to test, enrolment and follow-up. We conclude that the TBI-Prognosis prospective multicentre study in severe traumatic brain injury patients in Canada is feasible.
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Affiliation(s)
- Alexis F Turgeon
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), CHU de Québec—Université Laval Research Centre, Québec City, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), CHU de Québec—Université Laval Research Centre, Québec City, Québec, Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, Québec, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, Section of Critical Care and of Haematology and Medical Oncology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Unit, Center for Transfusion and Critical Care Research, Ottawa Health Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Caroline Léger
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), CHU de Québec—Université Laval Research Centre, Québec City, Québec, Canada
| | - Lauralyn A McIntyre
- Clinical Epidemiology Unit, Center for Transfusion and Critical Care Research, Ottawa Health Research Institute, University of Ottawa, Ottawa, Ontario, Canada
- Department of Critical Care Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Francis Bernard
- Department of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Andrea Rigamonti
- Interdepartmental Division of Critical Care Medicine, St-Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Karen Burns
- Interdepartmental Division of Critical Care Medicine, St-Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Donald E Griesdale
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert Green
- Department of Critical Care Medicine, Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Damon C Scales
- Interdepartmental Division of Critical Care Medicine, Sunnybrook Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Maureen O Meade
- Department of Medicine, Division of Critical Care Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Martin Savard
- Department of Medicine, Division of Neurology, Université Laval, Québec, Québec, Canada
| | - Michèle Shemilt
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), CHU de Québec—Université Laval Research Centre, Québec City, Québec, Canada
| | - Jérôme Paquet
- Department of Surgery, Division of Neurosurgery, Université Laval, Québec, Québec, Canada
- Department Radiology and Nuclear Medicine, Université Laval, Québec, Québec, Canada
| | - Jean-Luc Gariépy
- Department Radiology and Nuclear Medicine, Université Laval, Québec, Québec, Canada
| | - André Lavoie
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), CHU de Québec—Université Laval Research Centre, Québec City, Québec, Canada
| | - Kesh Reddy
- Department of Surgery, Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Draga Jichici
- Department of Medicine, Division of Critical Care Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Giuseppe Pagliarello
- Department of Critical Care Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - David Zygun
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Lynne Moore
- Population Health and Optimal Health Practices Research Unit (Trauma—Emergency—Critical Care Medicine), CHU de Québec—Université Laval Research Centre, Québec City, Québec, Canada
- Department of Preventive and Social Medicine, Université Laval, Québec, Québec, Canada
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Su WH, Huang MY, Lai EY. Outcomes of Palliative Care Team Consultation for Ventilator Withdrawal from Terminally Ill Patients in the Intensive Care Unit. INT J GERONTOL 2016. [DOI: 10.1016/j.ijge.2016.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Cottereau A, Robert R, le Gouge A, Adda M, Audibert J, Barbier F, Bardou P, Bourcier S, Boyer A, Brenas F, Canet E, Da Silva D, Das V, Desachy A, Devaquet J, Embriaco N, Eon B, Feissel M, Friedman D, Ganster F, Garrouste-Orgeas M, Grillet G, Guisset O, Guitton C, Hamidfar-Roy R, Hyacinthe AC, Jochmans S, Lion F, Jourdain M, Lautrette A, Lerolle N, Lesieur O, Mateu P, Megarbane B, Mercier E, Messika J, Morin-Longuet P, Philippon-Jouve B, Quenot JP, Renault A, Repesse X, Rigaud JP, Robin S, Roquilly A, Seguin A, Thevenin D, Tirot P, Contentin L, Kentish-Barnes N, Reignier J. ICU physicians' and nurses' perceptions of terminal extubation and terminal weaning: a self-questionnaire study. Intensive Care Med 2016; 42:1248-57. [PMID: 27155604 DOI: 10.1007/s00134-016-4373-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 04/26/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE Terminal extubation (TE) and terminal weaning (TW) are the methods available for withdrawing mechanical ventilation. Perceptions of TE and TW by intensive care unit (ICU) staff may influence bedside practices and the feasibility of studies comparing these methods. METHODS From January to June 2013, 5 nurses and 5 physicians in each of 46 (out of 70, 65.7 %) French ICUs completed an anonymous self-questionnaire. Clusters of staff members defined by perceptions of TE and TW were identified by exploratory analysis. Denominators for computing percentages were total numbers of responses to each item; cases with missing data were excluded for the relevant item. RESULTS Of the 451 (98 %) participants (225 nurses and 226 physicians), 37 (8.4 %) had never or almost never performed TW and 138 (31.3 %) had never or almost never performed TE. A moral difference between TW and TE was perceived by 205 (45.8 %) participants. The exploratory analysis identified three clusters defined by personal beliefs about TW and TE: 21.2 % of participants preferred TW, 18.1 % preferred TE, and 60.7 % had no preference. A preference for TW seemed chiefly related to unfavorable perceptions or insufficient knowledge of TE. Staff members who preferred TE and those with no preference perceived TE as providing a more natural dying process with less ambiguity. CONCLUSION Nearly two-fifths of ICU nurses and physicians in participating ICUs preferred TW or TE. This finding suggests both a need for shared decision-making and training before performing TE or TW and a high risk of poor compliance with randomly allocated TW or TE.
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Affiliation(s)
- Alice Cottereau
- Medical-Surgical Intensive Care Unit, District Hospital Center, Montreuil, France
| | - René Robert
- Medical Intensive Care Unit, University Hospital, Poitiers, France.,INSERM CIC 1402, Equipe 5 ALIVE, University Hospital, Poitiers, France
| | - Amélie le Gouge
- Biometrical Department, INSERM CIC 1415, University Hospital, Tours, France
| | - Mélanie Adda
- Medical Intensive Care Unit, University Hospital, Hopital Nord, Marseille, France
| | - Juliette Audibert
- Medical-Surgical Intensive Care Unit, District Hospital Center, Chartres, France
| | - François Barbier
- Orléans Medical Intensive Care Unit, District Hospital Center, Orléans, France
| | - Patrick Bardou
- Medical-Surgical Intensive Care Unit, District Hospital Center, Montauban, France
| | - Simon Bourcier
- Medical Intensive Care Unit, Cochin University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France
| | - Alexandre Boyer
- Medical Intensive Care Unit, Pellegrin University Hospital, Bordeaux, France
| | - François Brenas
- Medical-Surgical Intensive Care Unit, District Hospital Center, Le Puy-En-Velay, France
| | - Emmanuel Canet
- Medical Intensive Care Unit, Saint-Louis University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France
| | - Daniel Da Silva
- Medical-Surgical Intensive Care Unit, Delafontaine Hospital Center, Saint-Denis, France
| | - Vincent Das
- Medical-Surgical Intensive Care Unit, District Hospital Center, Montreuil, France
| | - Arnaud Desachy
- Medical-Surgical Intensive Care Unit, District Hospital Center, Angoulême, France
| | - Jérôme Devaquet
- Medical-Surgical Intensive Care Unit, Foch Hospital Center, Suresnes, France
| | - Nathalie Embriaco
- Medical-Surgical Intensive Care Unit, District Hospital Center, Toulon, France
| | - Beatrice Eon
- Medical Intensive Care Unit, University Hospital, Hopital La Timone, Marseille, France
| | - Marc Feissel
- Medical-Surgical Intensive Care Unit, District Hospital Center, Belfort, France
| | - Diane Friedman
- Medical Intensive Care Unit, Raymond Poincaré University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Garches, France
| | - Frédérique Ganster
- Medical-Surgical Intensive Care Unit, District Hospital Center, Mulhouse, France
| | | | - Guillaume Grillet
- Medical-Surgical Intensive Care Unit, District Hospital Center, Lorient, France
| | - Olivier Guisset
- Medical Intensive Care Unit, Saint-André University Hospital, Bordeaux, France
| | | | | | | | - Sebastien Jochmans
- Medical-Surgical Intensive Care Unit, Marc Jaquet Hospital Center, Melun, France
| | - Fabien Lion
- Medical-Surgical Intensive Care Unit, Institut Gustave Roussy, Villejuif, France
| | - Mercé Jourdain
- Medical Intensive Care Unit, University Hospital, Lille, France
| | - Alexandre Lautrette
- Medical Intensive Care Unit, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | - Nicolas Lerolle
- Medical Intensive Care Unit, Angers University Hospital, Angers, France
| | - Olivier Lesieur
- Medical-Surgical Intensive Care Unit, District Hospital Center, La Rochelle, France
| | - Philippe Mateu
- Medical-Surgical Intensive Care Unit, District Hospital Center, Charleville-Mézières, France
| | - Bruno Megarbane
- Medical Intensive Care Unit, Saint-Louis University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France
| | | | - Jonathan Messika
- Medical-Surgical Intensive Care Unit, Louis Mourier University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Colombes, France
| | - Paul Morin-Longuet
- Medical-Surgical Intensive Care Unit, District Hospital Center, Saint-Nazaire, France
| | | | | | - Anne Renault
- Medical Intensive Care Unit, La Cavale Blanche University Hospital, Brest, France
| | - Xavier Repesse
- Medical-Surgical Intensive Care Unit, Ambroise Paré University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Boulogne, France
| | | | - Ségolène Robin
- Surgical Intensive Care Unit, Hôpital Européen Georges Pompidou, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France
| | - Antoine Roquilly
- Surgical Intensive Care Unit, Hotel Dieu University Hospital, Nantes, France
| | - Amélie Seguin
- Medical Intensive Care Unit, Côte de Nacre University Hospital, Caen, France
| | - Didier Thevenin
- Medical-Surgical Intensive Care Unit, District Hospital Center, Lens, France
| | - Patrice Tirot
- Medical-Surgical Intensive Care Unit, District Hospital Center, Le Mans, France
| | - Laetitia Contentin
- Biometrical Department, INSERM CIC 1415, University Hospital, Tours, France
| | - Nancy Kentish-Barnes
- Saint-Louis University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris Diderot Sorbonne University, Paris, France
| | - Jean Reignier
- Medical Intensive Care Unit, Saint-André University Hospital, Bordeaux, France. .,Service de Réanimation Médicale, Centre Hospitalier Universitaire Hotel-Dieu, 30 Bd. Jean Monnet, 44093, Nantes Cedex 1, France.
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Long AC, Muni S, Treece PD, Engelberg RA, Nielsen EL, Fitzpatrick AL, Curtis JR. Time to Death after Terminal Withdrawal of Mechanical Ventilation: Specific Respiratory and Physiologic Parameters May Inform Physician Predictions. J Palliat Med 2015; 18:1040-7. [PMID: 26555010 DOI: 10.1089/jpm.2015.0115] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Discussions about withdrawal of life-sustaining therapies often include family members of critically ill patients. These conversations should address essential components of the dying process, including expected time to death after withdrawal. OBJECTIVES The study objective was to aid physician communication about the dying process by identifying predictors of time to death after terminal withdrawal of mechanical ventilation. METHODS We conducted an observational analysis from a single-center, before-after evaluation of an intervention to improve palliative care. We studied 330 patients who died after terminal withdrawal of mechanical ventilation. Predictors included patient demographics, laboratory, respiratory, and physiologic variables, and medication use. RESULTS The median time to death for the entire cohort was 0.58 hours (interquartile range (IQR) 0.22-2.25 hours) after withdrawal of mechanical ventilation. Using Cox regression, independent predictors of shorter time to death included higher positive end-expiratory pressure (per 1 cm H2O hazard ratio [HR], 1.07; 95% CI 1.04-1.11); higher static pressure (per 1 cm H2O HR, 1.03; 95% CI 1.01-1.04); extubation prior to death (HR, 1.41; 95% CI 1.06-1.86); and presence of diabetes (HR, 1.75; 95% CI 1.25-2.44). Higher noninvasive mean arterial pressure predicted longer time to death (per 1 mmHg HR, 0.98; 95% CI 0.97-0.99). CONCLUSIONS Comorbid illness and key respiratory and physiologic parameters may inform physician predictions of time to death after withdrawal of mechanical ventilation. An understanding of the predictors of time to death may facilitate discussions with family members of dying patients and improve communication about end-of-life care.
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Affiliation(s)
- Ann C Long
- 1 Department of Medicine, Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington , Seattle, Washington
| | - Sarah Muni
- 2 EvergreenHealth Pulmonary Care , Kirkland, Washington
| | - Patsy D Treece
- 1 Department of Medicine, Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington , Seattle, Washington
| | - Ruth A Engelberg
- 1 Department of Medicine, Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington , Seattle, Washington
| | - Elizabeth L Nielsen
- 1 Department of Medicine, Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington , Seattle, Washington
| | - Annette L Fitzpatrick
- 3 Department of Family Medicine, University of Washington , Seattle, Washington.,4 Department of Epidemiology, University of Washington , Seattle, Washington
| | - J Randall Curtis
- 1 Department of Medicine, Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington , Seattle, Washington
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Epker JL, Bakker J, Lingsma HF, Kompanje EJO. An Observational Study on a Protocol for Withdrawal of Life-Sustaining Measures on Two Non-Academic Intensive Care Units in The Netherlands: Few Signs of Distress, No Suffering? J Pain Symptom Manage 2015; 50:676-84. [PMID: 26335762 DOI: 10.1016/j.jpainsymman.2015.05.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 05/27/2015] [Accepted: 06/11/2015] [Indexed: 10/23/2022]
Abstract
CONTEXT Because anticipation of death is common within the intensive care unit, attention must be paid to the prevention of distressing signs and symptoms, enabling the patient to die peacefully. In the relevant studies on this subject, there has been a lack of focus on measuring determinants of comfort in this population. OBJECTIVES To evaluate whether dying without distressing signs after the withdrawal of life-sustaining measures is possible using a newly introduced protocol and to analyze the potential influence of opioids and sedatives on time till death. METHODS This was a prospective observational study, in two nonacademic Dutch intensive care units after the introduction of a national protocol for end-of-life care. The study lasted two years and included adult patients in whom mechanical ventilation and/or vasoactive medication was withdrawn. Exclusion criteria included all other causes of death. RESULTS During the study period, 450 patients died; of these, 305 patients were eligible, and 241 were included. Ninety percent of patients were well sedated before and after withdrawal. Severe terminal restlessness, death rattle, or stridor was seen in less than 6%. Dosages of opioids and sedatives increased significantly after withdrawal, but did not contribute to a shorter time till death according the regression analysis. CONCLUSION The end-of-life protocol seems effective in realizing adequate patient comfort. Most patients in whom life-sustaining measures are withdrawn are well sedated and show few signs of distress. Dosages of opioids and sedatives increase significantly during treatment withdrawal but do not contribute to time until death. Dying with a minimum of distressing signs is thus practically possible and ethically feasible.
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Affiliation(s)
- Jelle L Epker
- Department of Intensive Care Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
| | - Jan Bakker
- Department of Intensive Care Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Erwin J O Kompanje
- Department of Intensive Care Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Munshi L, Dhanani S, Shemie SD, Hornby L, Gore G, Shahin J. Predicting time to death after withdrawal of life-sustaining therapy. Intensive Care Med 2015; 41:1014-28. [PMID: 25944573 DOI: 10.1007/s00134-015-3762-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 03/17/2015] [Indexed: 01/08/2023]
Abstract
PURPOSE Predicting time to death following the withdrawal of life-sustaining therapy is difficult. Accurate predictions may better prepare families and improve the process of donation after circulatory death. METHODS We systematically reviewed any predictive factors for time to death after withdrawal of life support therapy. RESULTS Fifteen observational studies met our inclusion criteria. The primary outcome was time to death, which was evaluated to be within 60 min in the majority of studies (13/15). Additional time endpoints evaluated included time to death within 30, 120 min, and 10 h, respectively. While most studies evaluated risk factors associated with time to death, a few derived or validated prediction tools. Consistent predictors of time to death that were identified in five or more studies included the following risk factors: controlled ventilation, oxygenation, vasopressor use, Glasgow Coma Scale/Score, and brain stem reflexes. Seven unique prediction tools were derived, validated, or both across some of the studies. These tools, at best, had only moderate sensitivity to predicting the time to death. Simultaneous withdrawal of all support and physician opinion were only evaluated in more recent studies and demonstrated promising predictor capabilities. CONCLUSIONS While the risk factors controlled ventilation, oxygenation, vasopressors, level of consciousness, and brainstem reflexes have been most consistently found to be associated with time to death, the addition of novel predictors, such as physician opinion and simultaneous withdrawal of all support, warrant further investigation. The currently existing prediction tools are not highly sensitive. A more accurate and generalizable tool is needed to inform end-of-life care and enhance the predictions of donation after circulatory death eligibility.
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Affiliation(s)
- Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, and Department of Medicine, University of Toronto, University Health Network and Mount Sinai Hospital, Toronto, Canada
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Abstract
Critically ill patients receiving palliative care at the end of life are at high risk for experiencing pain, dyspnea, and death rattle. Nearly all these patients are at risk for the development of delirium. Patients who are alert may experience anxiety. Advanced practice nurses and staff nurses are integral to detecting and treating these symptoms. Pain, dyspnea, and anxiety should be routinely assessed by patient self-report when possible. Routine behavioral screening for delirium is recommended. Behavioral observation tools to detect pain and dyspnea and proxy assessments guide symptom identification when the patient cannot provide a self-report. Evidence-based interventions are offered for both prevention and treatment of pain, dyspnea, anxiety, and delirium. Death rattle does not produce patient distress, and current pharmacological treatment lacks an evidence base. Pain management has a robust evidence base compared to management of dyspnea, anxiety, and delirium among this population; well-designed, adequately powered studies are needed.
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Affiliation(s)
- Margaret L. Campbell
- Margaret L. Campbell is Professor, College of Nursing, Wayne State University, 5557 Cass Ave, Detroit, MI 48202
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Kok VC. Compassionate extubation for a peaceful death in the setting of a community hospital: a case-series study. Clin Interv Aging 2015; 10:679-85. [PMID: 25897214 PMCID: PMC4396346 DOI: 10.2147/cia.s82760] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The use of compassionate extubation (CE) to alleviate suffering by terminating mechanical ventilation and withdrawing the endotracheal tube requires professional adherence and efficiency. The Hospice Palliative Care Act, amended on January 9, 2013, legalizes the CE procedure in Taiwan. METHODS From September 20, 2013 to September 2, 2014, the hospice palliative care team at a community hospital received 20 consultations for CE. Eight cases were excluded because of non-qualification. Following approval from the Ethics Committee, the medical records of the remaining 12 patients were reviewed and grouped by the underlying disease: A, "terminal-stage cancer"; B, "non-cancer out-of-hospital cardiac arrest"; and C, "non-cancer organ failure". Time to extubation using a cut-off at 48 hours was assessed. RESULTS The mean ages of patients (standard deviation) in groups A, B, and C were 66.3 (14.9) years, 72 (19.1) years, and 80.3 (4.0) years, respectively. The mean number of days of intubation at consultation were 6.8 (4.9), 7.3 (4.9), and 179.3 (271.6), respectively. The mean total doses of opioids (as morphine-equivalent dose) in the 24 hours preceding CE were 76 (87.5) mg, 3.3 (5.8) mg, and 43.3 (15.3) mg. The median times from extubation (range) to death were 97 (0.2-245) hours, 0.3 (0.2-0.4) hours, and 6.1 (3.6-71.8) hours. Compared to those requiring <48-hour preparatory time, patients requiring >48 hours to the moment of CE were younger (62.8 years vs 75.5 years), required a mean time of 122 hours (vs 30 hours) to CE (P=0.004), had shorter length of stay (33.3 days vs 77.8 days), required specialist social worker intervention in 75% of cases (vs 37.5%), and had a median duration of intubation of 11.5 days (vs 5.5 days). CONCLUSION CE was carried out according to protocol, and the median time from extubation to death varies determined by the underlying disease which was 0.3 hour in patients admitted after out-of-hospital cardiac arrest and 97 hours in patients with advanced cancer.
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Affiliation(s)
- Victor C Kok
- Division of Palliative Medicine and Hospice Palliative Care Team, Kuang Tien General Hospital, Asia University Taiwan, Taichung, Taiwan
- Department of Biomedical Informatics, Asia University Taiwan, Taichung, Taiwan
- Correspondence: Victor C Kok, Division of Palliative Medicine and Hospice Palliative Care Team, Kuang Tien General Hospital, Taichung 43303, Taiwan, Email
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