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Le Gal A, Barfield DM, Wignall RH, Cook SD. Outcome prediction in dogs admitted through the emergency room: Accuracy of staff prediction and comparison with an illness severity stratification system for hospitalized dogs. J Vet Emerg Crit Care (San Antonio) 2024; 34:69-75. [PMID: 37987140 DOI: 10.1111/vec.13350] [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: 04/28/2022] [Revised: 07/25/2022] [Accepted: 09/03/2022] [Indexed: 11/22/2023]
Abstract
OBJECTIVE To determine whether emergency staff and students can predict patient outcome within 24 hours of admission, comparing the accuracy of clinician prognostication with outcome prediction by Acute Patient Physiologic and Laboratory Evaluation (APPLE)fast scoring and identifying whether experience or mood would be associated with accuracy. DESIGN Prospective observational study between April 2020 and March 2021. SETTING University teaching hospital. ANIMALS One hundred and sixty-one dogs admitted through an Emergency Service were assessed. Where data were available, an APPLEfast score was calculated per patient. An APPLEfast score of >25 was deemed a predictor for mortality. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Emergency staff and students were asked to complete surveys about dogs admitted to the emergency room. All clinicopathological data were available for review, and the animals were available for examination. Data collected included opinions on whether the patient would be discharged from hospital, a mood score, position, and experience in Emergency and Critical Care. One-hundred and twenty-five dogs (77.6%) were discharged; 36 dogs (22.4%) died or were euthanized. Two hundred and sixty-six responses were obtained; 202 responses (75.9%) predicted the correct outcome. Students, interns, residents, faculty, and nurses predicted the correct outcome in 81.4%, 58.3%, 83.3%, 82.1%, and 65.5% of cases, respectively. Of 64 incorrect predictions, 43 (67.2%) predicted death in hospital. APPLEfast scores were obtained in 121 cases, predicting the correct outcome in 83 cases (68.6%). Of 38 cases in which APPLEfast was incorrect, 27 (71.1%) were dogs surviving to discharge. Mean APPLEfast score was 22.9 (± 6.2). There was no difference in outcome prediction accuracy between staff and APPLEfast scores (P = 0.13). Neither experience nor mood score was associated with outcome prediction ability (P = 0.55 and P = 0.74, respectively). CONCLUSIONS Outcome prediction accuracy by staff is not significantly different to APPLEfast scoring where a cutoff of >25 is used to predict mortality. When predictions were incorrect, they often predicted nonsurvival.
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Affiliation(s)
- Alice Le Gal
- Section of Emergency and Critical Care, Department of Clinical Science and Services, The Royal Veterinary College, Hatfield, UK
| | - Dominic Martin Barfield
- Section of Emergency and Critical Care, Department of Clinical Science and Services, The Royal Veterinary College, Hatfield, UK
| | - Roseanne Helen Wignall
- Section of Emergency and Critical Care, Department of Clinical Science and Services, The Royal Veterinary College, Hatfield, UK
| | - Simon David Cook
- Section of Emergency and Critical Care, Department of Clinical Science and Services, The Royal Veterinary College, Hatfield, UK
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Siddiqui S, Gusmano M, Dunn M, Agich G. Understanding the Underlying Causes of Tensions That Arise in ICU Care for Older Patients. THE JOURNAL OF CLINICAL ETHICS 2023; 34:148-157. [PMID: 37229736 DOI: 10.1086/724229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
AbstractObjective: We hypothesized that the reasons behind this tension are complex and can be understood better by applying social psychology theory.Design: A qualitative methodology was drawn on for data collection and thematic analysis, with focus group discussions adopted for interviews with patient families and ICU physicians. Additionally, we used a social psychology theory, the reasoned action approach (RAA) framework, to understand these tensions.Setting: Two 15-bedded ICUs of an academic university-affiliated teaching hospital in Singapore.Subjects: A total of 72 physicians and family members of older ICU patients (>70 years old).Measurements and Main Results: The primary analysis revealed five areas of tension around prognostication in the ICU. These dealt with issues of divergent views, different role expectations, conflicting emotional responses, and issues of communication and trust. Further analysis helped to identify underlying factors leading to tensions and behaviors. Differences in prognostication and in expectation of outcomes between clinicians and family members were the main cause of tensions. When the RAA framework was applied, these tensions could be predicted early on and understood more clearly.Conclusions: Tensions revolve around losing control of the patient's care, differences between hopeful expectations and clinical prognostication, perceived biases of physicians, and underlying mistrust between families and physicians.
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Damps M, Gajda M, Kowalska M, Kucewicz-Czech E. Limitation of Futile Therapy in the Opinion of Nursing Staff Employed in Polish Hospitals-Results of a Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16975. [PMID: 36554855 PMCID: PMC9778965 DOI: 10.3390/ijerph192416975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/11/2022] [Accepted: 12/14/2022] [Indexed: 06/17/2023]
Abstract
The debate on limiting futile therapy in the aspect of End of Life (EoL) care has been going on in Poland over the last decade. The growing demand for EoL care resulting from the aging of societies corresponds to the expectation of a satisfactory quality of life and self-determination. The authors designed a cross-sectional study using a newly designed questionnaire to assess the opinions of 190 nurses employed in intensive care units (ICUs) on futile therapy, practices, and the respondents' approach to the issue. The problem of futile therapy and its clinical implications are known to the nursing community. Among the most common reasons for undertaking futile therapy in adult patients, the respondents declared fear of legal liability for not taking such actions (71.58%), as well as fear of being accused of unethical conduct (56.32%), and fear of talking to the patient/patient's family and their reaction (43.16%). In the case of adult patients, the respondents believed that discontinuation of futile therapy should be decided by the patient (84.21%), followed by a doctor (64.21%). As for paediatric patients, two-thirds of the respondents mentioned a doctor and a court (64.74% and 64.21%, respectively). Overall, 65.26% of the respondents believe and agree that the comfort of the patient's last days is more important than the persistent continuation of therapy and prolonging life at all costs. The presented results clearly show the attitude of the respondents who defend the patient's dignity and autonomy.
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Affiliation(s)
- Maria Damps
- Department of Anaesthesiology and Intensive Care, Upper Silesian Child Health Centre, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Medyków 16, 40-752 Katowice, Poland
| | - Maksymilian Gajda
- Department of Epidemiology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
| | - Malgorzata Kowalska
- Department of Epidemiology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
| | - Ewa Kucewicz-Czech
- Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland
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de Jonge M, Wubben N, van Kaam CR, Frenzel T, Hoedemaekers CWE, Ambrogioni L, van der Hoeven JG, van den Boogaard M, Zegers M. Optimizing an existing prediction model for quality of life one-year post-intensive care unit: An exploratory analysis. Acta Anaesthesiol Scand 2022; 66:1228-1236. [PMID: 36054515 DOI: 10.1111/aas.14138] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 07/12/2022] [Accepted: 07/31/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND This study aimed to improve the PREPARE model, an existing linear regression prediction model for long-term quality of life (QoL) of intensive care unit (ICU) survivors by incorporating additional ICU data from patients' electronic health record (EHR) and bedside monitors. METHODS The 1308 adult ICU patients, aged ≥16, admitted between July 2016 and January 2019 were included. Several regression-based machine learning models were fitted on a combination of patient-reported data and expert-selected EHR variables and bedside monitor data to predict change in QoL 1 year after ICU admission. Predictive performance was compared to a five-feature linear regression prediction model using only 24-hour data (R2 = 0.54, mean square error (MSE) = 0.031, mean absolute error (MAE) = 0.128). RESULTS The 67.9% of the included ICU survivors was male and the median age was 65.0 [IQR: 57.0-71.0]. Median length of stay (LOS) was 1 day [IQR 1.0-2.0]. The incorporation of the additional data pertaining to the entire ICU stay did not improve the predictive performance of the original linear regression model. The best performing machine learning model used seven features (R2 = 0.52, MSE = 0.032, MAE = 0.125). Pre-ICU QoL, the presence of a cerebro vascular accident (CVA) upon admission and the highest temperature measured during the ICU stay were the most important contributors to predictive performance. Pre-ICU QoL's contribution to predictive performance far exceeded that of the other predictors. CONCLUSION Pre-ICU QoL was by far the most important predictor for change in QoL 1 year after ICU admission. The incorporation of the numerous additional features pertaining to the entire ICU stay did not improve predictive performance although the patients' LOS was relatively short.
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Affiliation(s)
- Manon de Jonge
- Department Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, Netherlands
| | - Nina Wubben
- Department Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, Netherlands
| | - Christiaan R van Kaam
- Department Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, Netherlands
| | - Tim Frenzel
- Department Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, Netherlands
| | - Cornelia W E Hoedemaekers
- Department Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, Netherlands
| | - Luca Ambrogioni
- Radboud University, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, Netherlands
| | - Johannes G van der Hoeven
- Department Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, Netherlands
| | - Mark van den Boogaard
- Department Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, Netherlands
| | - Marieke Zegers
- Department Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, Netherlands
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Fiest KM, Krewulak KD, Jaworska N, Spence KL, Mizen SJ, Bagshaw SM, Burns KEA, Cook DJ, Fowler RA, Olafson K, Patten SB, Rewa OG, Rochwerg B, Spence S, West A, Stelfox HT, Parsons Leigh J. Impact of restricted visitation policies during COVID-19 on critically ill adults, their families, critical care clinicians, and decision-makers: a qualitative interview study. Can J Anaesth 2022; 69:1248-1259. [PMID: 35978160 PMCID: PMC9385091 DOI: 10.1007/s12630-022-02301-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 02/22/2022] [Accepted: 04/11/2022] [Indexed: 01/20/2023] Open
Abstract
PURPOSE During the first wave of the COVID-19 pandemic, restricted visitation policies were enacted at acute care facilities to reduce the spread of COVID-19 and conserve personal protective equipment. In this study, we aimed to describe the impact of restricted visitation policies on critically ill patients, families, critical care clinicians, and decision-makers; highlight the challenges faced in translating these policies into practice; and delineate strategies to mitigate their effects. METHOD A qualitative description design was used. We conducted semistructured interviews with critically ill adult patients and their family members, critical care clinicians, and decision-makers (i.e., policy makers or enforcers) affected by restricted visitation policies. We transcribed semistructured interviews verbatim and analyzed the transcripts using inductive thematic analysis. RESULTS Three patients, eight family members, 30 clinicians (13 physicians, 17 nurses from 23 Canadian intensive care units [ICUs]), and three decision-makers participated in interviews. Thematic analysis was used to identify five themes: 1) acceptance of restricted visitation (e.g., accepting with concerns); 2) impact of restricted visitation (e.g., ethical challenges, moral distress, patients dying alone, intensified workload); 3) trust in the healthcare system during the pandemic (e.g., mistrust of clinical team); 4) modes of communication (e.g., communication using virtual platforms); and 5) impact of policy implementation on clinical practice (e.g., frequent changes and inconsistent implementation). CONCLUSIONS Restricted visitation policies across ICUs during the COVID-19 pandemic negatively affected critically ill patients and their families, critical care clinicians, and decision-makers.
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Affiliation(s)
- Kirsten M Fiest
- Department of Critical Care Medicine, Alberta Health Services & University of Calgary, Calgary, AB, Canada.
- Department of Community Health Sciences & O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
- Department of Psychiatry & Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
| | - Karla D Krewulak
- Department of Critical Care Medicine, Alberta Health Services & University of Calgary, Calgary, AB, Canada
| | - Natalia Jaworska
- Department of Critical Care Medicine, Alberta Health Services & University of Calgary, Calgary, AB, Canada
| | - Krista L Spence
- Department of Critical Care Medicine, Alberta Health Services & University of Calgary, Calgary, AB, Canada
| | - Sara J Mizen
- Faculty of Health, School of Health Administration, Dalhousie University, Halifax, NS, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
| | - Karen E A Burns
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Unity Health Toronto-St. Michael's Hospital, Toronto, ON, Canada
| | - Deborah J Cook
- Department of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Robert A Fowler
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine and Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Kendiss Olafson
- Department of Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Scott B Patten
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Oleksa G Rewa
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
- Critical Care Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
| | - Bram Rochwerg
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | - Sean Spence
- Department of Critical Care Medicine, Alberta Health Services & University of Calgary, Calgary, AB, Canada
| | - Andrew West
- Canadian Society of Respiratory Therapists, Ottawa, ON, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, Alberta Health Services & University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences & O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jeanna Parsons Leigh
- Faculty of Health, School of Health Administration, Dalhousie University, Halifax, NS, Canada
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Kiker WA, Rutz Voumard R, Plinke W, Longstreth WT, Curtis JR, Creutzfeldt CJ. Prognosis Predictions by Families, Physicians, and Nurses of Patients with Severe Acute Brain Injury: Agreement and Accuracy. Neurocrit Care 2022; 37:38-46. [PMID: 35474037 PMCID: PMC10760982 DOI: 10.1007/s12028-022-01501-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Effective shared decision-making relies on some degree of alignment between families and the medical team regarding a patient's likelihood of recovery. Patients with severe acute brain injury (SABI) are often unable to participate in decisions, and therefore family members make decisions on their behalf. The goal of this study was to evaluate agreement between prognostic predictions by families, physicians, and nurses of patients with SABI regarding their likelihood of regaining independence and to measure each group's prediction accuracy. METHODS This observational cohort study, conducted from 01/2018 to 07/2020, was based in the neuroscience and medical/cardiac intensive care units of a single center. Patient eligibility included a diagnosis of SABI-specifically stroke, traumatic brain injury, or hypoxic ischemic encephalopathy-and a Glasgow Coma Scale ≤ 12 after hospital day 2. At enrollment, families, physicians, and nurses were asked separately to predict a patient's likelihood of recovering to independence within 6 months on a 0-100 scale, regardless of whether a formal family meeting had occurred. True outcome was based on modified Rankin Scale assessment through a family report or medical chart review. Prognostic agreement was measured by (1) intraclass correlation coefficient; (2) mean group prediction comparisons using paired Student's t-tests; and (3) prevalence of concordance, defined as an absolute difference of less than 20 percentage points between predictions. Accuracy for each group was measured by calculating the area under a receiver operating characteristic curve (C statistic) and compared by using DeLong's test. RESULTS Data were collected from 222 patients and families, 45 physicians, and 103 nurses. Complete data on agreement and accuracy were available for 187 and 177 patients, respectively. The intraclass correlation coefficient, in which 1 indicates perfect correlation and 0 indicates no correlation, was 0.49 for physician-family pairs, 0.40 for family-nurse pairs, and 0.66 for physician-nurse pairs. The difference in mean predictions between families and physicians was 23.5 percentage points (p < 0.001), 25.4 between families and nurses (p < 0.001), and 1.9 between physicians and nurses (p = 0.38). Prevalence of concordance was 39.6% for family-physician pairs, 30.0% for family-nurse pairs, and 56.2% for physician-nurse pairs. The C statistic for prediction accuracy was 0.65 for families, 0.82 for physicians, and 0.76 for nurses. The p values for differences in C statistics were < 0.05 for family-physician and family-nurse groups and 0.18 for physician-nurse groups. CONCLUSIONS For patients with SABI, agreement in predictions between families, physicians, and nurses regarding likelihood of recovery is poor. Accuracy appears higher for physicians and nurses compared with families, with no significant difference between physicians and nurses.
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Affiliation(s)
- Whitney A Kiker
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA.
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA.
| | - Rachel Rutz Voumard
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA, USA
- Palliative and Supportive Care Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Wesley Plinke
- Oregon Health and Sciences University School of Medicine, Portland, OR, USA
| | - W T Longstreth
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - J Randall Curtis
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
| | - Claire J Creutzfeldt
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
- Department of Neurology, Harborview Medical Center, University of Washington, Seattle, WA, USA
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Shlobin NA, Clark JR, Campbell JM, Bernstein M, Jahromi BS, Potts MB. Ethical Considerations in Surgical Decompression for Stroke. Stroke 2022; 53:2673-2682. [PMID: 35703095 DOI: 10.1161/strokeaha.121.038493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Stroke is a major cause of morbidity and mortality. Neurosurgical decompression is often considered for the treatment of malignant infarcts and intraparenchymal hemorrhages, but this treatment can be frought with ethical dilemmas. In this article, the authors outline the primary principles of bioethics and their application to stroke care, provide an overview of key ethical issues and special situations in the neurosurgical management of stroke, and highlight methods to improve ethical decision-making for patients with stroke. Understanding these ethical principles is essential for stroke care teams to deliver appropriate, timely, and ethical care to patients with stroke.
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Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL. (N.A.S., J.R.C., B.S.J., M.B.P.)
| | - Jeffrey R Clark
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL. (N.A.S., J.R.C., B.S.J., M.B.P.)
| | | | - Mark Bernstein
- Division of Neurosurgery, Department of Surgery, University of Toronto, University Health Network, Ontario, Canada (M.B.)
| | - Babak S Jahromi
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL. (N.A.S., J.R.C., B.S.J., M.B.P.).,Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL. (B.S.J., M.B.P.).,Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL. (B.S.J., M.B.P.)
| | - Matthew B Potts
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL. (N.A.S., J.R.C., B.S.J., M.B.P.).,Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL. (B.S.J., M.B.P.).,Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL. (B.S.J., M.B.P.)
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De Georgia M. The intersection of prognostication and code status in patients with severe brain injury. J Crit Care 2022; 69:153997. [PMID: 35114602 DOI: 10.1016/j.jcrc.2022.153997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 12/27/2021] [Accepted: 01/18/2022] [Indexed: 11/16/2022]
Abstract
Accurately estimating the prognosis of brain injury patients can be difficult, especially early in their course. Prognostication is important because it largely determines the care level we provide, from aggressive treatment for patients we predict could have a good outcome to withdrawal of treatment for those we expect will have a poor outcome. Accurate prognostication is required for ethical decision-making. However, several studies have shown that prognostication is frequently inaccurate and variable. Overly optimistic prognostication can lead to false hope and futile care. Overly pessimistic prognostication can lead to therapeutic nihilism. Overlapping is the powerful effect that cognitive biases, in particular code status, can play in shaping our perceptions and the care level we provide. The presence of Do Not Resuscitate orders has been shown to be associated with increased mortality. Based on a comprehensive search of peer-reviewed journals using a wide range of key terms, including prognostication, critical illness, brain injury, cognitive bias, and code status, the following is a review of prognostic accuracy and the effect of code status on outcome. Because withdrawal of treatment is the most common cause of death in the ICU, a clearer understanding of this intersection of prognostication and code status is needed.
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Affiliation(s)
- Michael De Georgia
- University Hospitals Cleveland Medical Center, Cleveland, OH, United States of America.
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9
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Using long-term predicted Quality of Life in ICU clinical practice to prepare patients for life post-ICU: A feasibility study. J Crit Care 2022; 68:121-128. [PMID: 35007979 DOI: 10.1016/j.jcrc.2021.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 11/01/2021] [Accepted: 12/27/2021] [Indexed: 11/23/2022]
Abstract
PURPOSE To examine the feasibility of using the PREdicting PAtients' long-term outcome for Recovery (PREPARE) prediction model for Quality of Life (QoL) 1 year after ICU admission in ICU practice to prepare expected ICU survivors and their relatives for life post-ICU. MATERIALS AND METHODS Between June 2020 and February 2021, the predicted change in QoL after 1 year was discussed in 25 family conferences in the ICU. 13 physicians, 10 nurses and 19 patients and/or family members were interviewed to evaluate intervention feasibility in ICU practice. Interviews were analysed qualitatively using thematic coding. RESULTS Patients' median age was 68.0 years, five patients (20.0%) were female and seven patients (28.0%) died during ICU stay. Generally, study participants thought the intervention, which clarified the concept of QoL through visualization and served as a reminder to discuss QoL and expectations for life post-ICU, had merit. However, some participants, especially physicians, thought the prediction model needed more data on more severely ill ICU patients to curb uncertainty. CONCLUSIONS Using predicted QoL scores in ICU practice to prepare patients and family members for life after ICU discharge is feasible. After optimising the model and implementation strategy, its effectiveness can be evaluated in a larger trial.
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10
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Goss AL, Creutzfeldt CJ. Neuropalliative Care in the Inpatient Setting. Semin Neurol 2021; 41:619-630. [PMID: 34619785 DOI: 10.1055/s-0041-1731071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The palliative care needs of inpatients with neurologic illness are varied, depending on diagnosis, acuity of illness, available treatment options, prognosis, and goals of care. Inpatient neurologists ought to be proficient at providing primary palliative care and effective at determining when palliative care consultants are needed. In the acute setting, palliative care should be integrated with lifesaving treatments using a framework of determining goals of care, thoughtfully prognosticating, and engaging in shared decision-making. This framework remains important when aggressive treatments are not desired or not available, or when patients are admitted to the hospital for conditions related to advanced stages of chronic neurologic disease. Because prognostic uncertainty characterizes much of neurology, inpatient neurologists must develop communication strategies that account for uncertainty while supporting shared decision-making and allowing patients and families to preserve hope. In this article, we illustrate the approach to palliative care in inpatient neurology.
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Affiliation(s)
- Adeline L Goss
- Department of Neurology, University of California San Francisco, San Francisco, California
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Saint-Arnaud J, Mullins G, Ringuette L. Les principes d’équité et d’utilité dans l’allocation des ressources limitées en
situation de pandémie. CANADIAN JOURNAL OF BIOETHICS 2021. [DOI: 10.7202/1077622ar] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
La pandémie de COVID-19 remet à l’honneur la question éthique de l’allocation des
ressources limitées, en termes d’accès à des soins intensifs et à des respirateurs. Se pose
la question éthique suivante : sur quels principes éthiques se baser pour effectuer le
triage des patients qui auront accès aux ressources quand elles sont insuffisantes pour
répondre aux besoins de tous? Pour en débattre, deux références historiques de triage sont
d’abord présentées ; l’une s’appuie sur un principe égalitaire de réponse aux besoins
individuels, l’autre sur un principe d’utilité sociale. Après avoir défini les conditions
d’équité en tant qu’égalité procédurale et réponse adéquate aux besoins, deux types de
protocoles sont étudiés en mettant l’accent sur les critères d’équité et d’utilité qu’ils
préconisent. Les types de protocoles sont ensuite comparés en présentant leurs forces et
leurs limites dans la réponse qu’ils apportent aux besoins populationnels et individuels.
Notre analyse met en évidence la difficile conciliation entre les objectifs populationnels
et les objectifs cliniques en situation de pandémie, tout en montrant qu’un protocole qui
utilise comme outil le Sequential Organ Failure Assessment (SOFA) facilite cette
conciliation.
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Affiliation(s)
- Jocelyne Saint-Arnaud
- Département de médecine sociale et préventive, École de santé publique de
l’Université de Montréal, Montréal, Canada
| | | | - Louise Ringuette
- Département de médecine sociale et préventive, École de santé publique de
l’Université de Montréal, Montréal, Canada
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Wubben N, van den Boogaard M, Ramjith J, Bisschops LLA, Frenzel T, van der Hoeven JG, Zegers M. Development of a practically usable prediction model for quality of life of ICU survivors: A sub-analysis of the MONITOR-IC prospective cohort study. J Crit Care 2021; 65:76-83. [PMID: 34111683 DOI: 10.1016/j.jcrc.2021.04.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 03/18/2021] [Accepted: 04/08/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE As the goal of ICU treatment is survival in good health, we aimed to develop a prediction model for ICU survivors' change in quality of life (QoL) one year after ICU admission. MATERIALS & METHODS This is a sub-study of the prospective cohort MONITOR-IC study. Adults admitted ≥12 h to the ICU of a university hospital between July 2016-January 2019 were included. Moribund patients were excluded. Change in QoL one year after ICU admission was quantified using the EuroQol five-dimensional (EQ-5D-5L) questionnaire, and Short-Form 36 (SF-36). Multivariable linear regression analysis and best subsets regression analysis (SRA) were used. Models were internally validated by bootstrapping. RESULTS The PREdicting PAtients' long-term outcome for Recovery (PREPARE) model was developed (n = 1308 ICU survivors). The EQ-5D-models had better predictive performance than the SF-36-models. Explained variance (adjusted R2) of the best model (33 predictors) was 58.0%. SRA reduced the number of predictors to 5 (adjusted R2 = 55.3%, SE = 0.3), including QoL, diagnosis of a Cardiovascular Incident and frailty before admission, sex, and ICU-admission following planned surgery. CONCLUSIONS Though more long-term data are needed to ascertain model accuracy, in future, the PREPARE model may be used to better inform and prepare patients and their families for ICU recovery.
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Affiliation(s)
- Nina Wubben
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Intensive Care Medicine, Nijmegen, the Netherlands
| | - Mark van den Boogaard
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Intensive Care Medicine, Nijmegen, the Netherlands
| | - Jordache Ramjith
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Health Evidence, Nijmegen, the Netherlands
| | - Laurens L A Bisschops
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Intensive Care Medicine, Nijmegen, the Netherlands
| | - Tim Frenzel
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Intensive Care Medicine, Nijmegen, the Netherlands
| | - Johannes G van der Hoeven
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Intensive Care Medicine, Nijmegen, the Netherlands
| | - Marieke Zegers
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Intensive Care Medicine, Nijmegen, the Netherlands.
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Rath KA, Tucker KL, Lewis A. Fluctuating Code Status: Strategies to Minimize End-of-Life Conflict in the Neurocritical Care Setting. Am J Hosp Palliat Care 2021; 39:79-85. [PMID: 34002621 DOI: 10.1177/10499091211017872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND There are multiple factors that may cause end-of-life conflict in the critical care setting. These include severe illness, family distress, lack of awareness about a patient's wishes, prognostic uncertainty, and the participation of multiple providers in goals-of-care discussions. METHODS Case report and discussion of the associated ethical issues. RESULTS We present a case of a patient with a pontine stroke, in which the family struggled with decision-making about goals-of-care, leading to fluctuation in code status from Full Code to Do Not Resuscitate-Comfort Care, then back to Full Code, and finally to Do Not Resuscitate-Do Not Intubate. We discuss factors that contributed to this situation and methods to avoid conflict. Additionally, we review the effects of discord at the end-of-life on patients, families, and the healthcare team. CONCLUSION It is imperative that healthcare teams proactively collaborate with families to minimize end-of-life conflict by emphasizing decision-making that prioritizes the best interest and autonomy of the patient.
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Affiliation(s)
- Kelly A Rath
- Department of Neurocritical Care, Gardner Neuroscience Institute, University of Cincinnati, OH, USA
| | - Kristi L Tucker
- Section on Neurocritical Care, Department of Neurology, Wake Forest Baptist Health, Winston-Salem, NC, 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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Weekly Internal Ethical Case Discussions in an ICU-Results Based on 9 Years of Experience With a Highly Structured Approach. Crit Care Explor 2021; 3:e0352. [PMID: 33786431 PMCID: PMC7994040 DOI: 10.1097/cce.0000000000000352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objectives Various ethical challenges are prevalent in ICUs. In order to handle these problems, a highly structured internal ethical case discussion within the multiprofessional team was implemented in 2011 in a Swiss ICU and has been regularly practiced almost weekly until present. To explore the results of all ethical case discussions taking place in a general ICU and to discuss the outcomes of the patients. To identify the conditions facilitating the implementation of regular ethical case discussions. Design Retrospective case series analysis. Setting Mixed academic ICU. Patients AND INTERVENTION All patients who had an ethical case discussion between January 2011 and December 2019 following the approach called Modular, Ethical, Treatment decisions, Allocation of resources at the micro-level, and Process. MEASUREMENTS AND Main Results Weekly ethical case discussions held regularly on a fixed date were found to be practical for the observed ICU. A total of 314 ethical case discussions were realized in 281 patients. Median patient age was 70 years (interquartile range, 62-77 yr); two thirds were men. The results were categorized into the following groups: established therapy continues, complications to be treated (n = 53; 16.9%); therapy continues, patient's will to be explored further (n = 77; 24.5%); therapy continues, complications to be treated only after evaluation (n = 62; 19.7%); therapy continues with limitations (e.g., do-not-resuscitate order) (n = 98; 31.2%); and change of treatment plan to end-of-life care (n = 17; 5.4%). Of the discussed patients, 115 (40.9%) died in the ICU and 29 (10.3%) after transfer to the normal ward. Seven patients (2.5%) were transferred to a hospice and 55 (19.6%) to another hospital. Sixty-nine (24.6%) were discharged to a rehabilitative facility and six returned home. Conclusions Regular ethical case discussions can be successfully implemented, enabling careful review of the patient's will and balancing it with the prognosis of the disease. This facilitates a necessary change of the therapeutic goal whenever appropriate.
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Yarnell CJ, Jewell LM, Astell A, Pinto R, Devine LA, Detsky ME, Downar J, Ilan R, Rawal S, Wong N, You JJ, Fowler RA. Observational study of agreement between attending and trainee physicians on the surprise question: "Would you be surprised if this patient died in the next 12 months?". PLoS One 2021; 16:e0247571. [PMID: 33630939 PMCID: PMC7906409 DOI: 10.1371/journal.pone.0247571] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 02/10/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Optimal end-of-life care requires identifying patients that are near the end of life. The extent to which attending physicians and trainee physicians agree on the prognoses of their patients is unknown. We investigated agreement between attending and trainee physician on the surprise question: "Would you be surprised if this patient died in the next 12 months?", a question intended to assess mortality risk and unmet palliative care needs. METHODS This was a multicentre prospective cohort study of general internal medicine patients at 7 tertiary academic hospitals in Ontario, Canada. General internal medicine attending and senior trainee physician dyads were asked the surprise question for each of the patients for whom they were responsible. Surprise question response agreement was quantified by Cohen's kappa using Bayesian multilevel modeling to account for clustering by physician dyad. Mortality was recorded at 12 months. RESULTS Surprise question responses encompassed 546 patients from 30 attending-trainee physician dyads on academic general internal medicine teams at 7 tertiary academic hospitals in Ontario, Canada. Patients had median age 75 years (IQR 60-85), 260 (48%) were female, and 138 (25%) were dependent for some or all activities of daily living. Trainee and attending physician responses agreed in 406 (75%) patients with adjusted Cohen's kappa of 0.54 (95% credible interval 0.41 to 0.66). Vital status was confirmed for 417 (76%) patients of whom 160 (38% of 417) had died. Using a response of "No" to predict 12-month mortality had positive likelihood ratios of 1.84 (95% CrI 1.55 to 2.22, trainee physicians) and 1.51 (95% CrI 1.30 to 1.72, attending physicians), and negative likelihood ratios of 0.31 (95% CrI 0.17 to 0.48, trainee physicians) and 0.25 (95% CrI 0.10 to 0.46, attending physicians). CONCLUSION Trainee and attending physician responses to the surprise question agreed in 54% of cases after correcting for chance agreement. Physicians had similar discriminative accuracy; both groups had better accuracy predicting which patients would survive as opposed to which patients would die. Different opinions of a patient's prognosis may contribute to confusion for patients and missed opportunities for engagement with palliative care services.
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Affiliation(s)
- Christopher J. Yarnell
- Institute of Health Management, Policy, and Evaluation, University of Toronto, Toronto, Canada
- Department of Medicine, Sinai Health System, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Laura M. Jewell
- Memorial University of Newfoundland, Discipline of Family Medicine, Happy Valley-Goose Bay, Canada
| | - Alex Astell
- University of Manitoba Faculty of Medicine, Section of Critical Care Medicine, Manitoba, Canada
| | - Ruxandra Pinto
- Sunnybrook Health Sciences Centre Department of Critical Care, Toronto, Canada
| | - Luke A. Devine
- Department of Medicine, Sinai Health System, Toronto, Canada
- University of Toronto Temerty Faculty of Medicine, Division of General Internal Medicine, Toronto, Canada
| | - Michael E. Detsky
- Department of Medicine, Sinai Health System, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - James Downar
- The Ottawa Hospital, Ottawa, Canada
- University of Ottawa Faculty of Medicine, Division of Palliative Care, Ottawa, Canada
| | - Roy Ilan
- Department of Critical Care Medicine, Rambam Health Care Campus, Technion, Israel Institute of Technology, Haifa, Israel
| | - Shail Rawal
- University of Toronto Temerty Faculty of Medicine, Division of General Internal Medicine, Toronto, Canada
- University Health Network, General Internal Medicine, Toronto, Canada
| | - Natalie Wong
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- University of Toronto Temerty Faculty of Medicine, Division of General Internal Medicine, Toronto, Canada
- Departments of General Internal Medicine and Critical Care Medicine, St Michael’s Hospital, Toronto, Canada
| | - John J. You
- Division of General Internal and Hospitalist Medicine, Department of Medicine, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Rob A. Fowler
- Institute of Health Management, Policy, and Evaluation, University of Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Sunnybrook Health Sciences Centre Department of Critical Care, Toronto, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Canada
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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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Dahine J, Hébert PC, Ziegler D, Chenail N, Ferrari N, Hébert R. Practices in Triage and Transfer of Critically Ill Patients: A Qualitative Systematic Review of Selection Criteria. Crit Care Med 2020; 48:e1147-e1157. [PMID: 32858530 PMCID: PMC7493782 DOI: 10.1097/ccm.0000000000004624] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To identify and appraise articles describing criteria used to prioritize or withhold a critical care admission. DATA SOURCES PubMed, Embase, Medline, EBM Reviews, and CINAHL Complete databases. Gray literature searches and a manual review of references were also performed. Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed. STUDY SELECTION We sought all articles and abstracts of original research as well as local, provincial, or national policies on the topic of ICU resource allocation. We excluded studies whose population of interest was neonatal, pediatric, trauma, or noncritically ill. Screening of 6,633 citations was conducted. DATA EXTRACTION Triage and/or transport criteria were extracted, based on type of article, methodology, publication year, and country. An appraisal scale was developed to assess the quality of identified articles. We also developed a robustness score to further appraise the robustness of the evidence supporting each criterion. Finally, all criteria were extracted, evaluated, and grouped by theme. DATA SYNTHESIS One-hundred twenty-nine articles were included. These were mainly original research (34%), guidelines (26%), and reviews (21%). Among them, we identified 200 unique triage and transport criteria. Most articles highlighted an exclusion (71%) rather than a prioritization mechanism (17%). Very few articles pertained to transport of critically ill patients (4%). Criteria were classified in one of four emerging themes: patient, condition, physician, and context. The majority of criteria used were nonspecific. No study prospectively evaluated the implementation of its cited criteria. CONCLUSIONS This systematic review identified 200 criteria classified within four themes that may be included when devising triage programs including the coronavirus disease 2019 pandemic. We identified significant knowledge gaps where research would assist in improving existing triage criteria and guidelines, aiming to decrease arbitrary decisions and variability.
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Affiliation(s)
- Joseph Dahine
- Département de médecine spécialisée, Centre intégré de santé et services sociaux de Laval (CISSS de Laval), Hôpital Cité-de-la-Santé, Université de Montréal, Laval, QC, Canada
| | - Paul C. Hébert
- Département de médecine, Centre Hospitalier de l’Université de Montréal, Université de Montréal et Centre de Recherche, Montreal, QC, Canada
| | - Daniela Ziegler
- Bibliothèque, Centre hospitalier de l’Université de Montréal, Montreal, QC, Canada
| | | | - Nicolay Ferrari
- Centre de recherche du Centre hospitalier de l’Université de Montréal, Montreal, QC, Canada
| | - Réjean Hébert
- Department of Health Management, Evaluation and Policy, School of Public Health, Université de Montréal, Montreal, QC, Canada
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18
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Prognosis and futility in neurosurgical emergencies: A review. Clin Neurol Neurosurg 2020; 195:105851. [PMID: 32422469 DOI: 10.1016/j.clineuro.2020.105851] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/10/2020] [Accepted: 04/11/2020] [Indexed: 11/22/2022]
Abstract
A patient with a life-threatening intracranial insult presents a difficult situation to the neurosurgeon. In a few short minutes the neurosurgeon must assess the patient's neurologic status, imaging, and medical condition then confer with the patient's proxy regarding treatment. This assessment ideally includes recognition of situations where aggressive care is futile and therefore such treatments should not be offered. The proxy discussion must involve surgical and nonsurgical management options and the impact of these options on survival and residual disability. Surgical decision-making is frequently difficult, even for designated proxies armed with advance directives, as these documents are usually vague with regard to acceptable functional outcomes. To complicate things further, when emergencies are off-hours, housestaff or physician extenders may need to represent the medical team in these discussions so that surgical treatment, if desired, can be arranged expeditiously. These difficulties sometimes lead to the performance of emergent surgical procedures in situations where poor outcome is certain, with deleterious effects to the patient, family, and healthcare system. It is clear then that neurosurgeons as well as their housestaff and extenders should have working knowledge of prognostic information relating to intracranial insults and familiarity with the complex ethical concept of medical futility. In this paper we review the relevant literature and our goal is to juxtapose these topics so as to provide a framework for decision making in that critical time.
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Villa G, Amass T, Giua R, Lanini I, Chelazzi C, Tofani L, McFadden R, De Gaudio AR, OMahony S, Levy MM, Romagnoli S. Validation of END-of-life ScorING-system to identify the dying patient: a prospective analysis. BMC Anesthesiol 2020; 20:63. [PMID: 32164567 PMCID: PMC7068991 DOI: 10.1186/s12871-020-00979-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 03/04/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The "END-of-Life ScorING-System" (ENDING-S) was previously developed to identify patients at high-risk of dying in the ICU and to facilitate a practical integration between palliative and intensive care. The aim of this study is to prospectively validate ENDING-S in a cohort of long-term critical care patients. MATERIALS AND METHODS Adult long-term ICU patients (with a length-of-stay> 4 days) were considered for this prospective multicenter observational study. ENDING-S and SOFA score were calculated daily and evaluated against the patient's ICU outcome. The predictive properties were evaluated through a receiver operating characteristic (ROC) analysis. RESULTS Two hundred twenty patients were enrolled for this study. Among these, 21.46% died during the ICU stay. ENDING-S correctly predicted the ICU outcome in 71.4% of patients. Sensitivity, specificity, positive and negative predictive values associated with the previously identified ENDING-S cut-off of 11.5 were 68.1, 72.3, 60 and 89.3%, respectively. ROC-AUC for outcome prediction was 0.79 for ENDING-S and 0.88 for SOFA in this cohort. CONCLUSIONS ENDING-S, while not as accurately as in the pilot study, demonstrated acceptable discrimination properties in identifying long-term ICU patients at very high-risk of dying. ENDING-S may be a useful tool aimed at facilitating a practical integration between palliative, end-of-life and intensive care. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT02875912; First registration August 4, 2016.
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Affiliation(s)
- Gianluca Villa
- Section of Anesthesiology, Intensive Care and Pain Therapy, Departmnt of Health Sciences, University of Florence, Florence, Italy.
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla,3, 50134, Florence, Italy.
| | - Timothy Amass
- Department of Medicine, Division of Pulmonary Critical Care & Sleep, Brown University, Providence, RI, USA
| | - Rosa Giua
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla,3, 50134, Florence, Italy
| | - Iacopo Lanini
- Section of Anesthesiology, Intensive Care and Pain Therapy, Departmnt of Health Sciences, University of Florence, Florence, Italy
| | - Cosimo Chelazzi
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla,3, 50134, Florence, Italy
| | - Lorenzo Tofani
- Section of Anesthesiology, Intensive Care and Pain Therapy, Departmnt of Health Sciences, University of Florence, Florence, Italy
| | - Rory McFadden
- Department of Internal Medicine, Palliative Medicine Section, Rush University Medical Center, Chicago, IL, USA
| | - A Raffaele De Gaudio
- Section of Anesthesiology, Intensive Care and Pain Therapy, Departmnt of Health Sciences, University of Florence, Florence, Italy
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla,3, 50134, Florence, Italy
| | - Sean OMahony
- Department of Internal Medicine, Palliative Medicine Section, Rush University Medical Center, Chicago, IL, USA
| | - Mitchell M Levy
- Department of Medicine, Division of Pulmonary Critical Care & Sleep, Brown University, Providence, RI, USA
| | - Stefano Romagnoli
- Section of Anesthesiology, Intensive Care and Pain Therapy, Departmnt of Health Sciences, University of Florence, Florence, Italy
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla,3, 50134, Florence, Italy
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Sanson G, Marino C, Valenti A, Lucangelo U, Berlot G. Is my patient ready for a safe transfer to a lower-intensity care setting? Nursing complexity as an independent predictor of adverse events risk after ICU discharge. Heart Lung 2020; 49:407-414. [PMID: 32067723 DOI: 10.1016/j.hrtlng.2020.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 01/24/2020] [Accepted: 02/03/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Patients discharged from intensive care units (ICUs) are at risk for adverse events (AEs). Establishing safe discharge criteria is challenging. No available criteria consider nursing complexity among risk factors. OBJECTIVES To investigate whether nursing complexity upon ICU discharge is an independent predictor for AEs. METHODS Prospective observational study. The Patient Acuity and Complexity Score (PACS) was developed to measure nursing complexity. Its predictive power for AEs was tested using multivariate regression analysis. RESULTS The final regression model showed a very-good discrimination power (AUC 0.881; p<0.001) for identifying patients who experienced AEs. Age, ICU admission reason, PACS, cough strength, PaCO2, serum creatinine and sodium, and transfer to Internal Medicine showed to be predictive of AEs. Exceeding the identified PACS threshold increased by 3.3 times the AEs risk. CONCLUSIONS The level of nursing complexity independently predicts AEs risk and should be considered in establishing patient's eligibility for a safe ICU discharge.
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Affiliation(s)
- Gianfranco Sanson
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Strada di Fiume 447, 34100 Trieste, Italy.
| | - Cecilia Marino
- Department of Perioperative Medicine, Intensive Care and Emergency, University Hospital, Trieste, Italy.
| | - Andrea Valenti
- Department of Perioperative Medicine, Intensive Care and Emergency, University Hospital, Trieste, Italy.
| | - Umberto Lucangelo
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Strada di Fiume 447, 34100 Trieste, Italy; Department of Perioperative Medicine, Intensive Care and Emergency, University Hospital, Trieste, Italy.
| | - Giorgio Berlot
- Clinical Department of Medical, Surgical and Health Sciences, Trieste University, Strada di Fiume 447, 34100 Trieste, Italy; Department of Perioperative Medicine, Intensive Care and Emergency, University Hospital, Trieste, Italy.
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Numeracy and Interpretation of Prognostic Estimates in Intracerebral Hemorrhage Among Surrogate Decision Makers in the Neurologic ICU. Crit Care Med 2019; 46:264-271. [PMID: 29215368 DOI: 10.1097/ccm.0000000000002887] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Clinicians caring for patients with intracerebral hemorrhage must often discuss prognosis and goals of care with their patients' surrogate decision makers, and may make numeric estimates of likelihood of survival and functional independence, informed by validated prediction models. Surrogates' prognostic estimates are often discordant with physicians', suggesting that physicians' numeric statements may not be accurately interpreted. We sought to assess the relationship between numeracy and interpretation of prognostic estimates in intracerebral hemorrhage among surrogate decision makers. We also assessed surrogates' application of prognostic estimates to decisions regarding goals of care. DESIGN Single-center, survey-based, cross-sectional study. SETTING Twenty-two-bed neurologic ICU at an urban, academic hospital. SUBJECTS Surrogate decision makers for patients admitted to the neurologic ICU. INTERVENTIONS Participants completed a survey containing five clinical vignettes describing patients with nontraumatic intracerebral hemorrhage. For each patient, numerical estimates of survival and functional independence were explicitly provided, based on the validated outcome risk stratification scale (intracerebral hemorrhage score) and the Prediction of Functional Outcome in Patients with Primary Intracerebral Hemorrhage score. MEASUREMENTS AND MAIN RESULTS Participants were asked to make their own prognostic estimates, as well as to describe their preferred goals of care for each hypothetical patient. Respondent demographics were collected, and numeracy was assessed using a modified Lipkus 11-item scale. Poor numeracy was common (42 of 96 total subjects) in this relatively highly educated population. Most prognostic estimates (55%) made by surrogates were discordant with the provided estimates. High numeracy correlated with better concordance (odds ratio, 23.9 [5.57-97.64]; p < 0.001), independent of several factors, including level of education and religion. Numeracy also affected goals-of-care decisions made by surrogates. CONCLUSIONS Poor numeracy is common among surrogate decision makers in an intensive care setting and poses a barrier to communication between surrogates and clinicians regarding prognosis and goals of care.
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Krzak AM, Fowles JA, Vuylsteke A. Mobile extracorporeal membrane oxygenation service for severe acute respiratory failure - A review of five years of experience. J Intensive Care Soc 2019; 21:134-139. [PMID: 32489409 DOI: 10.1177/1751143719855207] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Provision of extracorporeal membrane oxygenation as part of support escalation in severe refractory acute respiratory failure in England is provided by five specialist centres that operate within a well-defined quality and safety framework. We conducted a qualitative study of the extracorporeal membrane oxygenation retrieval service provided by one of the five centres. We analysed 176 consecutive debrief reports written between October 2013 and April 2018 by the consultant. Main identified issues were short delays in retrieval predominantly due to insufficient communication or equipment failure. All issues were addressed in subsequent practice. Our results suggest a need for improved communication between the referring intensive care unit and retrieving team. Our findings highlight the value of regular reflection-based evaluation to ensure continued provision of safe and efficient service.
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Affiliation(s)
- Ada M Krzak
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | | | - Alain Vuylsteke
- School of Clinical Medicine, University of Cambridge, Cambridge, UK.,Royal Papworth Hospital, Cambridge, UK
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Bender MA, Andrilla CHA, Sharma RK, Hurd C, Solvang N, Mae-Baldwin L. Moral Distress and Attitudes About Timing Related to Comfort Care for Hospitalized Patients: A Survey of Inpatient Providers and Nurses. Am J Hosp Palliat Care 2019; 36:967-973. [DOI: 10.1177/1049909119843136] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Context: Providing nonbeneficial care at the end of life and delays in initiating comfort care have been associated with provider and nurse moral distress. Objective: Evaluate provider and nurse moral distress when using a comfort care order set and attitudes about timing of initiating comfort care for hospitalized patients. Methods: Cross-sectional survey of providers (physicians, nurse practitioners, and physician assistants) and nurses at 2 large academic hospitals in 2015. Providers and nurses were surveyed about their experiences providing comfort care in an inpatient setting. Results: Two hundred five nurse and 124 provider surveys were analyzed. A greater proportion of nurses compared to providers reported experiencing moral distress “some, most, or all of the time” when using the comfort care order set (40.5% and 19.4%, respectively, P = .002). Over 60% of nurses and providers reported comfort care was generally started too late in a patient’s course, with physician trainees (81.4%), as well as providers (80.9%) and nurses (84.0%) < 5 years from graduating professional school most likely to report that comfort care is generally started too late. Conclusions: The majority of providers and nurses reported that comfort care was started too late in a patient’s course. Nurses experienced higher levels of moral distress than providers when caring for patients using a comfort care order set. Further research is needed to determine what is driving this moral distress in order to tailor interventions for nurses and providers.
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Affiliation(s)
- Melissa A. Bender
- Department of Family Medicine, University of Washington, Seattle, WA, USA
| | | | - Rashmi K. Sharma
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
- Division of General Internal Medicine, University of Washington, Seattle, WA, USA
| | - Caroline Hurd
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
- Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, WA, USA
| | - Nicole Solvang
- University of Washington Medical Center, Seattle, WA, USA
| | - Laura Mae-Baldwin
- Department of Family Medicine, University of Washington, Seattle, WA, USA
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Schwarzkopf D. [Nonbeneficial care-a burden for clinicians and relatives]. Med Klin Intensivmed Notfmed 2019; 114:222-228. [PMID: 30918982 DOI: 10.1007/s00063-019-0531-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 12/14/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Ethically demanding decisions in intensive care as well as the perception of nonbeneficial care can be a burden for clinicians and patients' relatives. OBJECTIVES An overview of prevalence, causes, and consequences of perceived nonbeneficial care and possible interventions is provided. MATERIALS AND METHODS Narrative review. RESULTS AND CONCLUSIONS The perception of nonbeneficial care is a subjective moral judgement. Almost every ICU clinician regularly perceives nonbeneficial care. There is clear evidence that perceived nonbeneficial care is associated with burnout of clinicians and intention to leave the job. For relatives being involved in end-of-life decisions is of particular burden. Clinicians often state that relatives' whishes are the reason for nonbeneficial life-sustaining treatment. A good ethical climate as well as good nurse-physician collaboration are associated with less perception of nonbeneficial care and shorter time to therapy limitations. Structured communication to plan therapy involving relatives might reduce nonbeneficial care and together with supporting interventions reduce staff burnout. Improving communication by consultants in charge has been shown to reduce the burden of relatives. In future, co-treating surgeons must be more strongly involved in interventions.
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Affiliation(s)
- D Schwarzkopf
- Klinik für Anästhesiologie und Intensivmedizin, Center for Sepsis Control and Care, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland.
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The prevalence of perceptions of mismatch between treatment intensity and achievable goals of care in the intensive care unit: a cross-sectional study. Intensive Care Med 2019; 45:459-467. [DOI: 10.1007/s00134-019-05543-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 01/22/2019] [Indexed: 11/26/2022]
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Does Calculated Prognostic Estimation Lead to Different Outcomes Compared With Experience-Based Prognostication in the ICU? A Systematic Review. Crit Care Explor 2019; 1:e0004. [PMID: 32166250 DOI: 10.1097/cce.0000000000000004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Little is known about the impact of providing calculator/guideline based versus clinical experiential-based prognostic estimates to patients/caregivers in the ICU. We sought to determine whether studies have compared types of prognostic estimation in the ICU and associations with outcomes. Data Sources Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, databases searched were PubMed, Embase, Web of Science, and Cochrane Library. The search was run on January 4, 2016, and April 12, 2017. References for included articles were searched. Study Selection Studies meeting the following criteria were included in the analysis: communication of prognostic estimates, a comparator group, and in the adult ICU setting. Data Extraction Titles/abstracts were reviewed by two researchers. We identified 10,704 articles of which 10 met inclusion criteria. Seven of the studies included estimates obtained from calculators/guidelines and three were based on subjective estimation wherein clinicians were asked to estimate prognosis based on experience. Only the seven using calculated/guideline based estimation were used for pooled analysis. Of these, one was a randomized trial, and six were nonrandomized before/after studies. All of the studies communicated the calculated/guideline-based estimates to the clinician. Two studies involved the communication of calculated prognostic estimates to the ICU physicians for all ICU patients. Four included identification of high-risk patients based on guidelines or review of historical local data which triggered a palliative care/ethics consultation, and one study included communication to physicians about guideline based likely outcomes for neurologic recovery for patients with out-of-hospital cardiac arrest survivors. The comparator arm in all studies was usual care without protocolized prognostication. Data Synthesis Included studies were assessed for risk of bias. The most common outcomes measured were hospital mortality; do-not-resuscitate status; and medical ICU length of stay. In pooled analyses, there was an association between calculated/guideline based prognostic estimation and decreased medical ICU length of stay as well as increased do-not-resuscitate status, but no difference in hospital mortality. Conclusions Protocolized assessment of calculator/guideline based prognosis in ICU patients is associated with decreased medical ICU length of stay and increased do-not-resuscitate status but does not have a significant effect on mortality. Future studies should explore how communicating these estimates to physicians changes behaviors including communication to patients/families and whether calculator/guideline based prognostication is associated with improved patient and family rated outcomes.
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Lehnus KS, Fordyce PS, McMillan MW. Ethical dilemmas in clinical practice: a perspective on the results of an electronic survey of veterinary anaesthetists. Vet Anaesth Analg 2019; 46:260-275. [PMID: 30952440 DOI: 10.1016/j.vaa.2018.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/02/2018] [Accepted: 11/13/2018] [Indexed: 12/16/2022]
Abstract
Medical progress has greatly advanced our ability to manage animals with critical and terminal diseases. We now have the ability to sustain life even in the most dire of circumstances. However, the preservation of life may not be synonymous with providing 'quality of life', and worse, could cause unnecessary suffering. Using the results of an electronic survey, we aim to outline and give examples of ethical dilemmas faced by veterinary anaesthetists dealing with critically ill animals, how the impact of these dilemmas could be mitigated, and what thought processes underlie decision-making in such situations.
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Affiliation(s)
- Kristina S Lehnus
- Department of Veterinary Medicine, University of Cambridge, Cambridge, UK
| | - Peter S Fordyce
- Department of Veterinary Medicine, University of Cambridge, Cambridge, UK
| | - Matthew W McMillan
- Department of Veterinary Medicine, University of Cambridge, Cambridge, UK.
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Müller R, Kaiser S. Perceptions of medical futility in clinical practice – A qualitative systematic review. J Crit Care 2018; 48:78-84. [DOI: 10.1016/j.jcrc.2018.08.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 07/24/2018] [Accepted: 08/13/2018] [Indexed: 10/28/2022]
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Ko M, Shim M, Lee SM, Kim Y, Yoon S. Performance of APACHE IV in Medical Intensive Care Unit Patients: Comparisons with APACHE II, SAPS 3, and MPM 0 III. Acute Crit Care 2018; 33:216-221. [PMID: 31723888 PMCID: PMC6849024 DOI: 10.4266/acc.2018.00178] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 08/24/2018] [Accepted: 09/17/2018] [Indexed: 12/20/2022] Open
Abstract
Background In this study, we analyze the performance of the Acute Physiology and Chronic Health Evaluation (APACHE) II, APACHE IV, Simplified Acute Physiology Score (SAPS) 3, and Mortality Probability Model (MPM)0 III in order to determine which system best implements data related to the severity of medical intensive care unit (ICU) patients. Methods The present study was a retrospective investigation analyzing the discrimination and calibration of APACHE II, APACHE IV, SAPS 3, and MPM0 III when used to evaluate medical ICU patients. Data were collected for 788 patients admitted to the ICU from January 1, 2015 to December 31, 2015. All patients were aged 18 years or older with ICU stays of at least 24 hours. The discrimination abilities of the three systems were evaluated using c-statistics, while calibration was evaluated by the Hosmer-Lemeshow test. A severity correction model was created using logistics regression analysis. Results For the APACHE IV, SAPS 3, MPM0 III, and APACHE II systems, the area under the receiver operating characteristic curves was 0.745 for APACHE IV, resulting in the highest discrimination among all four scoring systems. The value was 0.729 for APACHE II, 0.700 for SAP 3, and 0.670 for MPM0 III. All severity scoring systems showed good calibrations: APACHE II (chi-square, 12.540; P=0.129), APACHE IV (chi-square, 6.959; P=0.541), SAPS 3 (chi-square, 9.290; P=0.318), and MPM0 III (chi-square, 11.128; P=0.133). Conclusions APACHE IV provided the best discrimination and calibration abilities and was useful for quality assessment and predicting mortality in medical ICU patients.
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Affiliation(s)
- Mihye Ko
- Seoul National University Hospital, Seoul, Korea
| | - Miyoung Shim
- Seoul National University Hospital, Seoul, Korea
| | - Sang-Min Lee
- Seoul National University Hospital, Seoul, Korea.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yujin Kim
- Seoul National University Hospital, Seoul, Korea
| | - Soyoung Yoon
- Seoul National University Hospital, Seoul, Korea
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Ecarnot F, Meunier-Beillard N, Seronde MF, Chopard R, Schiele F, Quenot JP, Meneveau N. End-of-life situations in cardiology: a qualitative study of physicians' and nurses' experience in a large university hospital. BMC Palliat Care 2018; 17:112. [PMID: 30290818 PMCID: PMC6173879 DOI: 10.1186/s12904-018-0366-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 09/26/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Professional societies call for integration of end-of-life discussions early in the trajectory of heart failure, yet it remains unclear where current practices stand in relation to these recommendations. We sought to describe the perceptions and attitudes of caregivers in cardiology regarding end-of-life situations. METHODS We performed a qualitative study using semi-directive interviews in the cardiology department of a university teaching hospital in France. Physicians, nurses and nurses' aides working full-time in the department at the time of the study were eligible. Participants were asked to describe how they experienced end-of-life situations. Interviews were recorded, transcribed and coded using thematic analysis to identify major and secondary themes. RESULTS All physicians (N = 16)(average age 43.5 ± 13 years), 16 nurses (average age 38.5 ± 7.6 years) and 5 nurses' aides (average age 49 ± 7.8 years) participated. Interviews were held between 30 March and 17 July 2017. The main themes to emerge from the physicians' discourse were the concept of cardiology being a very active discipline, and a very curative frame of mind was prevalent. Communication (with paramedical staff, patients and families) was deemed to be important. Advance directives were thought to be rare, and not especially useful. Nurses also reported communication as a major issue, but their form of communication is bounded by several factors (physicians' prior discourse, legislation). They commonly engage in reconciling: between the approach (curative or palliative) and the reality of the treatment prescribed; performing curative interventions in patients they deem to be dying cases causes them distress. The emergency context prevents nurses from taking the time necessary to engage in end-of-life discussions. They engage in comfort-giving behaviors to maximize patient comfort. CONCLUSION Current perceptions and practices vis-à-vis end-of-life situations in our department are individual, heterogeneous and not yet aligned with recommendations of professional societies.
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Affiliation(s)
- Fiona Ecarnot
- Department of Cardiology, University Hospital Jean Minjoz, 3 Boulevard Fleming, 25000, Besançon, France. .,EA3920, University of Burgundy Franche-Comté, 25000, Besançon, France.
| | - Nicolas Meunier-Beillard
- Department of Intensive Care, François-Mitterrand University Hospital, 14, rue Paul Gaffarel, 21000, Dijon, France.,Department of Sociology, Centre Georges Chevrier UMR 7366 CNRS, University of Burgundy, 21000, Dijon, France
| | - Marie-France Seronde
- Department of Cardiology, University Hospital Jean Minjoz, 3 Boulevard Fleming, 25000, Besançon, France.,EA3920, University of Burgundy Franche-Comté, 25000, Besançon, France
| | - Romain Chopard
- Department of Cardiology, University Hospital Jean Minjoz, 3 Boulevard Fleming, 25000, Besançon, France.,EA3920, University of Burgundy Franche-Comté, 25000, Besançon, France
| | - François Schiele
- Department of Cardiology, University Hospital Jean Minjoz, 3 Boulevard Fleming, 25000, Besançon, France.,EA3920, University of Burgundy Franche-Comté, 25000, Besançon, France
| | - Jean-Pierre Quenot
- Department of Intensive Care, François-Mitterrand University Hospital, 14, rue Paul Gaffarel, 21000, Dijon, France.,Lipness Team, Inserm Research Center LNC-UMR1231 and LabExLipSTIC, University of Burgundy, 21000, Dijon, France.,Inserm CIC 1432, Clinical Epidemiology, University of Burgundy, 21000, Dijon, France
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Jean Minjoz, 3 Boulevard Fleming, 25000, Besançon, France.,EA3920, University of Burgundy Franche-Comté, 25000, Besançon, France
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Jesus JE, Marshall KD, Kraus CK, Derse AR, Baker EF, McGreevy J. Should Emergency Department Patients with End-of-Life Directives be Admitted to the ICU? J Emerg Med 2018; 55:435-440. [PMID: 30054156 DOI: 10.1016/j.jemermed.2018.06.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 05/17/2018] [Accepted: 06/05/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Whether emergency physicians should utilize critical care resources for patients with advance care planning directives is a complex question. Because the cost of intensive care unit (ICU)-level care, in terms of human suffering and financial burden, can be considerable, ICU-level care ought to be provided only to those patients who would consent and who would benefit from it. OBJECTIVES In this article, we discuss the interplay between clinical indications, patient preferences, and advance care directives, and make recommendations about what the emergency physician must consider when deciding whether a patient with an advance care planning document should be admitted to the ICU. DISCUSSION Although some patients may wish to avoid certain aggressive or invasive measures available in an ICU, there may be a tendency, reinforced by recent Society of Critical Care Medicine guidelines, to presume that such patients will not benefit as much as other patients from the specialized care of the ICU. The ICU still may be the most appropriate setting for hospitalization to access care outside of the limitations set forward in those end-of-life care directives. On the other hand, ICU beds are a scarce and expensive resource that may offer aggressive treatments that can inflict suffering onto patients unlikely to benefit from them. Goals-of-care discussions are critical to align patient end-of-life care preferences with hospital resources, and therefore, the appropriateness of ICU disposition. CONCLUSIONS End-of-life care directives should not automatically exclude patients from the ICU. Rather, ICU admission should be based upon the alignment of uniquely beneficial treatment offered by the ICU and patients' values and stated goals of care.
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Affiliation(s)
| | | | | | | | - Eileen F Baker
- University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
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Ong CJ, Dhand A, Diringer MN. Early Withdrawal Decision-Making in Patients with Coma After Cardiac Arrest: A Qualitative Study of Intensive Care Clinicians. Neurocrit Care 2017; 25:258-65. [PMID: 27112149 DOI: 10.1007/s12028-016-0275-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Neurologists are often asked to define prognosis in comatose patients. However, comatose patients following cardiac arrest are usually cared for by cardiologists or intensivists, and it is their approach that will influence decisions regarding withdrawal of life-sustaining interventions (WLSI). We observed that factors leading to these decisions vary across specialties and considered whether they could result in self-fulfilling prophecies and early WLSI. We conducted a hypothesis-generating qualitative study to identify factors used by non-neurologists to define prognosis in these patients and construct an explanatory model for how early WLSI might occur. METHODS This was a single-center qualitative study of intensivists caring for cardiac arrest patients with hypoxic-ischemic coma. Thirty attending physicians (n = 16) and fellows (n = 14) from cardiac (n = 8), medical (n = 6), surgical (n = 10), and neuro (n = 6) intensive care units underwent semi-structured interviews. Interview transcripts were analyzed using grounded theory techniques. RESULTS We found three components of early WLSI among non-neurointensivists: (1) development of fixed negative opinions; (2) early framing of poor clinical pictures to families; and (3) shortened windows for judging recovery potential. In contrast to neurointensivists, non-neurointensivists' negative opinions were frequently driven by patients' lack of consciousness and cardiopulmonary resuscitation circumstances. Both groups were influenced by age and comorbidities. CONCLUSIONS The results demonstrate that factors influencing prognostication differ across specialties. Some differ from those recommended by published guidelines and may lead to self-fulfilling prophecies and early WLSI. Better understanding of this framework would facilitate educational interventions to mitigate this phenomenon and its implications on patient care.
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Affiliation(s)
- Charlene J Ong
- Department of Neurology, Washington University School of Medicine, 660 South Euclid Avenue, Box 8111, St. Louis, MO, 63110, USA.
| | - Amar Dhand
- Department of Neurology, Washington University School of Medicine, 660 South Euclid Avenue, Box 8111, St. Louis, MO, 63110, USA
| | - Michael N Diringer
- Department of Neurology, Washington University School of Medicine, 660 South Euclid Avenue, Box 8111, St. Louis, MO, 63110, USA
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Oeyen S, Vermeulen K, Benoit D, Annemans L, Decruyenaere J. Development of a prediction model for long-term quality of life in critically ill patients. J Crit Care 2017; 43:133-138. [PMID: 28892669 DOI: 10.1016/j.jcrc.2017.09.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 08/22/2017] [Accepted: 09/02/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE We developed a prediction model for quality of life (QOL) 1 year after intensive care unit (ICU) discharge based upon data available at the first ICU day to improve decision-making. METHODS The database of a 1-year prospective study concerning long-term outcome and QOL (assessed by EuroQol-5D) in critically ill adult patients consecutively admitted to the ICU of a university hospital was used. Cases with missing data were excluded. Utility indices at baseline (UIb) and at 1 year (UI1y) were surrogates for QOL. For 1-year non-survivors UI1y was set at zero. The grouped lasso technique selected the most important variables in the prediction model. R2 and adjusted R2 were calculated. RESULTS 1831 of 1953 cases (93.8%) were complete. UI1y depended significantly on: UIb (P<0.001); solid tumor (P<0.001); age (P<0.001); activity of daily living (P<0.001); imaging (P<0.001); APACHE II-score (P=0.001); ≥80 years (P=0.001); mechanical ventilation (P=0.006); hematological patient (P=0.007); SOFA-score (P=0.008); tracheotomy (P=0.018); admission diagnosis surgical P<0.001 (versus medical); and comorbidity (P=0.049). Only baseline health status and surgical patients were positively associated with UI1y. R2 was 0.3875 and adjusted R2 0.3807. CONCLUSION Although only 40% of variability in long-term QOL could be explained, this prediction model can be helpful in decision-making.
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Affiliation(s)
- Sandra Oeyen
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; Department of Intensive Care, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium.
| | - Karel Vermeulen
- Faculty of Bioscience Engineering, Department of Mathematical Modelling, Statistics and Bioinformatics, Ghent University, Coupure Links 653, 9000 Ghent, Belgium.
| | - Dominique Benoit
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; Department of Intensive Care, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium.
| | - Lieven Annemans
- Faculty of Medicine and Health Sciences, Department of Public Health, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium.
| | - Johan Decruyenaere
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; Department of Intensive Care, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium.
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Tarapore PE, Vassar MJ, Cooper S, Lay T, Galletly J, Manley GT, Huang MC. Establishing a Traumatic Brain Injury Program of Care: Benchmarking Outcomes after Institutional Adoption of Evidence-Based Guidelines. J Neurotrauma 2016; 33:2026-2033. [DOI: 10.1089/neu.2015.4114] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Phiroz E. Tarapore
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
- Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
| | - Mary J. Vassar
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
- Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
| | - Shelly Cooper
- Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
| | - Twyila Lay
- Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
| | - Julia Galletly
- Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
- School of Nursing, University of California San Francisco, San Francisco, California
| | - Geoffrey T. Manley
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
- Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
| | - Michael C. Huang
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
- Brain and Spinal Injury Center, San Francisco General Hospital, San Francisco, California
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Validation and Extension of the Prolonged Mechanical Ventilation Prognostic Model (ProVent) Score for Predicting 1-Year Mortality after Prolonged Mechanical Ventilation. Ann Am Thorac Soc 2016; 12:1845-51. [PMID: 26418231 DOI: 10.1513/annalsats.201504-200oc] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Prognostic models can inform management decisions for patients requiring prolonged mechanical ventilation. The Prolonged Mechanical Ventilation Prognostic model (ProVent) score was developed to predict 1-year mortality in these patients. External evaluation of such models is needed before they are adopted for routine use. OBJECTIVES The goal was to perform an independent external validation of the modified ProVent score and assess for spectrum extension at 14 days of mechanical ventilation. METHODS This was a retrospective cohort analysis of patients who received prolonged mechanical ventilation at the University of Iowa Hospitals. Patients who received 14 or more days of mechanical ventilation were identified from a database. Manual review of their medical records was performed to abstract relevant data including the four model variables at Days 14 and 21 of mechanical ventilation. Vital status at 1 year was checked in the medical records or the social security death index. Logistic regressions examined the associations between the different variables and mortality. Model performance at 14 to 20 days and 21+ days was assessed for discrimination by calculating the area under the receiver operating characteristic curve, and calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test. MEASUREMENTS AND MAIN RESULTS A total of 180 patients (21+ d) and 218 patients (14-20 d) were included. Overall, 75% were surgical patients. One-year mortality was 51% for 21+ days and 32% for 14 to 20 days of mechanical ventilation. Age greater than 65 years was the strongest predictor of mortality at 1 year in all cohorts. There was no significant difference between predicted and observed mortality rates for patients stratified by ProVent score. There was near-perfect specificity for mortality in the groups with higher ProVent scores. Areas under the curve were 0.69 and 0.75 for the 21+ days and the 14 to 20 days cohorts respectively. P values for the Hosmer-Lemeshow statistics were 0.24 for 21+ days and 0.22 for 14 to 20 days. CONCLUSIONS The modified ProVent model was accurate in our cohort. This supports its geographic and temporal generalizability. It can also accurately identify patients at risk of 1-year mortality at Day 14 of mechanical ventilation, but additional confirmation is required. Further studies should explore the implications of adopting the model into routine use.
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Nielson C, Wingett D. Intensive care and invasive ventilation in the elderly patient, implications of chronic lung disease and comorbidities. Chron Respir Dis 2016; 1:43-54. [PMID: 16281668 DOI: 10.1191/1479972304cd012rs] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Aims: Elderly patients have an increasing prevalence of illness that requires consideration of critical care and invasive ventilatory support. Although critical care of even the very elderly can provide value, with increasing age the potential risks of treatment and diminishing returns with respect to quality and quantity of life result in a need for careful evaluation. Variable combinations of impaired organ function, active disease and residual pathology from past disease and injury all affect critical care, with the consequence that the elderly are a very heterogeneous population. Recognizing that critical care is a limited resource, it is important to identify patients who may be at increased risk or least likely to benefit from treatment. Patients with functional impairments, nutritional deficiencies and multiple comorbidities may be at highest risk of poor outcomes. Those with very severe disease, extreme age and requirements for prolonged ventilatory support have high in-hospital mortality. Functional impairments, comorbidities and severity of illness are usually more important considerations than chronologic age. The objective of this review is to identify how common problems of the elderly affect critical care and decisions concerning use of invasive ventilatory support.
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The conceptualisation of health-related quality of life in decision-making by intensive care physicians: A qualitative inquiry. Aust Crit Care 2016; 30:152-159. [PMID: 27595412 DOI: 10.1016/j.aucc.2016.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 08/15/2016] [Accepted: 08/16/2016] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVES To explore how intensive care physicians conceptualise and prioritise patient health-related quality of life in their decision-making. RESEARCH METHODOLOGY/DESIGN General qualitative inquiry using elements of Grounded Theory. Six ICU physicians participated. SETTING A large, closed, mixed ICU at a university-affiliated hospital, Australia. RESULTS Three themes emerged: (1) Multi-dimensionality of HRQoL-HRQoL was described as difficult to understand; the patient was viewed as the best informant. Proxy information on HRQoL and health preferences was used to direct clinical care, despite not always being trusted. (2) Prioritisation of HRQoL within decision-making-this varied across the patient's health care trajectory. Premorbid HRQoL was prioritised when making admission decisions and used to predict future HRQoL. (3) Role of physician in decision-making-the physicians described their role as representing society with peers influencing their decision-making. All participants considered their practice to be similar to their peers, referring to their practice as the "middle of the road". This is a novel finding, emphasising other important influences in high-stakes decision-making. CONCLUSION Critical care physicians conceptualised HRQoL as a multi-dimensional subjective construct. Patient (or proxy) voice was integral in establishing patient HRQoL and future health preferences. HRQoL was important in high stakes decision-making including initiating invasive and burdensome therapies or in redirecting therapeutic goals.
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Dupuis JY. Clinical Predictions and Decisions to Perform Cardiac Surgery on High-Risk Patients. Semin Cardiothorac Vasc Anesth 2016; 9:179-86. [PMID: 15920646 DOI: 10.1177/108925320500900214] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The proportion of high-risk patients undergoing cardiac surgery has increased steadily over the last two decades. Many of those patients have a catastrophic postoperative course and use hospital resources in a proportion that largely outweighs their number. Consequently, the appropriateness of invasive and intensive interventions in those patients has been questioned. If futility of care were predictable preoperatively, cardiac surgery would probably be denied to many highrisk patients. Logistic regression has been used to develop many complex predictive models to identify high-risk patients and predict their outcome; however, those models do not provide much more discrimination than clinical judgment alone. Moreover, with continuous improvement in medical care all risk models lose their calibration over time. As a result, they often overestimate the probabilities of poor outcome in the individual patients. Many high-risk cardiac surgical patients require a prolonged stay in the intensive care unit (ICU). The analysis of small cohorts of patients who had a prolonged postoperative stay in the ICU shows that 50% and 40% of them are still alive at 1- and 2-year follow-up, respectively; and most survivors report a good quality of life. Considering the limitations of predictive risk models and the satisfaction of cardiac surgical patients who survive after a prolonged ICU stay, it is reasonable to recognize that cardiac surgery should rarely be denied to high-risk patients unless technically unfeasible, and clinical predictions should have only a marginal role in the decision to operate on those patients.
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Affiliation(s)
- Jean-Yves Dupuis
- Cardiac Division of Anesthesiology, University of Ottawa Heart Institute, Ontario, Canada.
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Dahine J, Mardini L, Jayaraman D. The Perceived Likelihood of Outcome of Critical Care Patients and Its Impact on Triage Decisions: A Case-Based Survey of Intensivists and Internists in a Canadian, Quaternary Care Hospital Network. PLoS One 2016; 11:e0149196. [PMID: 26871587 PMCID: PMC4752246 DOI: 10.1371/journal.pone.0149196] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Accepted: 01/28/2016] [Indexed: 11/18/2022] Open
Abstract
Introduction There is high variability amongst physicians’ assessments of appropriate ICU admissions, which may be based on potential assessments of benefit. We aimed to examine whether opinions over benefit of ICU admissions of critically ill medical inpatients differed based on physician specialty, namely intensivists and internists. Materials and Methods We carried out an anonymous, web-based questionnaire survey containing 5 typical ICU cases to all ICU physicians regardless of their base specialty as well as to all internists in 3 large teaching hospitals. For each case, we asked the participants to determine if the patient was an appropriate ICU admission and to assess different parameters (e.g. baseline function, likelihood of survival to ICU discharge, etc.). Agreement was measured using kappa values. Results 21 intensivists and 22 internists filled out the survey (response rate = 87.5% and 35% respectively). Predictions of likelihood of survival to ICU admission, hospital discharge and return to baseline were not significantly different between the two groups. However, agreement between individuals within each group was only slight to fair (kappa range = 0.09–0.22). There was no statistically significant difference in predicting ICU survival and prediction of survival to hospital discharge between both groups. The accuracy with which physicians predicted actual outcomes ranged between 35% and 100% and did not significantly differ between the two groups. A greater proportion of internists favoured non resuscitative measures (24.6% of intensivists and 46.9% internists [p = 0.002]). Conclusion In a case-based survey, physician specialty base did not affect assessments of ICU admission benefit or accuracy in outcome prediction, but resulted in a statistically significant difference in level of care assignments. Of note, significant disagreement amongst individuals in each group was found.
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Affiliation(s)
- Joseph Dahine
- Department of Critical Care, Royal Victoria Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Louay Mardini
- Department of Critical Care, Royal Victoria Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Dev Jayaraman
- Department of Critical Care, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
- Department of General Internal Medicine, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
- Department of Critical Care, Jewish General Hospital, Montreal, Quebec, Canada
- * E-mail:
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Davies H, McKenzie N, Williams TA, Leslie GD, McConigley R, Dobb GJ, Aoun SM. Challenges during long-term follow-up of ICU patients with and without chronic disease. Aust Crit Care 2016; 29:27-34. [DOI: 10.1016/j.aucc.2015.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Revised: 04/08/2015] [Accepted: 04/15/2015] [Indexed: 11/30/2022] Open
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Coombs MA, Darlington ASE, Long-Sutehall T, Pattison N, Richardson A. Transferring patients home to die: what is the potential population in UK critical care units? BMJ Support Palliat Care 2015; 7:98-101. [PMID: 26628534 PMCID: PMC5339543 DOI: 10.1136/bmjspcare-2014-000834] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 09/02/2015] [Accepted: 11/12/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Most people when asked, express a preference to die at home, but little is known about whether this is an option for critically ill patients. A retrospective cohort study was undertaken to describe the size and characteristics of the critical care population who could potentially be transferred home to die if they expressed such a wish. METHODS Medical notes of all patients who died in, or within 5 days of discharge from seven critical care units across two hospital sites over a 12-month period were reviewed. Inclusion/exclusion criteria were developed and applied to identify the number of patients who had potential to be transferred home to die and demographic and clinical data (eg, conscious state, respiratory and cardiac support therapies) collected. RESULTS 7844 patients were admitted over a 12-month period. 422 (5.4%) patients died. Using the criteria developed 100 (23.7%) patients could have potentially been transferred home to die. Of these 41 (41%) patients were diagnosed with respiratory disease. 53 (53%) patients were conscious, 47 (47%) patients were self-ventilating breathing room air/oxygen via a mask. 20 (20%) patients were ventilated via an endotracheal tube. 76 (76%) patients were not requiring inotropes/vasopressors. Mean time between discussion about treatment withdrawal and time of death was 36.4 h (SD=46.48). No patients in this cohort were transferred home. CONCLUSIONS A little over 20% of patients dying in critical care demonstrate potential to be transferred home to die. Staff should actively consider the practice of transferring home as an option for care at end of life for these patients.
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Affiliation(s)
- Maureen A Coombs
- Graduate School of Nursing, Midwifery and Health, Victoria University of Wellington, Wellington, New Zealand
| | | | | | | | - Alison Richardson
- Faculty of Health Sciences, University of Southampton, Southampton, UK
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Signorini G, Dagani J, Bulgari V, Ferrari C, de Girolamo G. Moderate efficiency of clinicians' predictions decreased for blurred clinical conditions and benefits from the use of BRASS index. A longitudinal study on geriatric patients' outcomes. J Clin Epidemiol 2015; 69:51-60. [PMID: 26358666 DOI: 10.1016/j.jclinepi.2015.08.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 07/10/2015] [Accepted: 08/28/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Accurate prognosis is an essential aspect of good clinical practice and efficient health services, particularly for chronic and disabling diseases, as in geriatric populations. This study aims to examine the accuracy of clinical prognostic predictions and to devise prediction models combining clinical variables and clinicians' prognosis for a geriatric patient sample. STUDY DESIGN AND SETTING In a sample of 329 consecutive older patients admitted to 10 geriatric units, we evaluated the accuracy of clinicians' prognosis regarding three outcomes at discharge: global functioning, length of stay (LoS) in hospital, and destination at discharge (DD). A comprehensive set of sociodemographic, clinical, and treatment-related information were also collected. RESULTS Moderate predictive performance was found for all three outcomes: area under receiver operating characteristic curve of 0.79 and 0.78 for functioning and LoS, respectively, and moderate concordance, Cohen's K = 0.45, between predicted and observed DD. Predictive models found the Blaylock Risk Assessment Screening Score together with clinicians' judgment relevant to improve predictions for all outcomes (absolute improvement in adjusted and pseudo-R(2) up to 19%). CONCLUSION Although the clinicians' estimates were important factors in predicting global functioning, LoS, and DD, more research is needed regarding both methodological aspects and clinical measurements, to improve prognostic clinical indices.
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Affiliation(s)
- Giulia Signorini
- Psychiatric Epidemiology and Evaluation Unit, Saint John of God Clinical Research Centre, Via Pilastroni 4, Brescia, Italy
| | - Jessica Dagani
- Psychiatric Epidemiology and Evaluation Unit, Saint John of God Clinical Research Centre, Via Pilastroni 4, Brescia, Italy
| | - Viola Bulgari
- Psychiatric Epidemiology and Evaluation Unit, Saint John of God Clinical Research Centre, Via Pilastroni 4, Brescia, Italy
| | - Clarissa Ferrari
- Psychiatric Epidemiology and Evaluation Unit, Saint John of God Clinical Research Centre, Via Pilastroni 4, Brescia, Italy
| | - Giovanni de Girolamo
- Psychiatric Epidemiology and Evaluation Unit, Saint John of God Clinical Research Centre, Via Pilastroni 4, Brescia, Italy.
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Conway Morris A. Triage during pandemic influenza: seeking absolution in numbers? Br J Anaesth 2015; 114:865-7. [PMID: 25991740 DOI: 10.1093/bja/aev141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Affiliation(s)
- A Conway Morris
- Division of Anaesthesia, University of Cambridge, Box 93, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
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Hutchison PJ. POINT: Do Physicians Have a Responsibility to Provide Recommendations Regarding Goals of Care to Surrogates of Dying Patients in the ICU? Yes. Chest 2015; 147:1453-5. [DOI: 10.1378/chest.15-0273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Weir CR, Staggers N, Gibson B, Doing-Harris K, Barrus R, Dunlea R. A qualitative evaluation of the crucial attributes of contextual information necessary in EHR design to support patient-centered medical home care. BMC Med Inform Decis Mak 2015; 15:30. [PMID: 25881181 PMCID: PMC4416274 DOI: 10.1186/s12911-015-0150-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 03/25/2015] [Indexed: 11/14/2022] Open
Abstract
Background Effective implementation of a Primary Care Medical Home model of care (PCMH) requires integration of patients’ contextual information (physical, mental, social and financial status) into an easily retrievable information source for the healthcare team and clinical decision-making. This project explored clinicians’ perceptions about important attributes of contextual information for clinical decision-making, how contextual information is expressed in CPRS clinical documentation as well as how clinicians in a highly computerized environment manage information flow related to these areas. Methods A qualitative design using Cognitive Task Analyses and a modified Critical Incident Technique were used. The study was conducted in a large VA with a fully implemented EHR located in the western United States. Seventeen providers working in a PCMH model of care in Primary Care, Home Based Care and Geriatrics reported on a recent difficult transition requiring contextual information for decision-making. The transcribed interviews were qualitatively analyzed for thematic development related to contextual information using an iterative process and multiple reviewers with ATLAS@ti software. Results Six overarching themes emerged as attributes of contextual information: Informativeness, goal language, temporality, source attribution, retrieval effort, and information quality. Conclusions These results indicate that specific attributes are needed to in order for contextual information to fully support clinical decision-making in a Medical Home care delivery environment. Improved EHR designs are needed for ease of contextual information access, displaying linkages across time and settings, and explicit linkages to both clinician and patient goals. Implications relevant to providers’ information needs, team functioning and EHR design are discussed.
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Affiliation(s)
- Charlene R Weir
- VA HSR&D Informatics and Decision Enhancement Center of Innovation (IDEAS), 500 Foothill Blvd, Salt Lake City, UT, 84108, USA. .,Department of Biomedical Informatics, School of Medicine, University of Utah, Suite 208, 421 Wakara Way, Salt Lake City, 84108, UT, USA.
| | - Nancy Staggers
- School of Nursing, University of Maryland, 522 West Lombard Street, Baltimore, MD 21201, USA
| | - Bryan Gibson
- VA HSR&D Informatics and Decision Enhancement Center of Innovation (IDEAS), 500 Foothill Blvd, Salt Lake City, UT, 84108, USA.,Division of Epidemiology, School of Medicine, University of Utah, 295 Chipeta Way, Salt Lake City, Utah, 84132, USA
| | - Kristina Doing-Harris
- Department of Biomedical Informatics, School of Medicine, University of Utah, Suite 208, 421 Wakara Way, Salt Lake City, 84108, UT, USA
| | - Robyn Barrus
- VA HSR&D Informatics and Decision Enhancement Center of Innovation (IDEAS), 500 Foothill Blvd, Salt Lake City, UT, 84108, USA
| | - Robert Dunlea
- Department of Biomedical Informatics, School of Medicine, University of Utah, Suite 208, 421 Wakara Way, Salt Lake City, 84108, UT, USA
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Coombs M. A scoping review of family experience and need during end of life care in intensive care. Nurs Open 2015; 2:24-35. [PMID: 27708798 PMCID: PMC5047309 DOI: 10.1002/nop2.14] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 02/02/2015] [Indexed: 11/07/2022] Open
Abstract
AIM To scope systematically and collate qualitative studies on family experience and need during end of life care in intensive care, from the perspective of family members. DESIGN Scoping review of qualitative research. METHODS Standardized processes of study identification, data extraction and data synthesis were used. Multiple bibliographic databases were accessed during 2011 and updated in 2013. RESULTS From an initial 876 references, 16 studies were identified for inclusion. These were predominantly single site, North American studies that explored issues relating to the temporal stages in the end of life trajectory and the requirement for information and emotional support at end of life. With a strong focus on family need and experience during the transition from active treatment to end of life care, more work is required to understand how doctors and nurses can support families from treatment withdrawal through to death.
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Affiliation(s)
- Maureen Coombs
- Graduate School of Nursing Midwifery and Health Victoria University Wellington Wellington 6242 New Zealand; Capital and Coast District Health Board Wellington Regional Hospital Wellington 6242 New Zealand
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