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Gkantsinikoudis N, Hossain I, Marklund N, Tsitsopoulos PP. Neurosurgical intervention in ultra-severe closed traumatic brain injury: Is it worth the effort? BRAIN & SPINE 2024; 4:102907. [PMID: 39262578 PMCID: PMC11388290 DOI: 10.1016/j.bas.2024.102907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 07/28/2024] [Accepted: 08/05/2024] [Indexed: 09/13/2024]
Abstract
Introduction A subgroup of severe Traumatic Brain Injury (TBI) patients, known as ultra-severe (us-TBI), is most commonly defined as a post-resuscitation Glasgow Coma Scale (GCS) of 3-5. There is uncertainty on whether these critically injured patients can benefit from neurosurgical intervention. Research question The available evidence regarding the decision-making and outcome following management of us-TBI patients is critically reviewed. Material and methods Selected databases (PubMed, Google Scholar, Scopus and Cochrane Library) were searched from 1979 to May 2024 for publications on us-TBI patients, with a focus on treatment strategy, mortality and functional outcomes. Inclusion criteria were adult patients >18 years old with closed head trauma and admission post-resuscitation GCS 3-5. Studies were independently assessed for inclusion by two reviewers, and potential disagreements were solved by consensus. Results Where such data could be extracted, mortality rate was 27-100%, and favorable outcome was observed in 4-30% of us-TBI patients. While early aggressive neurosurgical management was associated with decreased mortality, a high proportion of patients survived with unfavorable functional status. Discussion and conclusion With supportive care only, outcome of patients with us-TBI is almost universally poor. Early and aggressive neurosurgical intervention in addition to best medical management can lead to favorable functional outcome in selected cases particularly in younger patients with an initial GCS>3 and traumatic mass lesions. There is insufficient data regarding the effectiveness of neurosurgical management on the outcome of us-TBI patients. and the decision to initiate treatment should be based on an individual basis.
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Affiliation(s)
- Nikolaos Gkantsinikoudis
- Department of Neurosurgery, Hippokration General Hospital, Aristotle University School of Medicine, Thessaloniki, Greece
| | - Iftakher Hossain
- Neurocenter, Department of Neurosurgery, Turku University Hospital, Turku, Finland
- Department of Clinical Neurosciences, Neurosurgery Unit, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Niklas Marklund
- Department of Clinical Sciences Lund, Neurosurgery, Lund University, and Skåne University Hospital Lund, Sweden
| | - Parmenion P Tsitsopoulos
- Department of Neurosurgery, Hippokration General Hospital, Aristotle University School of Medicine, Thessaloniki, Greece
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Huang AP, Holloway RG. Navigating Neurologic Illness: Skills in Neuropalliative Care for Persons Hospitalized with Neurologic Disease. Semin Neurol 2024. [PMID: 39053504 DOI: 10.1055/s-0044-1788723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Persons hospitalized for neurologic illness face multidimensional care needs. They can benefit from a palliative care approach that focuses on quality of life for persons with serious illness. We describe neurology provider "skills" to help meet these palliative needs: assessing the patient as a whole; facilitating conversations with patients to connect prognosis to care preferences; navigating neurologic illness to prepare patients and care partners for the future; providing high-quality end-of-life care to promote peace in death; and addressing disparities in care delivery.
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Affiliation(s)
- Andrew P Huang
- Department of Neurology, University of Rochester, Rochester, New York
| | - Robert G Holloway
- Department of Neurology, University of Rochester, Rochester, New York
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3
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Sonneville R, Mazighi M, Collet M, Gayat E, Degos V, Duranteau J, Grégoire C, Sharshar T, Naim G, Cortier D, Jost PH, Foucrier A, Bagate F, de Montmollin E, Papin G, Magalhaes E, Guidet B, Ben Hadj Salem O, Benghanem S, le Guennec L, Delpierre E, Legriel S, Megarbane B, Toumert K, Tran M, Geri G, Monchi M, Bodiguel E, Mariotte E, Demoule A, Zarka J, Diehl JL, Roux D, Barré E, Tanaka S, Osman D, Pasquier P, Lamara F, Crassard I, Boursin P, Ruckly S, Staiquly Q, Timsit JF, Woimant F. One-Year Outcomes in Patients With Acute Stroke Requiring Mechanical Ventilation. Stroke 2023; 54:2328-2337. [PMID: 37497675 DOI: 10.1161/strokeaha.123.042910] [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: 02/14/2023] [Accepted: 06/22/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND Long-term outcomes of patients with severe stroke remain poorly documented. We aimed to characterize one-year outcomes of patients with stroke requiring mechanical ventilation in the intensive care unit (ICU). METHODS We conducted a prospective multicenter cohort study in 33 ICUs in France (2017-2019) on patients with consecutive strokes requiring mechanical ventilation for at least 24 hours. Outcomes were collected via telephone interviews by an independent research assistant. The primary end point was poor functional outcome, defined by a modified Rankin Scale score of 4 to 6 at 1 year. Multivariable mixed models investigated variables associated with the primary end point. Secondary end points included quality of life, activities of daily living, and anxiety and depression in 1-year survivors. RESULTS Among the 364 patients included, 244 patients (66.5% [95% CI, 61.7%-71.3%]) had a poor functional outcome, including 190 deaths (52.2%). After adjustment for non-neurological organ failure, age ≥70 years (odds ratio [OR], 2.38 [95% CI, 1.26-4.49]), Charlson comorbidity index ≥2 (OR, 2.01 [95% CI, 1.16-3.49]), a score on the Glasgow Coma Scale <8 at ICU admission (OR, 3.43 [95% CI, 1.98-5.96]), stroke subtype (intracerebral hemorrhage: OR, 2.44 [95% CI, 1.29-4.63] versus ischemic stroke: OR, 2.06 [95% CI, 1.06-4.00] versus subarachnoid hemorrhage: reference) remained independently associated with poor functional outcome. In contrast, a time between stroke diagnosis and initiation of mechanical ventilation >1 day was protective (OR, 0.56 [95% CI, 0.33-0.94]). A sensitivity analysis conducted after exclusion of patients with early decisions of withholding/withdrawal of care yielded similar results. We observed persistent physical and psychological problems at 1 year in >50% of survivors. CONCLUSIONS In patients with severe stroke requiring mechanical ventilation, several ICU admission variables may inform caregivers, patients, and their families on post-ICU trajectories and functional outcomes. The burden of persistent sequelae at 1 year reinforces the need for a personalized, multi-disciplinary, prolonged follow-up of these patients after ICU discharge. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03335995.
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Affiliation(s)
- Romain Sonneville
- Université de Paris, INSERM UMR 1148, F-75018 Paris, France (R.S., M. Mazighi)
- APHP, Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, F75018 Paris, France (R.S., G.P., F.L., J.-F.T.)
| | - Mikael Mazighi
- Université de Paris, INSERM UMR 1148, F-75018 Paris, France (R.S., M. Mazighi)
- APHP, Department of Neurology, Lariboisière University Hospital, Paris, France (M. Mazighi)
- APHP, Department of Neuroradiology, Rothschild Hospital Foundation, Paris, France (M. Mazighi, P.B.)
| | - Magalie Collet
- APHP.Nord, Department of Anesthesiology and Critical Care, DMU Parabol, Université de Paris, France (M.C., E.G.)
- UMR-S 942 "MASCOT," Inserm, Paris, France (M.C., E.G.)
| | - Etienne Gayat
- APHP.Nord, Department of Anesthesiology and Critical Care, DMU Parabol, Université de Paris, France (M.C., E.G.)
- UMR-S 942 "MASCOT," Inserm, Paris, France (M.C., E.G.)
| | - Vincent Degos
- APHP, Department of Critical Care, Anesthesia and Perioperative Medicine, Pitié-Salpétrière University Hospital and Sorbonne Université, Paris, France (V.D.)
- GRC ARPE, Sorbonne Université, Paris, France (V.D.)
| | - Jacques Duranteau
- APHP, Department of Anesthesiology and Critical Care, Bicêtre University Hospitals, Le Kremlin Bicêtre, France (J.D.)
| | - Charles Grégoire
- Department of Intensive Care, Rothschild Hospital Foundation, Paris, France (C.G.)
| | - Tarek Sharshar
- Department of Neuroanesthesiology and Intensive Care, Saint Anne Hospital, Paris, France (T.S., G.N.)
| | - Giulia Naim
- Department of Neuroanesthesiology and Intensive Care, Saint Anne Hospital, Paris, France (T.S., G.N.)
| | - David Cortier
- Department of Intensive Care, Foch Hospital, Paris, France (D.C.)
| | - Paul-Henri Jost
- APHP, Department of Anesthesiology and Critical Care, Henri Mondor University Hospital, Créteil, France (P.-H.J.)
| | - Arnaud Foucrier
- APHP, Department of Anesthesiology and Critical Care, Beaujon University Hospital, Clichy, France (A.F.)
| | - François Bagate
- APHP, Department of Intensive Care Medicine, Henri Mondor University Hospital and Université de Paris Est Créteil, France (F.B.)
| | - Etienne de Montmollin
- Department of Intensive Care Medicine, Delafontaine Hospital, Saint-Denis, France (E.d.M.)
| | - Gregory Papin
- APHP, Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, F75018 Paris, France (R.S., G.P., F.L., J.-F.T.)
| | - Eric Magalhaes
- Department of Intensive Care Medicine, Sud Francilien Hospital, Corbeil, France (E.M.)
| | - Bertrand Guidet
- APHP, Department of Intensive Care Medicine, Saint Antoine University Hospital, Paris, France (B.G.)
| | - Omar Ben Hadj Salem
- Department of Intensive Care Medicine, Poissy-Saint Germain en Laye Hospital, Paris, France (O.B.H.S.)
| | - Sarah Benghanem
- APHP, Medical ICU, Cochin University Hospital and Université Paris Cité, France (S.B.)
| | - Loïc le Guennec
- APHP, Department of Intensive Care Medicine, La Pitié-Salpêtrière University Hospital and Sorbonne Université, Paris, France (L.l.G.)
| | - Eric Delpierre
- Department of Intensive Care Medicine, Meaux Hospital, France (E.D.)
| | - Stephane Legriel
- Department of Intensive Care Medicine, Versailles Hospital, Le Chesnay, and Paris-Saclay University UVSQ, INSERM, CESP, Villejuif, France (S.L.)
| | - Bruno Megarbane
- APHP, Department of Medical and Toxicological Critical Care, Lariboisière Hospital and INSERM UMRS-1144, Université Paris Cité, France (B.M.)
| | - Karim Toumert
- Department of Intensive Care Medicine, Gonesse Hospital, France (K.T.)
| | - Marc Tran
- Department of Intensive Care Medicine, Paris Saint-Joseph Hospital, Paris, France (M.T.)
| | - Guillaume Geri
- APHP, Department of Intensive Care Medicine, Ambroise Paré University Hospital, Boulogne, France (G.G.)
| | - Mehran Monchi
- Department of Intensive Care Medicine, Melun-Senart Hospital, France (M. Monchi)
| | - Eric Bodiguel
- APHP, Emergency Department, Georges Pompidou University Hospital, Paris, France (E. Bodiguel)
| | - Eric Mariotte
- APHP, Department of Intensive Care Medicine, Saint Louis University Hospital, Paris, France (E.M.)
| | - Alexandre Demoule
- APHP, Department of Intensive Care Medicine (R3S) and Sorbonne Université, INSERM, UMRS1158, Pitié-Salpétrière University Hospital, Paris, France (A.D.)
| | - Jonathan Zarka
- Department of Intensive Care Medicine, Lagny Hospital, France (J.Z.)
| | - Jean-Luc Diehl
- APHP, Department of Intensive Care Medicine, Georges Pompidou University Hospital and INSERM UMR_S 1140 Paris, France (J.-L.D.)
| | - Damien Roux
- APHP, Medico-Surgical ICU, Louis Mourier University Hospital, Colombes and Université Paris Cité, IAME, INSERM, UMR1137, France (D.R.)
| | - Eric Barré
- Department of Intensive Care Medicine, Mantes-la-Jolie Hospital, France (E. Barré)
| | - Sebastien Tanaka
- APHP, Department of Anesthesia and Critical Care Medicine, Bichat-Claude Bernard University Hospital and INSERM UMR 1188 DéTROI, Université de la Réunion, Saint-Denis de la Réunion, France (S.T.)
| | - David Osman
- APHP, Department of Intensive Care Medicine, Bicêtre University Hospital, Le Kremlin Bicêtre, France (D.O.)
| | - Pierre Pasquier
- Department of Anesthesiology and Critical Care, Percy Military Training Hospital, Clamart, France (P.P.)
| | - Fariza Lamara
- APHP, Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, F75018 Paris, France (R.S., G.P., F.L., J.-F.T.)
| | | | - Perrine Boursin
- APHP, Department of Neuroradiology, Rothschild Hospital Foundation, Paris, France (M. Mazighi, P.B.)
| | - Stéphane Ruckly
- Department of Biostatistics, ICUREsearch, Paris, France (S.R., Q.S.)
| | - Quentin Staiquly
- Department of Biostatistics, ICUREsearch, Paris, France (S.R., Q.S.)
| | - Jean-François Timsit
- APHP, Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, F75018 Paris, France (R.S., G.P., F.L., J.-F.T.)
| | - France Woimant
- Agence Régionale de Santé Ile-de-France, Paris, France (I.C., F.W.)
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Alkhachroum A, Zhou L, Asdaghi N, Gardener H, Ying H, Gutierrez CM, Manolovitz BM, Samano D, Bass D, Foster D, Sur NB, Rose DZ, Jameson A, Massad N, Kottapally M, Merenda A, Starke RM, O'Phelan K, Romano JG, Claassen J, Sacco RL, Rundek T. Predictors and Temporal Trends of Withdrawal of Life-Sustaining Therapy After Acute Stroke in the Florida Stroke Registry. Crit Care Explor 2023; 5:e0934. [PMID: 37378082 PMCID: PMC10292735 DOI: 10.1097/cce.0000000000000934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023] Open
Abstract
Temporal trends and factors associated with the withdrawal of life-sustaining therapy (WLST) after acute stroke are not well determined. DESIGN Observational study (2008-2021). SETTING Florida Stroke Registry (152 hospitals). PATIENTS Acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Importance plots were performed to generate the most predictive factors of WLST. Area under the curve (AUC) for the receiver operating curve were generated for the performance of logistic regression (LR) and random forest (RF) models. Regression analysis was applied to evaluate temporal trends. Among 309,393 AIS patients, 47,485 ICH patients, and 16,694 SAH patients; 9%, 28%, and 19% subsequently had WLST. Patients who had WLST were older (77 vs 70 yr), more women (57% vs 49%), White (76% vs 67%), with greater stroke severity on the National Institutes of Health Stroke Scale greater than or equal to 5 (29% vs 19%), more likely hospitalized in comprehensive stroke centers (52% vs 44%), had Medicare insurance (53% vs 44%), and more likely to have impaired level of consciousness (38% vs 12%). Most predictors associated with the decision to WLST in AIS were age, stroke severity, region, insurance status, center type, race, and level of consciousness (RF AUC of 0.93 and LR AUC of 0.85). Predictors in ICH included age, impaired level of consciousness, region, race, insurance status, center type, and prestroke ambulation status (RF AUC of 0.76 and LR AUC of 0.71). Factors in SAH included age, impaired level of consciousness, region, insurance status, race, and stroke center type (RF AUC of 0.82 and LR AUC of 0.72). Despite a decrease in the rates of early WLST (< 2 d) and mortality, the overall rates of WLST remained stable. CONCLUSIONS In acute hospitalized stroke patients in Florida, factors other than brain injury alone contribute to the decision to WLST. Potential predictors not measured in this study include education, culture, faith and beliefs, and patient/family and physician preferences. The overall rates of WLST have not changed in the last 2 decades.
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Affiliation(s)
| | - Lili Zhou
- Department of Neurology, University of Miami, Miami, FL
| | - Negar Asdaghi
- Department of Neurology, University of Miami, Miami, FL
| | | | - Hao Ying
- Department of Neurology, University of Miami, Miami, FL
| | | | | | - Daniel Samano
- Department of Neurology, University of Miami, Miami, FL
| | - Danielle Bass
- Department of Neurology, University of Miami, Miami, FL
| | - Dianne Foster
- Regional Director Quality Improvement, American Heart Association, Dallas, TX
| | - Nicole B Sur
- Department of Neurology, University of Miami, Miami, FL
| | - David Z Rose
- Department of Neurology, Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Angus Jameson
- Department of Emergency Medicine, Pinellas County Emergency Medical Services, Largo, FL
| | - Nina Massad
- Department of Neurology, University of Miami, Miami, FL
| | | | | | - Robert M Starke
- Department of Neurological Surgery, University of Miami, Miami, FL
| | | | - Jose G Romano
- Department of Neurology, University of Miami, Miami, FL
| | - Jan Claassen
- Department of Neurology, Columbia University, New York, NY
| | - Ralph L Sacco
- Department of Neurology, University of Miami, Miami, FL
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5
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Lewis A. International variability in the diagnosis and management of disorders of consciousness. Presse Med 2023; 52:104162. [PMID: 36564000 DOI: 10.1016/j.lpm.2022.104162] [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: 05/16/2022] [Revised: 10/31/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
This manuscript explores the international variability in the diagnosis and management of disorders of consciousness (DoC). The identification, evaluation, intervention, exploration, prognostication and limitation of therapy for patients with DoC is reviewed through an international lens. The myriad factors that impact the diagnosis and management of DoC including 1) financial, 2) legal and regulatory, 3) cultural, 4) religious and 5) psychosocial considerations are discussed. As data comparing patients with DoC internationally are limited, findings from the general critical care or neurocritical care literature are described when information specific to patients with DoC is unavailable. There is a need for improvements in clinical care, education, advocacy and research related to patients with DoC worldwide. It is imperative to standardize methodology to evaluate consciousness and prognosticate outcome. Further, education is needed to 1) generate awareness of the impact of the aforementioned considerations on patients with DoC and 2) develop techniques to optimize communication about DoC with families. It is necessary to promote equity in access to expertise and resources for patients with DoC to enhance the care of patients with DoC worldwide. Improving understanding and management of patients with DoC requires harmonization of existing datasets, development of registries where none exist and establishment of international clinical trial networks that include patients in all phases along the spectrum of care. The work of international organizations like the Curing Coma Campaign can hopefully minimize international variability in the diagnosis and management of DoC and optimize care.
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Affiliation(s)
- Ariane Lewis
- Departments of Neurology and Neurosurgery, NYU Langone Medical Center, New York, NY, United States.
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6
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Nagel H, Pinho J, Hasan D, Ridwan H, Habib P, Schulz JB, Wiesmann M, Reich A, Nikoubashman O. Causes of Death in Endovascularly Treated Patients with Acute Stroke. AJNR Am J Neuroradiol 2022; 43:1299-1303. [PMID: 35953279 PMCID: PMC9451643 DOI: 10.3174/ajnr.a7599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 06/17/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Because stroke therapy has changed with the introduction of endovascular stroke treatment as a standard approach, studies on intrahospital causes of death from stroke are no longer up-to-date. The purpose of this observational study was to present the causes of death during hospitalization of patients with ischemic stroke who received endovascular stroke treatment, with the focus on a differentiation of curative and secondary palliative treatment. MATERIALS AND METHODS We studied a total cohort of 1342 patients who received endovascular stroke treatment in a tertiary stroke center (Aachen, Germany) between 2010 and 2020 and analyzed the causes of death in all 326 consecutive deceased patients. We distinguished between curative treatment and a secondary palliative approach and analyzed causes of death and treatment numbers across the years. RESULTS In the entire cohort of 326 deceased patients, the most common cause of death was of a cerebrovascular nature (51.5%), followed by pneumonia and sepsis (25.8%) and cardiovascular causes (8.3%). Neurovascular causes constituted 75.8% of reasons for palliation. In the group with a secondary palliative approach, causes of death were neurovascular in 54.0% of patients and pneumonia and sepsis in 26.0% of patients. CONCLUSIONS Cerebrovascular causes in patients with stroke play a major role in the intrahospital causes of death and reasons for palliation. Considering the large proportion of secondarily palliative-treated patients, reasons for palliation should be considered instead of causes of death to avoid concealment by, for example, life-terminating measures.
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Affiliation(s)
- H Nagel
- From the Departments of Neuroradiology (H.N., D.H., H.R., M.W., O.N.)
| | - J Pinho
- Neurology (J.P., P.H., J.B.S., A.R.), University Hospital RWTH, Aachen, Germany
| | - D Hasan
- From the Departments of Neuroradiology (H.N., D.H., H.R., M.W., O.N.)
| | - H Ridwan
- From the Departments of Neuroradiology (H.N., D.H., H.R., M.W., O.N.)
| | - P Habib
- Neurology (J.P., P.H., J.B.S., A.R.), University Hospital RWTH, Aachen, Germany
| | - J B Schulz
- Neurology (J.P., P.H., J.B.S., A.R.), University Hospital RWTH, Aachen, Germany
| | - M Wiesmann
- From the Departments of Neuroradiology (H.N., D.H., H.R., M.W., O.N.)
| | - A Reich
- Neurology (J.P., P.H., J.B.S., A.R.), University Hospital RWTH, Aachen, Germany
| | - O Nikoubashman
- From the Departments of Neuroradiology (H.N., D.H., H.R., M.W., O.N.)
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7
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DeMario BS, Stanley SP, Truong EI, Ladhani HA, Brown LR, Ho VP, Kelly ML. Predictors for Withdrawal of Life-Sustaining Therapies in Patients With Traumatic Brain Injury: A Retrospective Trauma Quality Improvement Program Database Study. Neurosurgery 2022; 91:e45-e50. [PMID: 35471648 PMCID: PMC9514740 DOI: 10.1227/neu.0000000000002020] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 03/05/2022] [Indexed: 12/21/2022] Open
Abstract
Many patients with severe traumatic brain injuries (TBIs) undergo withdrawal of life-sustaining therapies (WLSTs) or transition to comfort measures, but noninjury factors that influence this decision have not been well characterized. We hypothesized that WLST would be associated with institutional and geographic noninjury factors. All patients with a head Abbreviated Injury Scale score ≥3 were identified from 2016 Trauma Quality Improvement Program data. We analyzed factors that might be associated with WLST, including procedure type, age, sex, race, insurance, Glasgow Coma Scale score, mechanism of injury, geographic region, and institutional size and teaching status. Adjusted logistic regression was performed to examine factors associated with WLST. Sixty-nine thousand fifty-three patients were identified: 66% male, 77% with isolated TBI, and 7.8% had WLST. The median age was 56 years (34-73). A positive correlation was found between increasing age and WLST. Women were less likely to undergo WLST than men (odds ratio 0.91 [0.84-0.98]) and took more time to for WLST (3 vs 2 days, P < .001). African Americans underwent WLST at a significantly lower rate (odds ratio 0.66 [0.58-0.75]). Variations were also discovered based on US region, hospital characteristics, and neurosurgical procedures. WLST in severe TBI is independently associated with noninjury factors such as sex, age, race, hospital characteristics, and geographic region. The effect of noninjury factors on these decisions is poorly understood; further study of WLST patterns can aid health care providers in decision making for patients with severe TBI.
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Affiliation(s)
| | - Samuel P. Stanley
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Evelyn I. Truong
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Husayn A. Ladhani
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Laura R. Brown
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Vanessa P. Ho
- Department of Surgery, MetroHealth Medical Center, Cleveland, Ohio, USA
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Michael L. Kelly
- Department of Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio, USA
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8
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Carval T, Garret C, Guillon B, Lascarrou JB, Martin M, Lemarié J, Dupeyrat J, Seguin A, Zambon O, Reignier J, Canet E. Outcomes of patients admitted to the ICU for acute stroke: a retrospective cohort. BMC Anesthesiol 2022; 22:235. [PMID: 35879652 PMCID: PMC9310455 DOI: 10.1186/s12871-022-01777-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 07/15/2022] [Indexed: 11/10/2022] Open
Abstract
Background Although acute stroke is a leading cause of morbidity and mortality worldwide, data on outcomes of stroke patients requiring ICU admission are limited. We aimed to identify factors associated with a good neurological outcome (defined as a modified Rankin Scale score [mRS] of 0–2) 6 months after ICU admission. Methods We retrospectively studied consecutive patients who were admitted to the ICU of a French university-affiliated hospital between January 2014 and December 2018 and whose ICD-10 code indicated acute stroke. Patients with isolated subarachnoid hemorrhage or posttraumatic stroke were excluded. Results The 323 identified patients had a median age of 67 [54.5–77] years; 173 (53.6%) were male. The main reasons for ICU admission were neurological failure (87%), hemodynamic instability (28.2%), acute respiratory failure (26%), and cardiac arrest (5.3%). At ICU admission, the Glasgow Coma Scale score was 6 [4–10] and the SAPSII was 54 [35–64]. The stroke was hemorrhagic in 248 (76.8%) patients and ischemic in 75 (23.2%). Mechanical ventilation was required in 257 patients (79.6%). Six months after ICU admission, 61 (19.5%) patients had a good neurological outcome (mRS, 0–2), 50 (16%) had significant disability (mRS, 3–5), and 202 (64.5%) had died; 10 were lost to follow-up. By multivariable analysis, factors independently associated with not having an mRS of 0–2 at 6 months were older age (odds ratio, 0.93/year; 95% confidence interval, 0.89–0.96; P < 0.01) and lower Glasgow Coma Scale score at ICU admission (odds ratio, 1.23/point; 95% confidence interval, 1.07–1.40; P < 0.01). Conclusions Acute stroke requiring ICU admission carried a poor prognosis, with less than a fifth of patients having a good neurological outcome at 6 months. Age and depth of coma independently predicted the outcome.
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Affiliation(s)
- Thibaut Carval
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Centre Hospitalier Universitaire Hôtel-Dieu, 30 Bd. Jean Monnet, 44093 Nantes Cedex 1, Nantes, France
| | - Charlotte Garret
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Centre Hospitalier Universitaire Hôtel-Dieu, 30 Bd. Jean Monnet, 44093 Nantes Cedex 1, Nantes, France
| | - Benoît Guillon
- Service de Neurologie, Centre Hospitalier Universitaire de Nantes, Université de Nantes, Nantes, France
| | - Jean-Baptiste Lascarrou
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Centre Hospitalier Universitaire Hôtel-Dieu, 30 Bd. Jean Monnet, 44093 Nantes Cedex 1, Nantes, France
| | - Maëlle Martin
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Centre Hospitalier Universitaire Hôtel-Dieu, 30 Bd. Jean Monnet, 44093 Nantes Cedex 1, Nantes, France
| | - Jérémie Lemarié
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Centre Hospitalier Universitaire Hôtel-Dieu, 30 Bd. Jean Monnet, 44093 Nantes Cedex 1, Nantes, France
| | - Julien Dupeyrat
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Centre Hospitalier Universitaire Hôtel-Dieu, 30 Bd. Jean Monnet, 44093 Nantes Cedex 1, Nantes, France
| | - Amélie Seguin
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Centre Hospitalier Universitaire Hôtel-Dieu, 30 Bd. Jean Monnet, 44093 Nantes Cedex 1, Nantes, France
| | - Olivier Zambon
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Centre Hospitalier Universitaire Hôtel-Dieu, 30 Bd. Jean Monnet, 44093 Nantes Cedex 1, Nantes, France
| | - Jean Reignier
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Centre Hospitalier Universitaire Hôtel-Dieu, 30 Bd. Jean Monnet, 44093 Nantes Cedex 1, Nantes, France
| | - Emmanuel Canet
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Centre Hospitalier Universitaire Hôtel-Dieu, 30 Bd. Jean Monnet, 44093 Nantes Cedex 1, Nantes, France.
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Finley Caulfield A, Mlynash M, Eyngorn I, Lansberg MG, Afjei A, Venkatasubramanian C, Buckwalter MS, Hirsch KG. Prognostication of ICU Patients by Providers with and without Neurocritical Care Training. Neurocrit Care 2022; 37:190-199. [PMID: 35314970 DOI: 10.1007/s12028-022-01467-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 02/04/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND Predictions of functional outcome in neurocritical care (NCC) patients impact care decisions. This study compared the predictive values (PVs) of good and poor functional outcome among health care providers with and without NCC training. METHODS Consecutive patients who were intubated for ≥ 72 h with primary neurological illness or neurological complications were prospectively enrolled and followed for 6-month functional outcome. Medical intensive care unit (MICU) attendings, NCC attendings, residents (RES), and nurses (RN) predicted 6-month functional outcome on the modified Rankin scale (mRS). The primary objective was to compare these four groups' PVs of a good (mRS score 0-3) and a poor (mRS score 4-6) outcome prediction. RESULTS Two hundred eighty-nine patients were enrolled. One hundred seventy-six had mRS scores predicted by a provider from each group and were included in the primary outcome analysis. At 6 months, 54 (31%) patients had good outcome and 122 (69%) had poor outcome. Compared with other providers, NCC attendings expected better outcomes (p < 0.001). Consequently, the PV of a poor outcome prediction by NCC attendings was higher (96% [95% confidence interval [CI] 89-99%]) than that by MICU attendings (88% [95% CI 80-93%]), RES (82% [95% CI 74-88%]), and RN (85% [95% CI 77-91%]) (p = 0.047, 0.002, and 0.012, respectively). When patients who had withdrawal of life-sustaining therapy (n = 67) were excluded, NCC attendings remained better at predicting poor outcome (NCC 90% [95% CI 75-97%] vs. MICU 73% [95% CI 59-84%], p = 0.064). The PV of a good outcome prediction was similar among groups (MICU 65% [95% CI 52-76%], NCC 63% [95% CI 51-73%], RES 71% [95% CI 55-84%], and RN 64% [95% CI 50-76%]). CONCLUSIONS Neurointensivists expected better outcomes than other providers and were better at predicting poor functional outcomes. The PV of a good outcome prediction was modest among all providers.
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Affiliation(s)
- Anna Finley Caulfield
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA.
| | - Michael Mlynash
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
| | - Irina Eyngorn
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
| | - Maarten G Lansberg
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
| | - Anousheh Afjei
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
| | - Chitra Venkatasubramanian
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
| | - Marion S Buckwalter
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
| | - Karen G Hirsch
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
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10
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Dawson B, McConvey K, Gofton TE. When to initiate palliative care in neurology. HANDBOOK OF CLINICAL NEUROLOGY 2022; 190:105-125. [PMID: 36055710 DOI: 10.1016/b978-0-323-85029-2.00011-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Life-limiting and life-threatening neurologic conditions often progress slowly. Patients live with a substantial symptom burden over a long period of time, and there is often a high degree of functional and cognitive impairment. Because of this, the most appropriate time to initiate neuropalliative care is often difficult to identify. Further challenges to the incorporation of neuropalliative care include communication barriers, such as profound dysarthria or language impairments, and loss of cognitive function and decision-making capacity that prevent shared decision making and threaten patient autonomy. As a result, earlier initiation of at least some components of palliative care is paramount to ensuring patient-centered care while the patient is still able to communicate effectively and participate as fully as possible in their medical care. For these reasons, neuropalliative care is also distinct from palliative care in oncology, and there is a growing evidence base to guide timely initiation and integration of neuropalliative care. In this chapter, we will focus on when to initiate palliative care in patients with life-limiting, life-threatening, and advanced neurologic conditions. We will address three main questions, which patients with neurologic conditions will benefit from initiation of palliative care, what aspects of neurologic illness are most amenable to neuropalliative care, and when to initiate neuropalliative care?
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Affiliation(s)
- Benjamin Dawson
- Department of Clinical Neurologic Sciences, Western University, London, ON, Canada
| | - Kayla McConvey
- Department of Clinical Neurologic Sciences, Western University, London, ON, Canada
| | - Teneille E Gofton
- Department of Clinical Neurologic Sciences, Western University, London, ON, Canada.
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11
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Stefanou MI, Sulyok M, Koehnlein M, Scheibe F, Fleischmann R, Hoffmann S, Hotter B, Ziemann U, Meisel A, Mengel AM. Withholding or withdrawing life support in long-term neurointensive care patients: a single-centre, prospective, observational pilot study. JOURNAL OF MEDICAL ETHICS 2022; 48:50-55. [PMID: 32371594 DOI: 10.1136/medethics-2019-106027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 02/24/2020] [Accepted: 03/03/2020] [Indexed: 06/11/2023]
Abstract
PURPOSE Scarce evidence exists regarding end-of-life decision (EOLD) in neurocritically ill patients. We investigated the factors associated with EOLD making, including the group and individual characteristics of involved healthcare professionals, in a multiprofessional neurointensive care unit (NICU) setting. MATERIALS AND METHODS A prospective, observational pilot study was conducted between 2013 and 2014 in a 10-bed NICU. Factors associated with EOLD in long-term neurocritically ill patients were evaluated using an anonymised survey based on a standardised questionnaire. RESULTS 8 (25%) physicians and 24 (75%) nurses participated in the study by providing their 'treatment decisions' for 14 patients at several time points. EOLD was 'made' 44 (31%) times, while maintenance of life support 98 (69%) times. EOLD patterns were not significantly different between professional groups. The individual characteristics of the professionals (age, gender, religion, personal experience with death of family member and NICU experience) had no significant impact on decisions to forgo or maintain life-sustaining therapy. EOLD was patient-specific (intraclass correlation coefficient: 0.861), with the presence of acute life-threatening disease (OR (95% CI): 18.199 (1.721 to 192.405), p=0.038) and low expected patient quality of life (OR (95% CI): 9.276 (1.131 to 76.099), p=0.016) being significant and independent determinants for withholding or withdrawing life-sustaining treatment. CONCLUSIONS Our findings suggest that EOLD in NICU relies mainly on patient prognosis and not on the characteristics of the healthcare professionals.
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Affiliation(s)
- Maria-Ioanna Stefanou
- Department of Neurology and Stroke and Hertie Institute of Clinical Brain Reseach, University Hospital Tübingen, Tübingen, Germany
| | - Mihaly Sulyok
- Department of Pathology, University Hospital Tübingen, Tübingen, Germany
| | - Martin Koehnlein
- Department of Neurology, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Franziska Scheibe
- Department of Neurology, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Robert Fleischmann
- Department of Neurology, Universitätsklinik Greifswald, Greifswald, Germany
| | - Sarah Hoffmann
- Department of Neurology, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Benjamin Hotter
- Department of Neurology, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Ulf Ziemann
- Department of Neurology and Stroke and Hertie Institute of Clinical Brain Reseach, University Hospital Tübingen, Tübingen, Germany
| | - Andreas Meisel
- Department of Neurology, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Annerose Maria Mengel
- Department of Neurology and Stroke and Hertie Institute of Clinical Brain Reseach, University Hospital Tübingen, Tübingen, Germany
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12
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Alkhachroum A, Bustillo AJ, Asdaghi N, Marulanda-Londono E, Gutierrez CM, Samano D, Sobczak E, Foster D, Kottapally M, Merenda A, Koch S, Romano JG, O’Phelan K, Claassen J, Sacco RL, Rundek T. Withdrawal of Life-Sustaining Treatment Mediates Mortality in Patients With Intracerebral Hemorrhage With Impaired Consciousness. Stroke 2021; 52:3891-3898. [PMID: 34583530 PMCID: PMC8608746 DOI: 10.1161/strokeaha.121.035233] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Impaired level of consciousness (LOC) on presentation at hospital admission in patients with intracerebral hemorrhage (ICH) may affect outcomes and the decision to withhold or withdraw life-sustaining treatment (WOLST). METHODS Patients with ICH were included across 121 Florida hospitals participating in the Florida Stroke Registry from 2010 to 2019. We studied the effect of LOC on presentation on in-hospital mortality (primary outcome), WOLST, ambulation status on discharge, hospital length of stay, and discharge disposition. RESULTS Among 37 613 cases with ICH (mean age 71, 46% women, 61% White, 20% Black, 15% Hispanic), 12 272 (33%) had impaired LOC at onset. Compared with cases with preserved LOC, patients with impaired LOC were older (72 versus 70 years), more women (49% versus 45%), more likely to have aphasia (38% versus 16%), had greater ICH score (3 versus 1), greater risk of WOLST (41% versus 18%), and had an increased in-hospital mortality (32% versus 12%). In the multivariable-logistic regression with generalized estimating equations accounting for basic demographics, comorbidities, ICH severity, hospital size and teaching status, impaired LOC was associated with greater mortality (odds ratio, 3.7 [95% CI, 3.1-4.3], P<0.0001) and less likely discharged home or to rehab (odds ratio, 0.3 [95% CI, 0.3-0.4], P<0.0001). WOLST significantly mediated the effect of impaired LOC on mortality (mediation effect, 190 [95% CI, 152-229], P<0.0001). Early WOLST (<2 days) occurred among 51% of patients. A reduction in early WOLST was observed in patients with impaired LOC after the 2015 American Heart Association/American Stroke Association ICH guidelines recommending aggressive treatment and against early do-not-resuscitate. CONCLUSIONS In this large multicenter stroke registry, a third of ICH cases presented with impaired LOC. Impaired LOC was associated with greater in-hospital mortality and worse disposition at discharge, largely influenced by early decision to withhold or WOLST.
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Affiliation(s)
- Ayham Alkhachroum
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Antonio J Bustillo
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Negar Asdaghi
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Erika Marulanda-Londono
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Carolina M Gutierrez
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Daniel Samano
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Evie Sobczak
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Dianne Foster
- Regional Director Quality Improvement, American Heart Association, USA
| | - Mohan Kottapally
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Amedeo Merenda
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Sebastian Koch
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Jose G. Romano
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Kristine O’Phelan
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Jan Claassen
- Department of Neurology, Columbia University, New York, NY, USA
| | - Ralph L. Sacco
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
| | - Tatjana Rundek
- Department of Neurology, University of Miami, Miami, Florida, USA
- Department of Neurology, Jackson Memorial Hospital, Miami, Florida, USA
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Poi CH, Koh MYH, Koh TLY, Wong YL, Mei Ong WY, Gu C, Yow FC, Tan HL. Integrating Palliative Care Into a Neurosurgical Intensive Care Unit (NS-ICU): A Quality Improvement (QI) Project. Am J Hosp Palliat Care 2021; 39:667-677. [PMID: 34525873 DOI: 10.1177/10499091211045616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES We conducted a pilot quality improvement (QI) project with the aim of improving accessibility of palliative care to critically ill neurosurgical patients. METHODS The QI project was conducted in the neurosurgical intensive care unit (NS-ICU). Prior to the QI project, referral rates to palliative care were low. The ICU-Palliative Care collaborative comprising of the palliative and intensive care team led the QI project from 2013 to 2015. The interventions included engaging key stake-holders, establishing formal screening and referral criteria, standardizing workflows and having combined meetings with interdisciplinary teams in ICU to discuss patients' care plans. The Palliative care team would review patients for symptom optimization, attend joint family conferences with the ICU team and support patients and families post-ICU care. We also collected data in the post-QI period from 2016 to 2018 to review the sustainability of the interventions. RESULTS Interventions from our QI project and the ICU-Palliative Care collaborative resulted in a significant increase in the number of referrals from 9 in 2012 to 44 in 2014 and 47 the year later. The collaboration was beneficial in facilitating transfers out of ICU with more deaths outside ICU on comfort-directed care (96%) than patients not referred (75.7%, p < 0.05). Significantly more patients had a Do-Not-Resuscitation (DNR) order upon transfer out of ICU (89.7%) compared to patients not referred (74.2.%, p < 0.001), and had fewer investigations in the last 48 hours of life (p < 0.001). Per-day ICU cost was decreased for referred patients (p < 0.05). CONCLUSIONS Multi-faceted QI interventions increased referral rates to palliative care. Referred patients had fewer investigations at the end-of-life and per-day ICU costs.
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Affiliation(s)
- Choo Hwee Poi
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore.,Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore
| | - Mervyn Yong Hwang Koh
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore.,Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore
| | - Tessa Li-Yen Koh
- Department of Palliative Medicine, Tan Tock Seng Hospital, Singapore, Singapore.,Palliative Care Centre for Excellence in Research and Education, Singapore, Singapore
| | - Yu-Lin Wong
- Anaesthesiology, Intensive Care and Pain Medicine Department, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Chunguang Gu
- Nursing Service, Tan Tock Seng Hospital, Singapore, Singapore
| | | | - Hui Ling Tan
- Anaesthesiology, Intensive Care and Pain Medicine Department, Tan Tock Seng Hospital, Singapore, Singapore
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15
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Occurrence and timing of withdrawal of life-sustaining measures in traumatic brain injury patients: a CENTER-TBI study. Intensive Care Med 2021; 47:1115-1129. [PMID: 34351445 PMCID: PMC8486724 DOI: 10.1007/s00134-021-06484-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 07/14/2021] [Indexed: 12/16/2022]
Abstract
Background In patients with severe brain injury, withdrawal of life-sustaining measures (WLSM) is common in intensive care units (ICU). WLSM constitutes a dilemma: instituting WLSM too early could result in death despite the possibility of an acceptable functional outcome, whereas delaying WLSM could unnecessarily burden patients, families, clinicians, and hospital resources. We aimed to describe the occurrence and timing of WLSM, and factors associated with timing of WLSM in European ICUs in patients with traumatic brain injury (TBI). Methods The CENTER-TBI Study is a prospective multi-center cohort study. For the current study, patients with traumatic brain injury (TBI) admitted to the ICU and aged 16 or older were included. Occurrence and timing of WLSM were documented. For the analyses, we dichotomized timing of WLSM in early (< 72 h after injury) versus later (≥ 72 h after injury) based on recent guideline recommendations. We assessed factors associated with initiating WLSM early versus later, including geographic region, center, patient, injury, and treatment characteristics with univariable and multivariable (mixed effects) logistic regression. Results A total of 2022 patients aged 16 or older were admitted to the ICU. ICU mortality was 13% (n = 267). Of these, 229 (86%) patients died after WLSM, and were included in the analyses. The occurrence of WLSM varied between regions ranging from 0% in Eastern Europe to 96% in Northern Europe. In 51% of the patients, WLSM was early. Patients in the early WLSM group had a lower maximum therapy intensity level (TIL) score than patients in the later WLSM group (median of 5 versus 10) The strongest independent variables associated with early WLSM were one unreactive pupil (odds ratio (OR) 4.0, 95% confidence interval (CI) 1.3–12.4) or two unreactive pupils (OR 5.8, CI 2.6–13.1) compared to two reactive pupils, and an Injury Severity Score (ISS) if over 41 (OR per point above 41 = 1.1, CI 1.0–1.1). Timing of WLSM was not significantly associated with region or center. Conclusion WLSM occurs early in half of the patients, mostly in patients with severe TBI affecting brainstem reflexes who were severely injured. We found no regional or center influences in timing of WLSM. Whether WLSM is always appropriate or may contribute to a self-fulfilling prophecy requires further research and argues for reluctance to institute WLSM early in case of any doubt on prognosis. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06484-1.
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Williamson T, Ryser MD, Ubel PA, Abdelgadir J, Spears CA, Liu B, Komisarow J, Lemmon ME, Elsamadicy A, Lad SP. Withdrawal of Life-supporting Treatment in Severe Traumatic Brain Injury. JAMA Surg 2021; 155:723-731. [PMID: 32584926 DOI: 10.1001/jamasurg.2020.1790] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Importance There are limited data on which factors affect the critical and complex decision to withdraw life-supporting treatment (LST) in patients with severe traumatic brain injury (sTBI). Objective To determine demographic and clinical factors associated with the decision to withdraw LST in patients with sTBI. Design, Setting, and Participants This retrospective analysis of inpatient data from more than 825 trauma centers across the US in the American College of Surgeons Trauma Quality Improvement Program database from January 2013 to December 2015 included adult patients with sTBI and documentation of a decision regarding withdrawal of LST (WLST). Data analysis was conducted in September 2019. Main Outcomes and Measures Factors associated with WLST in sTBI. Results A total of 37931 patients (9817 women [25.9%]) were included in the multivariable analysis; 7864 (20.7%) had WLST. Black patients (4806 [13.2%]; odds ratio [OR], 0.66; 95% CI, 0.59-0.72; P < .001) and patients of other race (4798 [13.2%]; OR, 0.83; 95% CI, 0.76-0.91; P < .001) were less likely than white patients (26 864 [73.7%]) to have WLST. Patients from hospitals in the Midwest (OR, 1.12; 95% CI, 1.04-1.20; P = .002) or Northeast (OR, 1.23; 95% CI, 1.13-1.34; P < .001) were more likely to have WLST than patients from hospitals in the South. Patients with Medicare (OR, 1.55; 95% CI, 1.43-1.69; P < .001) and self-pay patients (OR, 1.36; 95% CI, 1.25-1.47; P < .001) were more likely to have WLST than patients with private insurance. Older patients and those with lower Glasgow Coma Scale scores, higher Injury Severity Scores, or craniotomy were generally more likely to have WLST. Withdrawal of LST was more likely for patients with functionally dependent health status (OR, 1.30; 95% CI, 1.08-1.58; P = .01), hematoma (OR, 1.19; 95% CI, 1.12-1.27; P < .001), dementia (OR, 1.29; 95% CI, 1.08-1.53; P = .004), and disseminated cancer (OR, 2.82; 95% CI, 2.07-3.82; P < .001) than for patients without these conditions. Conclusions and Relevance Withdrawal of LST is common in sTBI and socioeconomic factors are associated with the decision to withdraw LST. These results highlight the many factors that contribute to decision-making in sTBI and demonstrate that in a complex and variable disease process, variation based on race, payment, and region presents as a potential challenge.
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Affiliation(s)
- Theresa Williamson
- Duke University Medical Center, Department of Neurosurgery, Durham, North Carolina.,Duke University School of Medicine, Duke University, Durham, North Carolina
| | - Marc D Ryser
- Duke University Medical Center, Department of Population Health Sciences, Durham, North Carolina
| | - Peter A Ubel
- Duke-Margolis Center for Health Policy, Durham, North Carolina.,The Fuqua School of Business, Duke University, Durham, North Carolina
| | - Jihad Abdelgadir
- Duke University Medical Center, Department of Neurosurgery, Durham, North Carolina.,Duke University School of Medicine, Duke University, Durham, North Carolina
| | - Charis A Spears
- Duke University Medical Center, Department of Neurosurgery, Durham, North Carolina.,Duke University School of Medicine, Duke University, Durham, North Carolina
| | - Beiyu Liu
- Duke University School of Medicine, Duke University, Durham, North Carolina
| | - Jordan Komisarow
- Duke University Medical Center, Department of Neurosurgery, Durham, North Carolina.,Duke University School of Medicine, Duke University, Durham, North Carolina
| | - Monica E Lemmon
- Duke University School of Medicine, Duke University, Durham, North Carolina.,Duke University Medical Center, Department of Pediatrics, Durham, North Carolina
| | - Aladine Elsamadicy
- Duke University Medical Center, Department of Neurosurgery, Durham, North Carolina
| | - Shivanand P Lad
- Duke University Medical Center, Department of Neurosurgery, Durham, North Carolina.,Duke University School of Medicine, Duke University, Durham, North Carolina
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Abstract
Supplemental Digital Content is available in the text. Objectives: The determinants of decisions to limit life support (withholding or withdrawal) in ventilated stroke patients have been evaluated mainly for patients with intracranial hemorrhages. We aimed to evaluate the frequency of life support limitations in ventilated ischemic and hemorrhagic stroke patients compared with a nonbrain-injured population and to determine factors associated with such decisions. Design: Multicenter prospective French observational study. Setting: Fourteen ICUs of the French OutcomeRea network. PATIENTS: From 2005 to 2016, we included stroke patients and nonbrain-injured patients requiring invasive ventilation within 24 hours of ICU admission. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: We identified 373 stroke patients (ischemic, n = 167 [45%]; hemorrhagic, n = 206 [55%]) and 5,683 nonbrain-injured patients. Decisions to limit life support were taken in 41% of ischemic stroke cases (vs nonbrain-injured patients, subdistribution hazard ratio, 3.59 [95% CI, 2.78–4.65]) and in 33% of hemorrhagic stroke cases (vs nonbrain-injured patients, subdistribution hazard ratio, 3.9 [95% CI, 2.97–5.11]). Time from ICU admission to the first limitation was longer in ischemic than in hemorrhagic stroke (5 [3–9] vs 2 d [1–6] d; p < 0.01). Limitation of life support preceded ICU death in 70% of ischemic strokes and 45% of hemorrhagic strokes (p < 0.01). Life support limitations in ischemic stroke were increased by a vertebrobasilar location (vs anterior circulation, subdistribution hazard ratio, 1.61 [95% CI, 1.01–2.59]) and a prestroke modified Rankin score greater than 2 (2.38 [1.27–4.55]). In hemorrhagic stroke, an age greater than 70 years (2.29 [1.43–3.69]) and a Glasgow Coma Scale score less than 8 (2.15 [1.08–4.3]) were associated with an increased risk of limitation, whereas a higher nonneurologic admission Sequential Organ Failure Assessment score was associated with a reduced risk (per point, 0.89 [0.82–0.97]). Conclusions: In ventilated stroke patients, decisions to limit life support are more than three times more frequent than in nonbrain-injured patients, with different timing and associated risk factors between ischemic and hemorrhagic strokes.
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Sonneville R, Mazighi M, Bresson D, Crassard I, Crozier S, de Montmollin E, Degos V, Faugeras F, Gayat E, Josse L, Lamy C, Magalhaes E, Maldjian A, Ruckly S, Servan J, Vassel P, Vigué B, Timsit JF, Woimant F. Outcomes of Acute Stroke Patients Requiring Mechanical Ventilation: Study Protocol for the SPICE Multicenter Prospective Observational Study. Neurocrit Care 2021; 32:624-629. [PMID: 32026446 DOI: 10.1007/s12028-019-00907-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Care pathways and long-term outcomes of acute stroke patients requiring mechanical ventilation have not been thoroughly studied. METHODS AND RESULTS Stroke Prognosis in Intensive Care (SPICE) is a prospective multicenter cohort study which will be conducted in 34 intensive care units (ICUs) in the Paris, France area. Patients will be eligible if they meet all of the following inclusion criteria: (1) age of 18 years or older; (2) acute stroke (i.e., ischemic stroke, intracranial hemorrhage, or subarachnoid hemorrhage) diagnosed on neuroimaging; (3) ICU admission within 7 days before or after stroke onset; and (4) need for mechanical ventilation for a duration of at least 24 h. Patients will be excluded if they meet any of the following: (1) stroke of traumatic origin; (2) refusal to participate; and (3) privation of liberty by administrative or judicial decision. The primary endpoint is poor functional outcome at 1 year, defined by a score of 4 to 6 on the modified Rankin scale (mRS), indicating severe disability or death. Main secondary endpoints will include decisions to withhold or withdraw care, mRS scores at 3 and 6 months, and health-related quality of life at 1 year. CONCLUSIONS The SPICE multicenter study will investigate 1-year outcomes, ethical issues, as well as care pathways of acute stroke patients requiring invasive ventilation in the ICU. Gathered data will delineate human resources and facilities needs for adequate management. The identification of prognostic factors at the acute phase will help to identify patients who may benefit from prolonged intensive care and rehabilitation. TRIAL REGISTRATION NCT03335995.
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Affiliation(s)
- R Sonneville
- INSERM UMR1148, Team 6, Université de Paris, 75018, Paris, France. .,APHP, Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, 46 Rue Henri Huchard, 75018, Paris, France.
| | - M Mazighi
- INSERM UMR1148, Team 6, Université de Paris, 75018, Paris, France.,Department of Neurology, Lariboisière University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.,Department of Neuroradiology, Rothschild Hospital, Paris, France
| | - D Bresson
- Department of Neurosurgery, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - I Crassard
- Department of Neurology, Lariboisière University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.,Agence Régionale de Santé, Paris, France
| | - S Crozier
- Department of Neurology, Pitié-Salpétrière University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - E de Montmollin
- APHP, Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, 46 Rue Henri Huchard, 75018, Paris, France.,INSERM UMR1137, Team 6, Université de Paris, 75018, Paris, France
| | - V Degos
- Department of Critical Care, Anesthesia and Perioperative Medicine, Pitié-Salpétrière Hospital, Assistance Publique - Hôpitaux de Paris-Sorbonne University, Paris, France.,GRC ARPE, Sorbonne University, Paris, France
| | - F Faugeras
- Department of Neurology, Henri Mondor University Hospital, Assistance Publique - Hôpitaux de Paris, Créteil, France.,INSERM U955, Institut Mondor de Recherche Biomédicale, EQuipe E01 Neuropsychologie Interventionnelle, 94000, Créteil, France
| | - E Gayat
- Department of Anesthesiology and Critical Care, DMU Parabol, APHP Nord, Université de Paris, Paris, France.,UMR-S 942, Inserm, MASCOT, Paris, France
| | - L Josse
- Department of Rehabilitation Medicine, Fernand Widal University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - C Lamy
- Department of Neurology, Saint Anne Hospital, Paris, France.,INSERM U1266, Université Paris Descartes, Paris, France
| | - E Magalhaes
- Department of Intensive Care Medicine, Sud Francilien Hospital, Corbeil, France
| | - A Maldjian
- Department of Rehabilitation Medicine, 317 Lostihuel Braz, 56250, Sulniac, France
| | - S Ruckly
- APHP, Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, 46 Rue Henri Huchard, 75018, Paris, France.,INSERM UMR1137, Team 6, Université de Paris, 75018, Paris, France
| | - J Servan
- Department of Neurology, André Mignot Hospital, Le Chesnay, France
| | - P Vassel
- Department of Rehabilitation Medicine, Le Parc, Pontault-Combault, France
| | - B Vigué
- Department of Anesthesiology and Critical Care, Kremlin Bicêtre University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - J-F Timsit
- APHP, Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, 46 Rue Henri Huchard, 75018, Paris, France.,INSERM UMR1137, Team 6, Université de Paris, 75018, Paris, France
| | - F Woimant
- Department of Neurology, Lariboisière University Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.,Agence Régionale de Santé, Paris, France
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Psychological Attachment Orientations of Surrogate Decision-Makers and Goals-of-Care Decisions for Brain Injury Patients in ICUs. Crit Care Explor 2020; 2:e0151. [PMID: 32696015 PMCID: PMC7340333 DOI: 10.1097/cce.0000000000000151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Supplemental Digital Content is available in the text. To determine whether ICU surrogates with “insecure” psychologic attachment orientations are more prone to requesting tracheostomy and gastrostomy (i.e., life-sustaining therapy) for severe acute brain injury patients with poor prognosis compared to surrogates with “secure” orientations.
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20
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Lillemoe K, Lord A, Torres J, Ishida K, Czeisler B, Lewis A. Factors Associated With DNR Status After Nontraumatic Intracranial Hemorrhage. Neurohospitalist 2020; 10:168-175. [PMID: 32549939 DOI: 10.1177/1941874419873812] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background We explored factors associated with admission and discharge code status after nontraumatic intracranial hemorrhage. Methods We extracted data from patients admitted to our institution between January 1, 2013, and March 1, 2016 with nontraumatic intracerebral hemorrhage or subarachnoid hemorrhage who had a discharge modified Rankin Scale (mRS) of 4 to 6. We reviewed data based on admission and discharge code status. Results Of 88 patients who met inclusion criteria, 6 (7%) were do not resuscitate (DNR) on admission (aDNR). Do not resuscitate on admission patients were significantly older than those who were full code on admission (P = 0.04). There was no significant difference between admission code status and sex, marital status, active cancer, premorbid mRS, admission Glasgow Coma scale (GCS), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, or bleed severity. At discharge, 66 (75%) patients were full code (dFULL), 11 (13%) were DNR (dDNR), and 11 (13%) were comfort care. African American and Hispanic patients were significantly more likely to be dFULL than Asian or white patients (P = .01) and less likely to be seen by palliative care (P = .004). Patients with less aggressive code status had higher median APACHE II scores (P = .008) and were more likely to have active cancer (P = .06). There was no significant difference between discharge code status and sex, age, marital status, premorbid mRS, discharge GCS, or bleed severity. Conclusions Limitation of code status after nontraumatic intracranial hemorrhage appears to be associated with older age, white race, worse APACHE II score, and active cancer. The role of palliative care after intracranial hemorrhage and the racial disparity in limitation and de-escalation of treatment deserves further exploration.
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Affiliation(s)
- Kaitlyn Lillemoe
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA
| | - Aaron Lord
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA.,Department of Neurosurgery, NYU Langone Medical Center, New York, NY, USA
| | - Jose Torres
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA
| | - Koto Ishida
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA
| | - Barry Czeisler
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA.,Department of Neurosurgery, NYU Langone Medical Center, New York, NY, USA
| | - Ariane Lewis
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA.,Department of Neurosurgery, NYU Langone Medical Center, New York, NY, USA
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21
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McCredie VA, Turgeon AF. Shades of Gray Matter in Severe Traumatic Brain Injury. Am J Respir Crit Care Med 2020; 201:128-129. [PMID: 31770494 PMCID: PMC6961752 DOI: 10.1164/rccm.201911-2223ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Victoria A McCredie
- Interdepartmental Division of Critical Care MedicineUniversity of TorontoToronto, Ontario, Canada.,Department of MedicineUniversity Health NetworkToronto, Ontario, Canada
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care MedicineUniversité LavalQuébec City, Quebec, Canadaand.,CHU de Québec-Université Laval Research CentrePopulation Health and Optimal Health Practices UnitQuébec City, Quebec, Canada
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22
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Minority Patients are Less Likely to Undergo Withdrawal of Care After Spontaneous Intracerebral Hemorrhage. Neurocrit Care 2019; 29:419-425. [PMID: 29949003 DOI: 10.1007/s12028-018-0554-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Prior studies of patients in the intensive care unit have suggested racial/ethnic variation in end-of-life decision making. We sought to evaluate whether race/ethnicity modifies the implementation of comfort measures only status (CMOs) in patients with spontaneous, non-traumatic intracerebral hemorrhage (ICH). METHODS We analyzed data from the Ethnic/Racial Variations of Intracerebral Hemorrhage (ERICH) study, a prospective cohort study specifically designed to enroll equal numbers of white, black, and Hispanic subjects. ICH patients aged ≥ 18 years were enrolled in ERICH at 42 hospitals in the USA from 2010 to 2015. Univariate and multivariate logistic regression analyses were implemented to evaluate the association between race/ethnicity and CMOs after adjustment for potential confounders. RESULTS A total of 2705 ICH cases (912 black, 893 Hispanic, 900 white) were included in this study (mean age 62 [SD 14], female sex 1119 [41%]). CMOs patients comprised 276 (10%) of the entire cohort; of these, 64 (7%) were black, 79 (9%) Hispanic, and 133 (15%) white (univariate p < 0.001). In multivariate analysis, compared to whites, blacks were half as likely to be made CMOs (OR 0.50, 95% CI 0.34-0.75; p = 0.001), and no statistically significant difference was observed for Hispanics. All three racial/ethnic groups had similar mortality rates at discharge (whites 12%, blacks 9%, and Hispanics 10%; p = 0.108). Other factors independently associated with CMOs included age (p < 0.001), premorbid modified Rankin Scale (p < 0.001), dementia (p = 0.008), admission Glasgow Coma Scale (p = 0.009), hematoma volume (p < 0.001), intraventricular hematoma volume (p < 0.001), lobar (p = 0.032) and brainstem (p < 0.001) location and endotracheal intubation (p < 0.001). CONCLUSIONS In ICH, black patients are less likely than white patients to have CMOs. However, in-hospital mortality is similar across all racial/ethnic groups. Further investigation is warranted to better understand the causes and implications of racial disparities in CMO decisions.
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23
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Stretti F, Klinzing S, Ehlers U, Steiger P, Schuepbach R, Krones T, Brandi G. Low Level of Vegetative State After Traumatic Brain Injury in a Swiss Academic Hospital. Anesth Analg 2019; 127:698-703. [PMID: 29649031 DOI: 10.1213/ane.0000000000003375] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND No standards exist regarding decision making for comatose patients, especially concerning life-saving treatments. The aim of this retrospective, single-center study was to analyze outcomes and the decision-making process at the end of life (EOL) in patients with traumatic brain injury (TBI) in a Swiss academic tertiary care hospital. METHODS Consecutive admissions to the surgical intensive care unit (ICU) with stays of at least 48 hours between January 1, 2012 and June 30, 2015 in patients with moderate to severe TBI and with fatality within 6 months after trauma were included. Descriptive statistics were used. RESULTS Of 994 ICU admissions with TBI in the study period, 182 had an initial Glasgow Coma Scale <13 and a length of stay in the ICU >48 hours. For 174 of them, a 6-month outcome assessment based on the Glasgow Outcome Scale (GOS) was available: 43.1% (36.0%-50.5%) had favorable outcomes (GOS 4 or 5), 28.7% (22.5%-35.9%) a severe disability (GOS 3), 0.6% (0%-3.2%) a vegetative state (GOS 2), and 27.6% (21.5%-34.7%) died (GOS 1). Among the GOS 1 individuals, 45 patients had a complete dataset (73% men; median age, 67 years; interquartile range, 43-79 years). Life-prolonging therapies were limited in 95.6% (85.2%-99.2%) of the cases after interdisciplinary prognostication and involvement of the surrogate decision maker (SDM) to respect the patient's documented or presumed will. In 97.7% (87.9%-99.9%) of the cases, a next of kin was the SDM and was involved in the EOL decision and process in 100% (96.3%-100.0%) of the cases. Written advance directives (ADs) were available for 14.0% (6.6%-27.3%) of the patients, and 34.9% (22.4%-49.8%) of the patients had shared their EOL will with relatives before trauma. In the other cases, each patient's presumed will was acknowledged after a meeting with the SDM and was binding for the EOL decision. CONCLUSIONS At our institution, the majority of deaths after TBI follow a decision to limit life-prolonging therapies. The frequency of patients in vegetative state 6 months after TBI is lower than expected; this could be due to the high prevalence of limitation of life-prolonging therapies. EOL decision making follows a standardized process, based on patients' will documented in the ADs or on preferences assumed by the SDM. The prevalence of ADs was low and should be encouraged.
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Affiliation(s)
- Federica Stretti
- From the Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy
| | | | | | | | | | - Tanja Krones
- Clinical Ethics, University Hospital of Zurich, Zurich, Switzerland
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Patient factors and outcomes associated with the withdrawal or withholding of life-sustaining therapies in mechanically ventilated brain-injured patients: An observational multicentre study. Eur J Anaesthesiol 2019; 35:511-518. [PMID: 29419564 DOI: 10.1097/eja.0000000000000783] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Knowledge of the factors associated with the decision to withdraw or withhold life support (WWLS) in brain-injured patients is limited. However, most deaths in these patients may involve such a decision. OBJECTIVES To identify factors associated with the decision to WWLS in brain-injured patients requiring mechanical ventilation who survive the first 24 h in the ICU, and to analyse the outcomes and time to death. DESIGN A retrospective observational multicentre study. SETTINGS Twenty French ICUs in 18 university hospitals. PATIENTS A total of 793 mechanically ventilated brain-injured adult patients. INTERVENTIONS None. MAIN OUTCOME MEASURES Decision to WWLS within 3 months of ICU admission, and death or Glasgow Outcome Scale (GOS) score at day 90. RESULTS A decision to WWLS was made in 171 patients (22%), of whom 89% were dead at day 90. Out of the 247 deaths recorded at day 90, 153 (62%) were observed after a decision to WWLS. The median time between admission and death when a decision to WWLS was made was 10 (5 to 20) days vs. 10 (5 to 26) days when no end-of-life decision was made (P < 0.924). Among the 18 patients with a decision to WWLS who were still alive at day 90, three patients (2%) had a GOS score of 2, nine patients (5%) had a GOS score of 3 and five patients (3%) a GOS score of 4. Older age, presence of one nonreactive and dilated pupil, Glasgow Coma Scale less than 7, barbiturate use, acute respiratory distress syndrome and worsening lesions on computed tomography scans were each independently associated with decisions to WWLS. CONCLUSION Using a nationwide cohort of brain-injured patients, we observed a high proportion of deaths associated with an end-of-life decision. Older age and several disease severity factors were associated with the decision to WWLS.
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Comfort care in trauma patients without severe head injury: In-hospital complications as a trigger for goals of care discussions. Injury 2019; 50:1064-1067. [PMID: 30745124 DOI: 10.1016/j.injury.2019.01.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 01/08/2019] [Accepted: 01/12/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Many injured patients or their families make the difficult decision to withdraw life-sustaining therapies (WLST) following severe injury. While this population has been studied in the setting of severe traumatic brain injury (TBI), little is known about patients who undergo WLST without TBI. We sought to describe patients who may benefit from early involvement of end-of-life resources. METHODS Trauma Quality Improvement Program (2013-2014) patients who underwent WLST were identified. WLST patients were compared to those who died with full supportive care (FSC). Patients were excluded for death within 24 h of admission, or head AIS > 3. Intergroup comparisons were by student's t tests or Wilcoxon rank sum tests; significance for p < 0.05. RESULTS We identified 3471 total injured patients without major TBI who died > 24 h after admission. Of these death after WLST occurred in 2301 (66% of total). This group had a mean age of 66.8 years; 35.7% were women, and 95.4% sustained blunt injury. WLST patients had a higher ISS (21.6 vs. 12.5, p = 0.001), more in-hospital complications (71.4% vs. 41.6%, p = < 0.0001), and a longer ICU length of stay (8.9 days vs. 7.5 days, p = <0.0001) compared to patients who died with FSC. CONCLUSION WLST occurs in two-thirds of injured patients without severe TBI who die in the hospital. In-hospital complications are more frequent in this patient group than those who die with FSC. Early palliative care consultation may improve patient and family satisfaction after acute injury when the timeframe to leverage such services is significantly condensed.
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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: 24] [Impact Index Per Article: 4.8] [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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Gutierrez C, Hsu W, Ouyang Q, Yao H, Pollack S, Pan CX. Palliative Care Intervention in the Intensive Care Unit: Comparing Outcomes among Seriously Ill Asian Patients and those of Other Ethnicities. J Palliat Care 2018. [DOI: 10.1177/082585971403000304] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: The literature describing the attitude of Asians toward palliative care in the intensive care unit (ICU) is scarce. Aim: The purpose of this study was to compare outcomes of Asians and people of other ethnicities after palliative care intervention in the ICU. Methods: A retrospective chart review was conducted of all ICU patients evaluated by palliative care; the outcomes measured were incidence of life-sustaining treatments, institution of advance care directives, and preferences for end-of-life care. Results: The palliative care team evaluated 119 patients (46.2 percent Caucasian, 27.2 percent Asian, and 26.1 percent other ethnicities). There were no differences in demographics or clinical variables. Thirty-six percent of the Asians, 49 percent of the Caucasians, and 28.6 percent of the patients of other ethnicities (p=0.19) had healthcare proxies. The palliative care team increased advance care directives by more than 40 percent in all groups (p<0.001). There were no differences in the use of life-sustaining treatments or preferences for comfort measures among ethnic groups. Conclusion: Asians are as likely as people of other ethnicities to decide on advance care directives, life-sustaining treatments, and comfort measures after palliative care evaluation in the ICU. Contexte: Il existe très peu de publications décrivant l'attitude des asiatiques envers l'intervention des spécialistes en soins palliatifs dans le service de soins intensifs. But: Cette étude avait pour but de comparer les résultats obtenus chez les asiatiques et d'autres groupes ethniques après l'intervention de ces spécialistes auprès des patients et de leur famille dans le service de soins intensifs. Méthode: On a fait l'analyse rétrospective des dossiers de tous les patients ayant été rencontrés par l'équipe de soins palliatifs; les résultats de l'analyse portaient sur la fréquence des traitements de prolongation de vie, les directives de fin de vie, et les préférences des patients en ce qui avait trait aux soins de fin de vie. Résultats: L'équipe de soins palliatifs a évalué les dossiers de 119 patients (46,2 pourcent d'origine caucasienne, 27,2 pourcent d'origine asiatique, et 26,1 pourcent de diverses origines). Trente-six pourcent des asiatiques, 49 pourcent des caucasiens, et 28,6 pourcent des autres ethniques (p=19) avaient déjà choisi leur mandataire légal. L'équipe de soins palliatifs a augmenté le recours aux directives de fin de vie par plus de 40 pourcent dans tous les groupes (p=<0,001). Il n'y avait aucune différence entre ces groupes quant au recours aux traitements de fin de vie et aux mesures de confort du patient. Conclusion: Suite à une rencontre avec l'équipe de soins palliatifs, les asiatiques, tout comme les autres groupes ethniques, sont tout autant susceptibles de décider de leurs traitements de fin de vie et de recourir aux mesures de confort et aux directives préalables.
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Affiliation(s)
- Cristina Gutierrez
- Critical Care Medicine Service, Department of Medicine, New York Hospital Queens, 56–45 Main Street, Room WA-100, Flushing, New York 11355, USA
| | - William Hsu
- Internal Medicine, Department of Medicine, New York Hospital Queens, Flushing, New York, USA
| | - Qin Ouyang
- Internal Medicine, Department of Medicine, New York Hospital Queens, Flushing, New York, USA
| | - Haijun Yao
- Department of Pathology and Laboratory, Lutheran Medical Center, Brooklyn, New York, USA
| | - Simcha Pollack
- Computer Information Systems and Decision Sciences, Tobin College of Business, St. John's University, Jamaica, New York, USA
| | - Cynthia X. Pan
- Geriatrics and Palliative Care Medicine, Department of Medicine, New York Hospital Queens, Flushing, New York, USA
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Boyer F, Audibert G, Baumann C, Colnat-Coulbois S, Pinelli C, Claudot F, Baumann A. [Decision-making regarding treatment limitation after severe traumatic brain injury: A survey of French neurosurgeons]. Neurochirurgie 2018; 64:401-409. [PMID: 30424955 DOI: 10.1016/j.neuchi.2018.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 06/11/2018] [Accepted: 07/27/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND/INTRODUCTION In France, the law defines and prohibits "unreasonable obstinacy" and provides a framework for the subsequent decision to limit or to cease treatment. It also gives the person the right to appoint a trusted person and to draft advance directives regarding this issue. There have been few studies of neurosurgeons' involvement in decision-making in regard to treatment limitation after severe traumatic brain injury. AIM OF THE STUDY The first aim of the study was to assess French neurosurgeons' adherence to the law on patients' rights and end of life which governs such decision-making. The second aim was to assess the prognostic and decision-making criteria applied by neurosurgeons. METHODS A declarative practice and opinion survey, using a self-administered questionnaire emailed to all practising neurosurgeons members of the French Society of Neurosurgery, was conducted from April to June 2016. RESULTS Of the 197 neurosurgeons contacted, 62 filled in the questionnaire. Discussions regarding treatment limitation were in all cases collegial, as required under the law, and the patient's neurosurgeon was always involved. The trusted person and/or family were always informed and consulted, but their opinions were not consistently taken into account. Advance directives were most often lacking (68%) [56; 80] or inappropriate (27%) [16; 38]. The most frequently used prognostic criteria were clinical parameters, intracranial pressure, cerebral perfusion pressure, and imaging, with significant interindividual variation in their use. The main decision-making criteria were foreseeable disability, expected future quality of life, and age. CONCLUSIONS Neurosurgeons showed good compliance with legal requirements, except in the matter of calling for the opinion of an external consultant. Furthermore, this survey confirmed variability in the use of prognosis predictors, and the need for further clinical research so as to achieve more-standardized practices to minimise the subjectivity in decision-making.
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Affiliation(s)
- F Boyer
- Service de neurochirurgie, CHRU de Nancy, hôpital central, 54000 Nancy, France; Faculté de médecine, université de Lorraine, 54505 Vandœuvre-lès-Nancy, France
| | - G Audibert
- Faculté de médecine, université de Lorraine, 54505 Vandœuvre-lès-Nancy, France; Service d'anesthésie réanimation chirurgicale, CHRU de Nancy, hôpital central, 54000 Nancy, France
| | - C Baumann
- UMDS, CHRU de Nancy-hôpitaux de Brabois, plateforme d'aide à la recherche clinique (PARC), 54505 Vandœuvre-lès-Nancy, France
| | - S Colnat-Coulbois
- Service de neurochirurgie, CHRU de Nancy, hôpital central, 54000 Nancy, France; Faculté de médecine, université de Lorraine, 54505 Vandœuvre-lès-Nancy, France
| | - C Pinelli
- Service de neurochirurgie, CHRU de Nancy, hôpital central, 54000 Nancy, France
| | - F Claudot
- UMDS, CHRU de Nancy-hôpitaux de Brabois, plateforme d'aide à la recherche clinique (PARC), 54505 Vandœuvre-lès-Nancy, France; EA4360 APEMAC, université de Lorraine, 54000 Nancy, France
| | - A Baumann
- EA4360 APEMAC, université de Lorraine, 54000 Nancy, France; Département d'anesthésie réanimation, hôpitaux universitaires Paris-Sud, hôpital Bicêtre, 78, rue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France.
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Abstract
BACKGROUND The early subjective clinical judgment of clinicians outperforms formal prognostic scales for accurate determination of outcome after intracerebral hemorrhage (ICH), with the judgment of physicians and nurses having equivalent accuracy. This study assessed specific decisional factors that physicians and nurses incorporate into early predictions of functional outcome. METHODS This prospective observational study enrolled 121 ICH patients at five US centers. Within 24 h of each patient's admission, one physician and one nurse on the clinical team were each surveyed to predict the patient's modified Rankin Scale (mRS) at 3 months and to list up to 10 subjective factors used in prognostication. Factors were coded and compared between (1) physician and nurse and (2) accurate and inaccurate surveys, with accuracy defined as an exact prediction of mRS. RESULTS Aside from factors that are components of the ICH or FUNC scores, surveys reported pre-existing comorbidities (40.0%), other clinical or radiographic factors not in clinical scales (43.0%), and non-clinical/radiographic factors (21.9%) as important. Compared to physicians, nurses more frequently listed neurologic examination components (Glasgow Coma Scale motor, 27.3 vs. 5.8%, p < 0.0001; GCS verbal, 12.4 vs. 0.0%, p < 0.0001) and non-clinical/radiographic factors (31.4 vs. 12.4%, p = 0.0005). Physicians more frequently listed neuroimaging factors (ICH location, 33.9 vs. 7.4%, p < 0.0001; intraventricular hemorrhage, 13.2 vs. 2.5%, p = 0.003). There was no difference in listed factors between accurate versus inaccurate surveys. CONCLUSIONS Clinicians frequently utilize factors outside of the components of clinical scales for prognostication, with physician and nurses focusing on different factors despite having similar accuracy.
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Leblanc G, Boutin A, Shemilt M, Lauzier F, Moore L, Potvin V, Zarychanski R, Archambault P, Lamontagne F, Léger C, Turgeon AF. Incidence and impact of withdrawal of life-sustaining therapies in clinical trials of severe traumatic brain injury: A systematic review. Clin Trials 2018; 15:398-412. [PMID: 29865897 DOI: 10.1177/1740774518771233] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Most deaths following severe traumatic brain injury follow decisions to withdraw life-sustaining therapies. However, the incidence of the withdrawal of life-sustaining therapies and its potential impact on research data interpretation have been poorly characterized. The aim of this systematic review was to assess the reporting and the impact of withdrawal of life-sustaining therapies in randomized clinical trials of patients with severe traumatic brain injury. Methods We searched Medline, Embase, Cochrane Central, BIOSIS, and CINAHL databases and references of included trials. All randomized controlled trials published between January 2002 and August 2015 in the six highest impact journals in general medicine, critical care medicine, and neurocritical care (total of 18 journals) were considered for eligibility. Randomized controlled trials were included if they enrolled adult patients with severe traumatic brain injury (Glasgow Coma Scale ≤ 8) and reported data on mortality. Our primary objective was to assess the proportion of trials reporting the withdrawal of life-sustaining therapies in a publication. Our secondary objectives were to describe the overall mortality rate, the proportion of deaths following the withdrawal of life-sustaining therapies, and to assess the impact of the withdrawal of life-sustaining therapies on trial results. Results From 5987 citations retrieved, we included 41 randomized trials (n = 16,364, ranging from 11 to 10,008 patients). Overall mortality was 23% (range = 3%-57%). Withdrawal of life-sustaining therapies was reported in 20% of trials (8/41, 932 patients in trials) and the crude number of deaths due to the withdrawal of life-sustaining therapies was reported in 17% of trials (7/41, 884 patients in trials). In these trials, 63% of deaths were associated with the withdrawal of life-sustaining therapies (105/168). An analysis carried out by imputing a 4% differential rate in instances of withdrawal of life-sustaining therapies between study groups yielded different results and conclusions in one third of the trials. Conclusion Data on the withdrawal of life-sustaining therapies are incompletely reported in randomized controlled trials of patients with severe traumatic brain injury. Given the high proportion of deaths due to the withdrawal of life-sustaining therapies in severe traumatic brain injury patients, and the potential of this medical decision to influence the results of clinical trials, instances of withdrawal of life-sustaining therapies should be systematically reported in clinical trials in this group of patients.
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Affiliation(s)
- Guillaume Leblanc
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,2 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Amélie Boutin
- 3 Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Michèle Shemilt
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - François Lauzier
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,2 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada.,4 Department of Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Lynne Moore
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,3 Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Véronique Potvin
- 2 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Ryan Zarychanski
- 5 Department of Internal Medicine, Sections of Critical Care Medicine, Haematology and Medical Oncology, Faculty of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Patrick Archambault
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,2 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada.,6 Department of Family and Emergency Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - François Lamontagne
- 7 Department of Medicine, Faculty of Medicine, University of Sherbrooke, Sherbrooke, QC, Canada.,8 Centre de recherche du CHU de Sherbrooke, Sherbrooke, QC, Canada
| | - Caroline Léger
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Alexis F Turgeon
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,2 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
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Haines KL, Jung HS, Zens T, Turner S, Warner-Hillard C, Agarwal S. Barriers to Hospice Care in Trauma Patients: The Disparities in End-of-Life Care. Am J Hosp Palliat Care 2018; 35:1081-1084. [PMID: 29361829 DOI: 10.1177/1049909117753377] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION End-of-life and palliative care are important aspects of trauma care and are not well defined. This analysis evaluates the racial and socioeconomic disparities in terms of utilization of hospice services for critically ill trauma patients. METHODS Trauma patients ≥15 years old from 2012 to 2015 were queried from the National Trauma Databank. Chi-square and multivariate logistic regression analyses for disposition to hospice were performed after controlling for age, gender, comorbidities, injury severity, insurance, race, and ethnicity. Negative binomial regression analysis with margins for length of stay (LOS) was calculated for all patients discharged to hospice. RESULTS Chi-square analysis of 2 966 444 patient's transition to hospice found patients with cardiac disease, bleeding and psychiatric disorders, chemotherapy, cancer, diabetes, cirrhosis, respiratory disease, renal failure, cirrhosis, and cerebrovascular accident (CVA) affected transfer ( P < .0001). Logistic regression analysis after controlling for covariates showed uninsured patients were discharged to hospice significantly less than insured patients (odds ratio [OR]: 0.71; P < .0001). Asian, African American, and Hispanic patients all received less hospice care than Caucasian patients (OR: 0.65, 0.60, 0.73; P < .0001). Negative binomial regression analysis with margins for LOS showed Medicare patients were transferred to hospice 1.2 days sooner than insured patients while uninsured patients remained in the hospital 1.6 days longer ( P < .001). When compare to Caucasians, African Americans patients stayed 3.7 days longer in the hospital and Hispanics 2.4 days longer prior to transfer to hospice ( P < .0001). In all patients with polytrauma, African Americans stayed 4.9 days longer and Hispanics 2.3 days longer as compared to Caucasians ( P < .0001). CONCLUSIONS Race and ethnicity are independent predictors of a trauma patient's transition to hospice care and significantly affect LOS. Our data demonstrate prominent racial and socioeconomic disparities exist, with uninsured and minority patients being less likely to receive hospice services and having a delay in transition to hospice care when compared to their insured Caucasian counterparts.
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Affiliation(s)
- Krista L Haines
- 1 Division of Trauma and Critical Care, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Hee Soo Jung
- 1 Division of Trauma and Critical Care, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Tiffany Zens
- 1 Division of Trauma and Critical Care, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Scott Turner
- 1 Division of Trauma and Critical Care, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Charles Warner-Hillard
- 2 Division of Trauma and Critical Care, Department of Surgery, Duke Health, Durham, NC, USA
| | - Suresh Agarwal
- 2 Division of Trauma and Critical Care, Department of Surgery, Duke Health, Durham, NC, USA
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Faigle R, Carrese JA, Cooper LA, Urrutia VC, Gottesman RF. Minority race and male sex as risk factors for non-beneficial gastrostomy tube placements after stroke. PLoS One 2018; 13:e0191293. [PMID: 29351343 PMCID: PMC5774766 DOI: 10.1371/journal.pone.0191293] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 01/02/2018] [Indexed: 01/27/2023] Open
Abstract
Background Percutaneous endoscopic gastrostomy (PEG) tubes are widely used for enteral feeding after stroke; however, PEG tubes placed in patients in whom death is imminent are considered non-beneficial. Aim We sought to determine whether placement of non-beneficial PEG tubes differs by race and sex. Design and setting/participants In this retrospective cohort study, inpatient admissions for stroke patients who underwent palliative/withdrawal of care, were discharged to hospice, or died during the hospitalization, were identified from the Nationwide Inpatient Sample between 2007 and 2011. Logistic regression was used to evaluate the association between race and sex with PEG placement. Results Of 36,109 stroke admissions who underwent palliative/withdrawal of care, were discharge to hospice, or experienced in-hospital death, a PEG was placed in 2,258 (6.3%). Among PEG recipients 41.1% were of a race other than white, while only 22.0% of patients without PEG were of a minority race (p<0.001). The proportion of men was higher among those with compared to without a PEG tube (50.0% vs. 39.2%, p<0.001). Minority race was associated with PEG placement compared to whites (OR 1.75, 95% CI 1.57–1.96), and men had 1.27 times higher odds of PEG compared to women (95% CI 1.16–1.40). Racial differences were most pronounced among women: ethnic/racial minority women had over 2-fold higher odds of a PEG compared to their white counterparts (OR 2.09, 95% CI 1.81–2.41), while male ethnic/racial minority patients had 1.44 increased odds of a PEG when compared to white men (95% CI 1.24–1.67, p-value for interaction <0.001). Conclusion Minority race and male sex are risk factors for non-beneficial PEG tube placements after stroke.
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Affiliation(s)
- Roland Faigle
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
- * E-mail:
| | - Joseph A. Carrese
- Department of Medicine, Johns Hopkins University School of Medicine and the Johns Hopkins Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, United States of America
| | - Lisa A. Cooper
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Victor C. Urrutia
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Rebecca F. Gottesman
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
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Barnato AE, Chang CCH, Lave JR, Angus DC. The Paradox of End-of-Life Hospital Treatment Intensity among Black Patients: A Retrospective Cohort Study. J Palliat Med 2017; 21:69-77. [PMID: 29106315 DOI: 10.1089/jpm.2016.0557] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Black patients are more likely than white patients to die in the hospital with intensive care and life-sustaining treatments and less likely to use hospice. Regional concentration of high end-of-life (EOL) treatment intensity practice patterns may disproportionately affect black patients. We calculated and compared race-specific hospital-level EOL treatment intensity in Pennsylvania. METHODS We conducted a retrospective cohort analysis of Pennsylvania acute care hospital admissions, 2001-2007, among black and white admissions ≥21 years old at high probability of dying (HPD) (≥15% predicted probability of dying at admission). We calculated hospitals' race-specific observed, expected, and Bayes' shrunken observed-to-expected ratios of intensive care unit (ICU) admission, ICU length of stay (LOS), intubation/mechanical ventilation, hemodialysis, tracheostomy, and gastrostomy among HPD admissions; and an empirically weighted EOL treatment intensity index summing these ratios. RESULTS There were 35,609 black HPD admissions (27,576 unique patients) and 311,896 white HPD admissions (252,662 unique patients) to 182 hospitals. Among 95 hospitals with ≥30 black HPD admissions, 80% of black admissions were concentrated in 29 hospitals, where black-specific observed and expected EOL measures were usually higher than white-specific measures (p < 0.001 for all but 5/24 measures). Hospitals' black-specific and white-specific observed-to-expected ratios of ICU and life-sustaining treatment (LST) (rho 0.52-0.90) and EOL index (rho = 0.92) were highly correlated. However, black-specific observed-to-expected ratios and overall EOL intensity index were consistently lower than white-specific ratios (p < 0.001 for all except hemodialysis). CONCLUSIONS In Pennsylvania, black-serving hospitals have higher standardized EOL treatment intensity than nonblack-serving hospitals, contributing to black patients' relatively higher use of intensive treatment. However, conditional on being admitted to the same high-intensity hospital and after risk adjustment, blacks are less intensively treated than whites.
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Affiliation(s)
- Amber E Barnato
- 1 The Dartmouth Institute for Health Policy and Clinical Practice , Geisel School of Medicine, Lebanon , New Hampshire
| | - Chung-Chou H Chang
- 2 Department of Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
- 3 Department of Biostatistics, University of Pittsburgh Graduate School of Public Health , Pittsburgh, Pennsylvania
| | - Judith R Lave
- 4 Department of Health Care Policy and Management, University of Pittsburgh Graduate School of Public Health , Pittsburgh, Pennsylvania
| | - Derek C Angus
- 4 Department of Health Care Policy and Management, University of Pittsburgh Graduate School of Public Health , Pittsburgh, Pennsylvania
- 5 Department of Critical Care Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
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Does Admission to the ICU Prevent African American Disparities in Withdrawal of Life-Sustaining Treatment? Crit Care Med 2017; 45:e1083-e1086. [PMID: 28471815 DOI: 10.1097/ccm.0000000000002478] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We sought to determine whether black patients admitted to an ICU were less likely than white patients to withdraw life-sustaining treatments. DESIGN We performed a retrospective cohort study of hospital discharges from October 20, 2015, to October 19, 2016, for inpatients 18 years old or older and recorded those patients, along with their respective races, who had an "Adult Comfort Care" order set placed prior to discharge. A two-sample test for equality of two proportions with continuity correction was performed to compare the proportions between blacks and whites. SETTING University of Florida Health. PATIENTS The study cohort included 29,590 inpatient discharges, with 21,212 Caucasians (71.69%), 5,825 African Americans (19.69%), and 2,546 non-Caucasians/non-African Americans (8.62%). INTERVENTIONS Withdrawal of life-sustaining treatments. MEASUREMENTS AND MAIN RESULTS Of the total discharges (n = 29,590), 525 (1.77%) had the Adult Comfort Care order set placed. Seventy-eight of 5,825 African American patients (1.34%) had the Adult Comfort Care order set placed, whereas 413 of 21,212 Caucasian patients (1.95%) had this order set placed (p = 0.00251; 95% CI, 0.00248-0.00968). Of the 29,590 patients evaluated, 6,324 patients (21.37%) spent at least one night in an ICU. Of these 6,324 patients, 4,821 (76.24%) were white and 1,056 (16.70%) were black. Three hundred fifty of 6,324 (5.53%) were discharged with an Adult Comfort Care order set. Two hundred seventy-one White patients (5.62%) with one night in an ICU were discharged with an Adult Comfort Care order set, whereas 54 Black patients (5.11%) with one night in an ICU had the order set (p = 0.516). CONCLUSIONS This study suggests that Black patients may be less likely to withdraw life-supportive measures than whites, but that this disparity may be absent in patients who spend time in the ICU during their hospitalization.
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Skjaker SA, Hoel H, Dahl V, Stavem K. Factors associated with life-sustaining treatment restriction in a general intensive care unit. PLoS One 2017; 12:e0181312. [PMID: 28719660 PMCID: PMC5515429 DOI: 10.1371/journal.pone.0181312] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 06/29/2017] [Indexed: 11/29/2022] Open
Abstract
Purpose Few previous studies have investigated associations between clinical variables available after 24 hours in the intensive care unit (ICU), including the Charlson Comorbidity Index (CCI), and decisions to restrict life-sustaining treatment. The aim of this study was to identify factors associated with the life-sustaining treatment restriction and to explore if CCI contributes to explaining decisions to restrict life-sustaining treatment in the ICU at a university hospital in Norway from 2007 to 2009. Methods Patients’ Simplified Acute Physiology Score II (SAPS II), age, sex, type of admission, and length of hospital stay prior to being admitted to the unit were recorded. We retrospectively registered the CCI for all patients based on the medical records prior to the index stay. A multivariable logistic regression analysis was used to assess factors associated with treatment restriction during the ICU stay. Results We included 936 patients, comprising 685 (73%) medical, 204 (22%) unscheduled and 47 (5%) scheduled surgical patients. Treatment restriction was experienced by 241 (26%) patients during their ICU stay. The variables that were significantly associated with treatment restriction in multivariable analysis were older age (odds ratio [OR] = 1.48 per 10 years, 95% confidence interval [CI] = 1.28–1.72 per 10 years), higher SAPS II (OR = 1.05, 95% CI = 1.04–1.07) and CCI values relative to the reference of CCI = 0: CCI = 2 (OR = 2.08, 95% CI = 1.20–3.61) and CCI≥3 (OR = 2.72, 95% CI = 1.65–4.47). Conclusions In multivariable analysis, older age, greater illness severity after 24 h in the ICU and greater comorbidity at hospital admission were independently associated with subsequent life-sustaining treatment restriction. The CCI score contributed additional information independent of the SAPS II illness severity rating.
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Affiliation(s)
- Stein Arve Skjaker
- Section of Orthopaedic Emergency, Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
- * E-mail:
| | - Henrik Hoel
- Department of Surgery, Sykehuset Innlandet Kongsvinger, Kongsvinger, Norway
| | - Vegard Dahl
- Department of Anaesthesiology, Surgical Division, Akershus University Hospital, Lørenskog, Norway
| | - Knut Stavem
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Pulmonary Medicine, Medical Division, Akershus University Hospital, Lørenskog, Norway
- Health Services Research Unit, Akershus University Hospital, Lørenskog, Norway
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Abstract
Clinicians caring for patients with severe stroke in intensive care units often grapple with requests from surrogate decision makers for life-prolonging treatment that members of the care team may believe to be futile. An example is a surrogate decision maker's request to place a tracheostomy and feeding tube in a patient who, in the clinical judgment of the neurocritical care team, is very unlikely to recover interactive capacity. This article presents a case, discusses definitions of medical futility, and summarizes recommended steps for mediating conflict regarding potentially inappropriate treatment.
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Robertsen A, Førde R, Skaga NO, Helseth E. Treatment-limiting decisions in patients with severe traumatic brain injury in a Norwegian regional trauma center. Scand J Trauma Resusc Emerg Med 2017; 25:44. [PMID: 28441973 PMCID: PMC5405474 DOI: 10.1186/s13049-017-0385-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 04/07/2017] [Indexed: 01/08/2023] Open
Abstract
Background Treatment-limiting decisions (TLD) for severe traumatic brain injury (sTBI) have been sparsely studied. This study determine prevalence, main reason for, categories and timing of TLDs in a Norwegian regional trauma setting. Methods A retrospective study of a 2-year cohort of 579 sTBI patients admitted to Oslo University Hospital (OUH). Prospectively collected data in the OUH Trauma Registry were combined with retrospective data from a chart review regarding TLDs. Results TLDs were documented for 101/579 sTBI patients (17%). The situation was evaluated as futile in 59 cases and as potentially inappropriate in 42 cases. The three most frequent types of TLDs were withholding of neurosurgery, do not resuscitate orders and withdrawing of organ support. In 70% of cases, the first TLD was made within 2 days after injury, while in 14%, the first TLD was made later than day 7. Twenty percent (20/101) of the first TLDs were later adjusted, revoked in 4 patients and broadening of TLDs in 16 patients. The median time from the decision to death was 2 days (range 1–652). TLDs were documented in 93% of in-hospital death cases (n = 79). In-hospital deaths occurred in 73% of TLD group cases and 1% of non-TLD group cases. Family interaction and multi-team discussions were documented in >88% of cases, but no advanced directives were found, and notifications of patients’ preferences were found in only 7% of cases. Discussion Clinicians should consider limiting treatment if continued treatment is not in the patients best interest. A range of different types of TLDs were applied for patients after sTBI in the trauma hospital setting. Conclusion TLDs were found in 17% of sTBI patients. Value considerations behind TLDs in this care context need to be further explored.
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Affiliation(s)
- Annette Robertsen
- Department of Anesthesiology and Critical Care, Oslo University Hospital, Ullevål, P.O.Box 4950, Nydalen, N-0424, Oslo, Norway. .,Department of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Reidun Førde
- Centre for Medical Ethics, University of Oslo, P.O.Box 1130, Blindern, N-0318, Oslo, Norway
| | - Nils Oddvar Skaga
- Department of Anesthesiology and Critical Care, Oslo University Hospital, Ullevål, P.O.Box 4950, Nydalen, N-0424, Oslo, Norway.,Oslo University Hospital Trauma Registry, Oslo, Norway
| | - Eirik Helseth
- Department of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Neurosurgery, Oslo University Hospital, Ullevål, P.O.Box 4950, Nydalen, N-0424, Oslo, Norway
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Worster B, Bell DK, Roy V, Cunningham A, LaNoue M, Parks S. Race as a Predictor of Palliative Care Referral Time, Hospice Utilization, and Hospital Length of Stay: A Retrospective Noncomparative Analysis. Am J Hosp Palliat Care 2017; 35:110-116. [PMID: 28056514 DOI: 10.1177/1049909116686733] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Palliative care is associated with significant benefits, including reduced pain and suffering, an increased likelihood of patients dying in their preferred location, and decreased health-care expenditures. Racial and ethnic disparities are well-documented in hospice use and referral patterns; however, it is unclear whether these disparities apply to inpatient palliative care services. OBJECTIVE To determine if race is a significant predictor of time to inpatient palliative care consult, patient enrollment in hospice, and patients' overall hospital length of stay among patients of an inpatient palliative care service. DESIGN Retrospective noncomparative analysis. SETTING Urban academic medical center in the United States. PATIENTS 3207 patients referred to an inpatient palliative care service between March 2006 and April 2015. MEASUREMENTS Time to palliative care consult, disposition of hospice/not hospice (excluding patients who died), and hospital length of stay among patients by racial (Asian, black, Native American/Eskimo, Hispanic, white, Unknown) and ethnic (Hispanic/Latino, non-Hispanic, Unknown) background. RESULTS Race was not a significant predictor of time to inpatient palliative care consult, discharge to hospice, or hospital length of stay. Similarly, black/white, Hispanic/white, and Asian/white variables were not significant predictors of hospice enrollment ( Ps > .05). LIMITATIONS Study was conducted at 1 urban academic medical center, limiting generalizability; hospital race and ethnicity categorizations may also limit interpretation of results. CONCLUSIONS In this urban hospital, race was not a predictor of time to inpatient palliative care service consult, discharge to hospice, or hospital length of stay. Confirmatory studies of inpatient palliative care services in other institutions are needed.
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Affiliation(s)
- Brooke Worster
- 1 Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Declan Kennedy Bell
- 1 Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Vibin Roy
- 1 Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Amy Cunningham
- 1 Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Marianna LaNoue
- 1 Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Susan Parks
- 1 Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
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Family discussions on life-sustaining interventions in neurocritical care. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:397-408. [PMID: 28187812 DOI: 10.1016/b978-0-444-63600-3.00022-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Approximately 20% of all deaths in the USA occur in the intensive care unit (ICU) and the majority of ICU deaths involves decision of de-escalation of life-sustaining interventions. Life-sustaining interventions may include intubation and mechanical ventilation, artificial nutrition and hydration, antibiotic treatment, brain surgery, or vasoactive support. Decision making about goals of care can be defined as an end-of-life communication and the decision-making process between a clinician and a patient (or a surrogate decision maker if the patient is incapable) in an institutional setting to establish a plan of care. This process includes deciding whether to use life-sustaining treatments. Therefore, family discussion is a critical element in the decision-making process throughout the patient's stay in the neurocritical care unit. A large part of care in the neurosciences intensive care unit is discussion of proportionality of care. This chapter provides a stepwise approach to hold these conferences and discusses ways to do it effectively.
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Lewis J, Peltier J, Nelson H, Snyder W, Schneider K, Steinberger D, Anderson M, Krichevsky A, Anderson J, Ellefson J, D'Alessandro A. Development of the University of Wisconsin Donation after Cardiac Death Evaluation Tool. Prog Transplant 2016; 13:265-73. [PMID: 14765718 DOI: 10.1177/152692480301300405] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Donation after cardiac death is a method by which severely neurologically injured patients not fulfilling brain-death criteria can donate organs. Objective To develop an evaluation tool that can be used to predict if a patient is a suitable candidate for donation after cardiac death. Methods The University of Wisconsin Donation After Cardiac Death Evaluation Tool assigns numeric values to observable clinical parameters to yield an overall predictive score of suitability for donation after cardiac death. This evaluation tool is typically utilized in a critical care unit to evaluate patients with a severe neurological injury, who do not meet brain-death criteria, and for whom the physician and family have chosen to terminally withdraw life support. Each patient is disconnected from a ventilator and observed for up to 10 minutes. Observations are then scored to yield a prediction of suitability for donation after cardiac death. Results Using the University of Wisconsin Donation After Cardiac Death Evaluation Tool, we were able to predict suitability for donation after cardiac death 83.7% of the time, within a 60-minute period and 74.4% of the time within a 120-minute period. The actual results using the tool were higher when clinical observations were included in the donation after cardiac death evaluation—an overall accuracy of 88.4%.
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Affiliation(s)
- Jonathan Lewis
- University of Wisconsin Hospital and Clinics Organ Procurement Organization, Madisin, Wis, USA
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McQuistion K, Zens T, Jung HS, Beems M, Leverson G, Liepert A, Scarborough J, Agarwal S. Insurance status and race affect treatment and outcome of traumatic brain injury. J Surg Res 2016; 205:261-271. [DOI: 10.1016/j.jss.2016.06.087] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 06/05/2016] [Accepted: 06/26/2016] [Indexed: 10/21/2022]
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The critical care management of spontaneous intracranial hemorrhage: a contemporary review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:272. [PMID: 27640182 PMCID: PMC5027096 DOI: 10.1186/s13054-016-1432-0] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Spontaneous intracerebral hemorrhage (ICH), defined as nontraumatic bleeding into the brain parenchyma, is the second most common subtype of stroke, with 5.3 million cases and over 3 million deaths reported worldwide in 2010. Case fatality is extremely high (reaching approximately 60 % at 1 year post event). Only 20 % of patients who survive are independent within 6 months. Factors such as chronic hypertension, cerebral amyloid angiopathy, and anticoagulation are commonly associated with ICH. Chronic arterial hypertension represents the major risk factor for bleeding. The incidence of hypertension-related ICH is decreasing in some regions due to improvements in the treatment of chronic hypertension. Anticoagulant-related ICH (vitamin K antagonists and the newer oral anticoagulant drugs) represents an increasing cause of ICH, currently accounting for more than 15 % of all cases. Although questions regarding the optimal medical and surgical management of ICH still remain, recent clinical trials examining hemostatic therapy, blood pressure control, and hematoma evacuation have advanced our understanding of ICH management. Timely and aggressive management in the acute phase may mitigate secondary brain injury. The initial management should include: initial medical stabilization; rapid, accurate neuroimaging to establish the diagnosis and elucidate an etiology; standardized neurologic assessment to determine baseline severity; prevention of hematoma expansion (blood pressure management and reversal of coagulopathy); consideration of early surgical intervention; and prevention of secondary brain injury. This review aims to provide a clinical approach for the practicing clinician.
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Timing of withdrawal of life-sustaining therapies in severe traumatic brain injury: Impact on overall mortality. J Trauma Acute Care Surg 2016; 80:484-91. [PMID: 26595711 DOI: 10.1097/ta.0000000000000922] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The care of patients with severe traumatic brain injury (TBI) is complex and confounded by uncertainty in prognoses. Studies have demonstrated significant unexplained variation in mortality between centers. Possible explanations include differences in the quality and intensity of care across centers, including the appropriateness and timing of withdrawal of life-sustaining therapies. We postulated that centers with a preponderance of early deaths might have a more pessimistic approach to the TBI patient, which would be reflected in an increased hospital TBI-related mortality. METHODS This is a retrospective cohort study. Time to death was used as a proxy for time to withdrawal of life-sustaining therapies. Centers were classified as early or late based on when the majority (75th percentile) of their TBI-related deaths occurred. We evaluated the association between adjusted mortality and center classification using a hierarchical multivariable model. Two hundred trauma centers contributing data to the American College of Surgeons Trauma Quality Improvement Program from 2010 through 2013 were involved. The cohort included 17,505 patients with severe isolated TBI. RESULTS One hundred eight centers were classified as early centers. The 75th percentile for time to death was 4 days among early centers versus 7 days in late centers. Mortality was 34% and 33%, respectively. After adjustment for case mix, care in an early center was not associated with increased odds of death (adjusted odds ratio, 0.95; 95% confidence interval, 0.83-1.09). Higher odds of death were independently associated with age, Glasgow Coma Scale (GCS) score, head Abbreviated Injury Scale (AIS) score, multiple comorbidities, traumatic subarachnoid hemorrhage, intracerebral mass lesions, brainstem lesions, and signs of compressed or absent basal cisterns. CONCLUSION Centers rendering early decisions related to withdrawal of life-sustaining therapies in TBI patients, as measured by time until death, do not have worse outcomes than those making later decisions. How and when these decisions are made requires further exploration to balance an opportunity for clinical improvement with appropriate resource use. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.
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Creutzfeldt CJ, Wunsch H, Curtis JR, Hua M. Prevalence and Outcomes of Patients Meeting Palliative Care Consultation Triggers in Neurological Intensive Care Units. Neurocrit Care 2016; 23:14-21. [PMID: 25940997 DOI: 10.1007/s12028-015-0143-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Palliative care needs among patients in the neurological intensive care unit (neuroICU) are poorly characterized. Our aim was to explore the prevalence and type of potential palliative care consultation triggers in neuroICUs. METHODS We conducted a retrospective cohort study of neuroICU admissions in Project IMPACT from 2001 to 2008. We assessed the prevalence of neuroICU admissions meeting one or more of five validated palliative care consultation triggers and compared the percentage of admissions meeting these triggers in other ICUs from the same hospitals. RESULTS Among 1268 admissions to 2 neuroICUs, 200 (15.8 %) met one or more triggers for palliative care consultation. Among 13,694 admissions to non-neuroICUs in the same hospitals, 1909 (13.9 %) met one or more palliative care triggers (p = 0.44). The most common trigger in the neuroICU was intracerebral hemorrhage with mechanical ventilation (n = 92; 7.3 %). The most common trigger in non-neuroICUs was ICU admission following ≥10-day hospital stay (n = 805; 5.9 %). Although ICU mortality was not significantly higher in neuroICU vs. non-neuroICU patients meeting triggers (23.4 vs 19.9 %, p = 0.46), neuroICU patients were significantly more likely to have withdrawal of life-sustaining therapies (19.4 vs 8.0 %, p < 0.001). CONCLUSIONS Among neuroICU patients, 15.8 % met triggers for palliative care consultation. Although prevalence of admissions meeting any trigger was similar amongst all ICUs, neuroICU admissions met different types of triggers and were more likely to have withdrawal of life-sustaining therapy. These data suggest that palliative care needs are common among neuroICU patients and discussions with patients and families regarding limitation of life-sustaining therapy may differ in this setting.
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Affiliation(s)
- Claire J Creutzfeldt
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA, USA,
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Carter EL, Hutchinson PJA, Kolias AG, Menon DK. Predicting the outcome for individual patients with traumatic brain injury: a case-based review. Br J Neurosurg 2016; 30:227-32. [PMID: 26853860 DOI: 10.3109/02688697.2016.1139048] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Traumatic brain injuries result in significant morbidity and mortality. Accurate prediction of prognosis is desirable to inform treatment decisions and counsel family members. Objective To review the currently available prognostic tools for use in traumatic brain injury (TBI), to analyse their value in individual patient management and to appraise ongoing research on prognostic modelling. METHODS AND RESULTS We present two patients who sustained a TBI in 2011-2012 and evaluate whether prognostic models could accurately predict their outcome. The methodology and validity of current prognostic models are analysed and current research that might contribute to improved individual patient prognostication is evaluated. CONCLUSION Predicting prognosis in the acute phase after TBI is complex and existing prognostic models are not suitable for use at the individual patient level. Data derived from these models should only be used as an adjunct to clinical judgement and should not be used to set limits for acute care interventions. Information from neuroimaging, physiological monitoring and analysis of biomarkers or genetic polymorphisms may be used in the future to improve accuracy of individual patient prognostication. Clinicians should consider offering full supportive treatment to patients in the early phase after injury whilst the outcome is unclear.
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Affiliation(s)
- Eleanor L Carter
- a Division of Anaesthesia and Intensive Care Medicine, Department of Medicine , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK ;,b Department of Anaesthesia , National Hospital for Neurology and Neurosurgery , London , UK
| | - Peter J A Hutchinson
- c Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK
| | - Angelos G Kolias
- c Division of Neurosurgery, Department of Clinical Neurosciences , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK
| | - David K Menon
- a Division of Anaesthesia and Intensive Care Medicine, Department of Medicine , Addenbrooke's Hospital & University of Cambridge , Cambridge , UK
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Integrating Palliative Care Into the Care of Neurocritically Ill Patients: A Report From the Improving Palliative Care in the ICU Project Advisory Board and the Center to Advance Palliative Care. Crit Care Med 2015; 43:1964-77. [PMID: 26154929 DOI: 10.1097/ccm.0000000000001131] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To describe unique features of neurocritical illness that are relevant to provision of high-quality palliative care; to discuss key prognostic aids and their limitations for neurocritical illnesses; to review challenges and strategies for establishing realistic goals of care for patients in the neuro-ICU; and to describe elements of best practice concerning symptom management, limitation of life support, and organ donation for the neurocritically ill. DATA SOURCES A search of PubMed and MEDLINE was conducted from inception through January 2015 for all English-language articles using the term "palliative care," "supportive care," "end-of-life care," "withdrawal of life-sustaining therapy," "limitation of life support," "prognosis," or "goals of care" together with "neurocritical care," "neurointensive care," "neurological," "stroke," "subarachnoid hemorrhage," "intracerebral hemorrhage," or "brain injury." DATA EXTRACTION AND SYNTHESIS We reviewed the existing literature on delivery of palliative care in the neurointensive care unit setting, focusing on challenges and strategies for establishing realistic and appropriate goals of care, symptom management, organ donation, and other considerations related to use and limitation of life-sustaining therapies for neurocritically ill patients. Based on review of these articles and the experiences of our interdisciplinary/interprofessional expert advisory board, this report was prepared to guide critical care staff, palliative care specialists, and others who practice in this setting. CONCLUSIONS Most neurocritically ill patients and their families face the sudden onset of devastating cognitive and functional changes that challenge clinicians to provide patient-centered palliative care within a complex and often uncertain prognostic environment. Application of palliative care principles concerning symptom relief, goal setting, and family emotional support will provide clinicians a framework to address decision making at a time of crisis that enhances patient/family autonomy and clinician professionalism.
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Creutzfeldt CJ, Engelberg RA, Healey L, Cheever CS, Becker KJ, Holloway RG, Curtis JR. Palliative Care Needs in the Neuro-ICU. Crit Care Med 2015; 43:1677-84. [PMID: 25867905 DOI: 10.1097/ccm.0000000000001018] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Patients admitted to the neurological or neurosurgical ICU are likely to have palliative care needs. The goals of this project are to encourage the ICU team to identify palliative care needs for patients and their families and potential ways to meet those needs. DESIGN Quality improvement project using a parallel-group prospective cohort design. SETTING Single neuro-ICU at a large, academic medical center. PATIENTS All patients admitted to the neuro-ICU from September 1, 2013, to November 30, 2013. INTERVENTIONS We developed a palliative care needs screening tool consisting of four questions: 1) Does the patient have distressing physical or psychological symptoms? 2) Are there specific support needs for patient or family? 3) Are treatment options matched with patient-centered goals? 4) Are there disagreements among teams and family? We implemented this daily screening tool on morning rounds for one of two neurocritical care services that alternate admitting days to a single neuro-ICU. We examined prevalence and nature of palliative care needs and actions to address those needs, comparing the services with and without screening. MEASUREMENTS AND MAIN RESULTS Over the 3-month period, 130 patients were admitted to the service with screening and 132 patients to the service without screening. The two groups did not differ with regard to age, gender, Glasgow Coma Scale, or diagnosis. Palliative care needs were identified in 62% of screened patients (80/130). Needs were mainly social support (53%) and establishing goals of care (28%). Screening was associated with more documented family conferences (p = 0.019) and a trend toward more palliative care consultations (p = 0.056). CONCLUSIONS We developed a brief palliative care needs screening tool that identified palliative care needs for 62% neuro-ICU patients. This tool was associated with actions to meet these needs, potentially improving care for patients and their families.
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Affiliation(s)
- Claire J Creutzfeldt
- 1Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA. 2Department of Pulmonary and Critical Care, University of Washington, Seattle, WA. 3Department of Neurocritical Care, University of Washington, Seattle, WA. 4Department of Neurology, University of Rochester, Rochester, NY
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Chima-Melton C, Murphy TE, Araujo KLB, Pisani MA. The Impact of Race on Intensity of Care Provided to Older Adults in the Medical Intensive Care Unit. J Racial Ethn Health Disparities 2015; 3:365-72. [PMID: 27271078 DOI: 10.1007/s40615-015-0162-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 06/12/2015] [Accepted: 08/24/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND African-Americans and Hispanics receive disproportionately less aggressive non-critical treatment for chronic diseases than their Caucasian counterparts. However, when it comes to end-of-life care, minority races are purportedly treated more aggressively in Medical Intensive Care Units (MICU) and are more likely to die there. OBJECTIVE We sought to determine the impact of race on the intensity of care provided to older adults in the Medical Intensive Care Unit (MICU) using the Therapeutic Intervention Scoring System-28 (TISS-28) and other MICU interventions. METHODS This is a prospective study of a cohort of 309 patients aged 60 years and older in the MICU. Interventions such as mechanical ventilation, vasopressors, new onset dialysis, feeding tubes, and pulmonary artery catheterization were recorded. Primary outcomes were TISS-28 scores and MICU interventions. RESULTS Non-white patients were younger and had more dementia and delirium although there was no difference in ICU mortality. The amount of critical care delivered to non-white and white patients were equivalent at p ≤ 0.05 based on their respective TISS-28 scores. Non-white patients received more renal replacement therapy than white patients. CONCLUSIONS Our study adds to the growing body of literature demonstrating that the relationship between race, patient preference, and the intensity of care provided in MICUs is multifaceted. Although prior studies have reported that non-white populations often opt for more aggressive care, the similar proportions of non-white and white "full code" patients in this study suggests that this idea is overly simplistic.
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Affiliation(s)
- Chidinma Chima-Melton
- Pulmonary & Critical Care Section, Cedars Sinai Medical Center, Los Angeles, CA, USA.
| | - Terrence E Murphy
- Department of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yale University School of Medicine and Yale New Haven Hospital, New Haven, CA, USA
| | - Katy L B Araujo
- Department of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Yale University School of Medicine and Yale New Haven Hospital, New Haven, CA, USA
| | - Margaret A Pisani
- Pulmonary & Critical Care Section, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, P.O. Box 208057, New Haven, CT, 06520-8057, USA
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"Do not resuscitate" decisions in acute respiratory distress syndrome. A secondary analysis of clinical trial data. Ann Am Thorac Soc 2015; 11:1592-6. [PMID: 25386717 DOI: 10.1513/annalsats.201406-244bc] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
RATIONALE Factors and outcomes associated with end-of-life decision-making among patients during clinical trials in the intensive care unit are unclear. OBJECTIVES We sought to determine patterns and outcomes of Do Not Resuscitate (DNR) decisions among critically ill patients with acute respiratory distress syndrome (ARDS) enrolled in a clinical trial. METHODS We performed a secondary analysis of data from the ARDS Network Fluid and Catheter Treatment Trial (FACTT), collected between 2000 and 2005. We calculated mortality outcomes stratified by code status, and compared baseline characteristics of patients who became DNR during the trial with participants who remained full code. MEASUREMENTS AND MAIN RESULTS Among 809 FACTT participants with a code status recorded, 232 (28.7%) elected DNR status. Specifically, 37 (15.9%) chose to withhold cardiopulmonary resuscitation alone, 44 (19.0%) elected to withhold some life support measures in addition to cardiopulmonary resuscitation, and 151 (65.1%) had life support withdrawn. Admission severity of illness as measured by APACHE III score was strongly associated with election of DNR status (odds ratio, 2.2; 95% confidence interval, 1.85-2.62; P < 0.0001). Almost all (97.0%; 225 of 232) patients who selected DNR status died, and 79% (225 of 284) of patients who died during the trial were DNR. Among patients who chose DNR status but did not elect withdrawal of life support, 91% (74 of 81) died. CONCLUSIONS The vast majority of deaths among clinical trial patients with ARDS were preceded by a DNR order. Unlike other studies of end-of-life decision-making in the intensive care unit, nearly all patients who became DNR died. The impact of variation of practice in end-of-life decision-making during clinical trials warrants further study.
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