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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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Mazzu MA, Campbell ML, Schwartzstein RM, White DB, Mitchell SL, Fehnel CR. Evidence Guiding Withdrawal of Mechanical Ventilation at the End of Life: A Review. J Pain Symptom Manage 2023; 66:e399-e426. [PMID: 37244527 PMCID: PMC10527530 DOI: 10.1016/j.jpainsymman.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 05/10/2023] [Accepted: 05/19/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVE Distress at the end of life in the intensive care unit (ICU) is common. We reviewed the evidence guiding symptom assessment, withdrawal of mechanical ventilation (WMV) process, support for the ICU team, and symptom management among adults, and specifically older adults, at end of life in the ICU. SETTING AND DESIGN Systematic search of published literature (January 1990-December 2021) pertaining to WMV at end of life among adults in the ICU setting using PubMed, Embase, and Web of Science. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed. PARTICIPANTS Adults (age 18 and over) undergoing WMV in the ICU. MEASUREMENTS Study quality was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. RESULTS Out of 574 articles screened, 130 underwent full text review, and 74 were reviewed and assessed for quality. The highest quality studies pertained to use of validated symptom scales during WMV. Studies of the WMV process itself were generally lower quality. Support for the ICU team best occurs via structured communication and social supports. Dyspnea is the most distressing symptom, and while high quality evidence supports the use of opiates, there is limited evidence to guide implementation of their use for specific patients. CONCLUSION High quality studies support some practices in palliative WMV, while gaps in evidence remain for the WMV process, supporting the ICU team, and medical management of distress. Future studies should rigorously compare WMV processes and symptom management to reduce distress at end of life.
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Affiliation(s)
- Maria A Mazzu
- University of New England College of Osteopathic Medicine (M.A.M.), Biddeford, Maine, USA
| | | | - Richard M Schwartzstein
- Beth Israel Deaconess Medical Center (R.M.S., S.L.M., C.R.F.), Boston, Massachusetts, USA; Harvard Medical School (R.M.S., S.L.M., C.R.F.), Boston, Massachusetts, USA
| | - Douglas B White
- University of Pittsburgh School of Medicine (D.B.W.), Pittsburgh, Pennsylvania, USA
| | - Susan L Mitchell
- Beth Israel Deaconess Medical Center (R.M.S., S.L.M., C.R.F.), Boston, Massachusetts, USA; Harvard Medical School (R.M.S., S.L.M., C.R.F.), Boston, Massachusetts, USA; Hebrew SeniorLife, Marcus Institute for Aging Research (S.L.M., C.R.F.), Boston, Massachusetts, USA
| | - Corey R Fehnel
- Beth Israel Deaconess Medical Center (R.M.S., S.L.M., C.R.F.), Boston, Massachusetts, USA; Harvard Medical School (R.M.S., S.L.M., C.R.F.), Boston, Massachusetts, USA; Hebrew SeniorLife, Marcus Institute for Aging Research (S.L.M., C.R.F.), Boston, Massachusetts, USA.
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7
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Ortega-Chen C, Van Buren N, Kwack J, Mariano JD, Wang SE, Raman C, Cipta A. Palliative Extubation: A Discussion of Practices and Considerations. J Pain Symptom Manage 2023; 66:e219-e231. [PMID: 37023832 DOI: 10.1016/j.jpainsymman.2023.03.011] [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: 10/27/2022] [Revised: 02/27/2023] [Accepted: 03/26/2023] [Indexed: 04/08/2023]
Abstract
Palliative extubation (PE), also known as compassionate extubation, is a common event in the critical care setting and an important aspect of end-of-life care.1 In a PE, mechanical ventilation is discontinued. Its goal is to honor the patient's preferences, optimize comfort, and allow a natural death when medical interventions, including maintenance of ventilatory support, are not achieving desired outcomes. If not done effectively, PE can cause unintended physical, emotional, psychosocial, or other stress for patients, families, and healthcare staff. Studies show that PE is done with much variability across the globe, and there is limited evidence of best practice. Nevertheless, the practice of PE increased during the coronavirus disease 2019 pandemic due to the surge of dying mechanically ventilated patients. Thus, the importance of effectively conducting a PE has never been more crucial. Some studies have provided guidelines for the process of PE. However, our goal is to provide a comprehensive review of issues to consider before, during, and after a PE. This paper highlights the core palliative skills of communication, planning, symptom assessment and management, and debriefing. Our aim is to better prepare healthcare workers to provide quality palliative care during PEs, most especially when facing future pandemics.
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Affiliation(s)
- Christina Ortega-Chen
- Department of Geriatrics and Palliative Medicine (COC), Kaiser Permanente Southern California, Panorama City, California, USA.
| | - Nicole Van Buren
- Department of Geriatrics and Palliative Medicine (NVB, JK,JDM, SEW, AC), Kaiser Permanente Southern California, West Los Angeles, California, USA
| | - Joseph Kwack
- Department of Geriatrics and Palliative Medicine (NVB, JK,JDM, SEW, AC), Kaiser Permanente Southern California, West Los Angeles, California, USA
| | - Jeffrey D Mariano
- Department of Geriatrics and Palliative Medicine (NVB, JK,JDM, SEW, AC), Kaiser Permanente Southern California, West Los Angeles, California, USA; Kaiser Permanente Bernard J. Tyson School of Medicine (JDM, AC), Pasadena, California, USA
| | - Susan Elizabeth Wang
- Department of Geriatrics and Palliative Medicine (NVB, JK,JDM, SEW, AC), Kaiser Permanente Southern California, West Los Angeles, California, USA
| | - Charlene Raman
- Department of Graduate and Medical Education (CR), Kaiser Permanente Southern California Los Angeles Medical Center, Los Angeles, California, USA
| | - Andre Cipta
- Department of Geriatrics and Palliative Medicine (NVB, JK,JDM, SEW, AC), Kaiser Permanente Southern California, West Los Angeles, California, USA; Kaiser Permanente Bernard J. Tyson School of Medicine (JDM, AC), Pasadena, California, USA
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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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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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10
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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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11
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Sloss R, Mehta R, Metaxa V. End-of-Life and Palliative Care in a Critical Care Setting: The Crucial Role of the Critical Care Pharmacist. PHARMACY 2022; 10:pharmacy10050107. [PMID: 36136840 PMCID: PMC9498871 DOI: 10.3390/pharmacy10050107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 08/23/2022] [Accepted: 08/26/2022] [Indexed: 11/16/2022] Open
Abstract
Critical care pharmacists play an important role in ICU patient care, with evidence showing reductions in drug prescribing errors, adverse drug events and costs, as well as improvement in clinical outcomes, such as mortality and length of ICU stay. Caring for critically ill patients around the end of their life is complicated by the acute onset of their illness and the fact that most of them are unable to communicate any distressing symptoms. Critical care pharmacists are an integral part of the ICU team during a patient’s end-of-life care and their multifaceted role includes clinical support for bedside staff, education, and training, as well as assistance with equipment and logistics. In this article, we highlight the important role of the ICU pharmacist using a ‘real-life’ clinical case from our hospital.
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Affiliation(s)
- Rhona Sloss
- Pharmacy Department, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK
- Department of Critical Care Medicine, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK
- Correspondence:
| | - Reena Mehta
- Pharmacy Department, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK
- Department of Critical Care Medicine, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK
- Faculty of Life Sciences and Medicine, School of Cancer & Pharmaceutical Sciences, King’s College London, London WC2R 2LS, UK
| | - Victoria Metaxa
- Department of Critical Care Medicine, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK
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12
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Predicting Time to Death After Withdrawal of Life-Sustaining Measures Using Vital Sign Variability: Derivation and Validation. Crit Care Explor 2022; 4:e0675. [PMID: 35415612 PMCID: PMC8994079 DOI: 10.1097/cce.0000000000000675] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
To develop a predictive model using vital sign (heart rate and arterial blood pressure) variability to predict time to death after withdrawal of life-supporting measures.
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13
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Palliative Care and Population Management Compassionate Extubation of the ICU Patient and the Use of the Respiratory Distress Observation Scale. Crit Care Nurs Clin North Am 2022; 34:67-78. [DOI: 10.1016/j.cnc.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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14
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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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15
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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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Curtis JR, Tonelli MR. Palliative Care in the ICU and the Role for Physician-Assisted Dying-Or Lack Thereof. Crit Care Med 2019; 45:356-357. [PMID: 28098632 DOI: 10.1097/ccm.0000000000001947] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- J Randall Curtis
- Cambia Palliative Care Center of Excellence; and Division of Pulmonary and Critical Care Medicine University of Washington Seattle, WA Division of Pulmonary and Critical Care Medicine University of Washington Seattle, WA
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18
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Bartley CN, Atwell K, Cairns B, Charles A. Predictors of withdrawal of life support after burn injury. Burns 2018; 45:322-327. [PMID: 30442381 DOI: 10.1016/j.burns.2018.10.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 10/05/2018] [Accepted: 10/15/2018] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Discussions regarding withdrawal of life support after burn injury are challenging and complex. Often, providers may facilitate this discussion when the extent of injury makes survival highly unlikely or when the patient's condition deteriorates during resuscitation. Few papers have evaluated withdrawal of life support in burn patients. We therefore sought to determine the predictor of withdrawal of life support (WLS) in a regional burn center. METHODS We conducted a retrospective analysis of all burn patients from 2002 to 2012. Patient characteristics included age, gender, burn mechanism, percentage total body surface area (%TBSA) burned, presence of inhalation injury, hospital length of stay, and pre-existing comorbidities. Patients <17years of age and patients with unknown disposition were excluded. Patients were categorized into three cohorts: Alive till discharge (Alive), death by withdrawal of life support (WLS), or death despite ongoing life support (DLS). DLS patients were then excluded from the study population. Multivariate logistic regression was used to estimate predictors of WLS. RESULTS 8,371 patients were included for analysis: 8134 Alive, 237 WLS. Females had an increased odd of WLS compared to males (OR 2.03, 95% CI 1.18-3.48; p=0.010). Based on higher CCI, patients with pre-existing comorbidities had an increased odd of WLS (OR 1.28, 95% CI 1.08-1.52; p=0.005). There was a significantly increased odds for WLS (OR 1.09, 95% CI 1.06-1.12; p<0.001) with increasing age. Similarly, there was an increased odd for WLS (OR 1.08, 95% CI 1.07-1.51; p<0.001) with increasing %TBSA. An increased odd of WLS (OR 2.47, 95% CI 1.05-5.78; p=0.038) was also found in patients with inhalation injury. CONCLUSION The decision to withdraw life support is a complex and difficult decision. Our current understanding of predictors of withdrawal of life support suggests that they mirror those factors which increase a patient's risk of mortality. Further research is needed to fully explore end-of-life decision making in regards to burn patients. The role of patient's sex, particularly women, in WLS decision making needs to be further explored.
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Affiliation(s)
- Colleen N Bartley
- Department of Surgery, University of North Carolina at Chapel Hill, North Carolina Jaycee Burn Center, United States
| | - Kenisha Atwell
- Department of Surgery, University of North Carolina at Chapel Hill, North Carolina Jaycee Burn Center, United States
| | - Bruce Cairns
- Department of Surgery, University of North Carolina at Chapel Hill, North Carolina Jaycee Burn Center, United States
| | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill, North Carolina Jaycee Burn Center, United States.
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19
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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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20
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Brown CE, Benoit DD, Curtis JR. Focus on palliative care in the ICU. Intensive Care Med 2017; 43:1898-1900. [PMID: 28932878 DOI: 10.1007/s00134-017-4938-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 09/13/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Crystal E Brown
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, University of Washington, Box 359762, Seattle, WA, 98104, USA
| | - Dominique D Benoit
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA.
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, University of Washington, Box 359762, Seattle, WA, 98104, USA.
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21
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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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22
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Abstract
The goal of this article is to discuss approaches to discontinuing invasive mechanical ventilation in a general intensive care unit (ICU) population. It considers approaches in which the clinician expects patient survival, as well as those that do not. Additionally, approaches to acute and chronic critical illness are included.
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Affiliation(s)
- Lingye Chen
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Duke University, 2301 Erwin Road, Durham, NC 27705, USA
| | - Daniel Gilstrap
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Duke University, 2301 Erwin Road, Durham, NC 27705, USA
| | - Christopher E Cox
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Duke University, 2301 Erwin Road, Durham, NC 27705, USA; Program to Support People and Enhance Recovery, Duke University, 2301 Erwin Road, Durham, NC 27705, USA.
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23
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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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