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Jennerich AL. An Approach to Caring for Patients and Family of Patients Dying in the ICU. Chest 2024; 166:127-135. [PMID: 38354905 DOI: 10.1016/j.chest.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 01/10/2024] [Accepted: 02/07/2024] [Indexed: 02/16/2024] Open
Abstract
TOPIC IMPORTANCE Death is common in the ICU and often occurs after a decision to withhold or withdraw life-sustaining therapies. Care of the dying is a core skill for ICU clinicians, requiring expert communication, primarily with family of critically ill patients. REVIEW FINDINGS Limited high-quality evidence supports specific practices related to the care of dying patients in the ICU; thus, many of the recommendations that exist are based on expert opinion. Value exists in sharing a practical approach to caring for patients during the dying process, including topics to be addressed with family members, rationales for recommended care, and strategies for implementing comfort measures only. Through dedicated preparation and planning, clinicians can help family members navigate this intense experience. SUMMARY After a decision had been made to discontinue life-sustaining therapies, family members need to be given a clear description of comfort measures only and provided with additional detail about what it entails, including therapies or interventions to be discontinued, monitoring during the dying process, and common features of the dying process. Order sets can be a valuable resource for ensuring that adequate analgesia and sedation are available and the care plan is enacted properly. To achieve a good death for patients, a collaborative effort among members of the care team is essential.
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Affiliation(s)
- Ann L Jennerich
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, and the Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA.
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Takahashi Y, Utsumi S, Fujizuka K, Suzuki H, Nakamura M. Factors associated with healthcare providers' satisfaction with end-of-life care in the intensive care unit: A systematic review. Anaesth Crit Care Pain Med 2024; 43:101330. [PMID: 37984633 DOI: 10.1016/j.accpm.2023.101330] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 11/14/2023] [Accepted: 11/14/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND We aimed to synthesize published data on and identify factors associated with healthcare providers' satisfaction with end-of-life care for critically ill adults. METHODS Electronic databases were searched from inception to January 23, 2023. We included trials involving adults admitted to intensive care units (ICUs) or high-dependency units to evaluate palliative care interventions. STUDY SELECTION The inclusion criteria were as follows: 1) Adult patients (age ≥18 years) or their family members admitted to the ICU or a high-dependency unit; 2) ICU palliative care interventions; 3) Randomized and non-randomized controlled trials; and 4) Full-text, peer-reviewed articles published in English. Two reviewers screened and extracted the data and assessed bias risk. The primary outcome was an improvement in the healthcare providers' satisfaction based on the validated scales. RESULTS Out of 12 studies, 9 investigated combined dimension intervention. Healthcare providers' satisfaction improved in 6/7 (85.7%) of the studies testing educational intervention, 5/7 (71.4%) studies testing the effectiveness of palliative care team involvement, 4/5 (80%) of studies testing communication interventions, while 0/2 (0%) study testing ethic consultations. CONCLUSIONS Most of the tested palliative care interventions were associated with improved healthcare provider satisfaction in intensive care units. The impacts of such intervention on mental health and burden remain to be investigated in this field.
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Affiliation(s)
- Yoshihiko Takahashi
- Advanced Medical Emergency Department and Critical Care Centre, Maebashi Red Cross Hospital, Gunma, Japan
| | - Shu Utsumi
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
| | - Kenji Fujizuka
- Advanced Medical Emergency Department and Critical Care Centre, Maebashi Red Cross Hospital, Gunma, Japan
| | - Hiroyuki Suzuki
- Advanced Medical Emergency Department and Critical Care Centre, Maebashi Red Cross Hospital, Gunma, Japan
| | - Mitsunobu Nakamura
- Advanced Medical Emergency Department and Critical Care Centre, Maebashi Red Cross Hospital, Gunma, Japan
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Tripathi S, Laksana E, McCrory MC, Hsu S, Zhou AX, Burkiewicz K, Ledbetter DR, Aczon MD, Shah S, Siegel L, Fainberg N, Morrow KR, Avesar M, Chandnani HK, Shah J, Pringle C, Winter MC. Analgesia and Sedation at Terminal Extubation: A Secondary Analysis From Death One Hour After Terminal Extubation Study Data. Pediatr Crit Care Med 2023; 24:463-472. [PMID: 36877028 DOI: 10.1097/pcc.0000000000003209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
OBJECTIVES To describe the doses of opioids and benzodiazepines administered around the time of terminal extubation (TE) to children who died within 1 hour of TE and to identify their association with the time to death (TTD). DESIGN Secondary analysis of data collected for the Death One Hour After Terminal Extubation study. SETTING Nine U.S. hospitals. PATIENTS Six hundred eighty patients between 0 and 21 years who died within 1 hour after TE (2010-2021). MEASUREMENTS AND MAIN RESULTS Medications included total doses of opioids and benzodiazepines 24 hours before and 1 hour after TE. Correlations between drug doses and TTD in minutes were calculated, and multivariable linear regression performed to determine their association with TTD after adjusting for age, sex, last recorded oxygen saturation/F io2 ratio and Glasgow Coma Scale score, inotrope requirement in the last 24 hours, and use of muscle relaxants within 1 hour of TE. Median age of the study population was 2.1 years (interquartile range [IQR], 0.4-11.0 yr). The median TTD was 15 minutes (IQR, 8-23 min). Forty percent patients (278/680) received either opioids or benzodiazepines within 1 hour after TE, with the largest proportion receiving opioids only (23%, 159/680). Among patients who received medications, the median IV morphine equivalent within 1 hour after TE was 0.75 mg/kg/hr (IQR, 0.3-1.8 mg/kg/hr) ( n = 263), and median lorazepam equivalent was 0.22 mg/kg/hr (IQR, 0.11-0.44 mg/kg/hr) ( n = 118). The median morphine equivalent and lorazepam equivalent rates after TE were 7.5-fold and 22-fold greater than the median pre-extubation rates, respectively. No significant direct correlation was observed between either opioid or benzodiazepine doses before or after TE and TTD. After adjusting for confounding variables, regression analysis also failed to show any association between drug dose and TTD. CONCLUSIONS Children after TE are often prescribed opioids and benzodiazepines. For patients dying within 1 hour of TE, TTD is not associated with the dose of medication administered as part of comfort care.
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Affiliation(s)
- Sandeep Tripathi
- Pediatric Intensive Care, OSF HealthCare, Children's Hospital of Illinois/University of Illinois College of Medicine, Peoria, IL
| | - Eugene Laksana
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Michael C McCrory
- Departments of Anesthesiology and Pediatrics, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Stephanie Hsu
- Division of Critical Care Medicine, Children's Health Medical Center Dallas, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Alice X Zhou
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Kimberly Burkiewicz
- Pediatric Intensive Care, OSF HealthCare, Children's Hospital of Illinois/University of Illinois College of Medicine, Peoria, IL
| | - David R Ledbetter
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Melissa D Aczon
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Sareen Shah
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Division of Critical Care, Department of Pediatrics, Cohen Children's Medical Center, Long Island, NY
| | - Linda Siegel
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Division of Critical Care, Department of Pediatrics, Cohen Children's Medical Center, Long Island, NY
| | - Nina Fainberg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Katie R Morrow
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Michael Avesar
- Division of Pediatric Critical Care Medicine, Loma Linda University Children's Hospital, Loma Linda, CA
| | - Harsha K Chandnani
- Division of Pediatric Critical Care Medicine, Loma Linda University Children's Hospital, Loma Linda, CA
| | - Jui Shah
- Division of Pediatric Critical Care Medicine, Loma Linda University Children's Hospital, Loma Linda, CA
| | - Charlene Pringle
- Department of Pediatrics, Critical Care Medicine, University of Florida, Gainesville, FL
| | - Meredith C Winter
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
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Kemery SA. Family perceptions of quality of end of life in LGBTQ+ individuals: a comparative study. Palliat Care Soc Pract 2022; 15:2632352421997153. [PMID: 35156039 PMCID: PMC8826269 DOI: 10.1177/2632352421997153] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 01/27/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Members of the lesbian, gay, bisexual, transgender, and
queer community have encountered discrimination and stigmatization related
to sexual orientation and/or gender identity both within healthcare
establishments and in the larger community. Despite the literature
describing inequities in healthcare, very little published research exists
on the experiences of lesbian, gay, bisexual, transgender, and queer
patients and family members in hospice care. Methods: A quantitative comparative descriptive design explored
the difference in end-of-life experiences between a lesbian, gay, bisexual,
transgender, and queer and non-lesbian, gay, bisexual, transgender, and
queer cohort. One hundred and twenty-two family members of individuals who
have died while under hospice care in the past 5 years completed the Quality
of Dying and Death Version 3.2a Family Member/Friend After-Death
Self-Administered Questionnaire. Results: Comparison of the experiences of the lesbian, gay,
bisexual, transgender, and queer cohort (n = 56) and
non-LGBTQ cohort (n = 66) yielded varying results, with the
LGBTQ cohort experiencing lower quality end of life in some Quality of Dying
and Death measures and no statistically significant difference from the
non-LGBTQ cohort in others. Discussion: The findings from this study in combination with
previously published works on lesbian, gay, bisexual, transgender, and queer
health support the position that hospice providers must take concrete steps
to ensure that professional caregivers and office staff are qualified to
meet the needs of this marginalized population.
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Affiliation(s)
- S Alexander Kemery
- Assistant Professor, School of Nursing, University of Indianapolis, Indianapolis, IN 46227, USA
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Wang Y, Liu M, Chan WCH, Zhou J, Chi I. Validation of the Quality of Dying and Death Questionnaire among the Chinese populations. Palliat Support Care 2021; 19:694-701. [PMID: 36942576 DOI: 10.1017/s1478951521001413] [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: 11/07/2022]
Abstract
OBJECTIVE This study reports the evaluation of the original 31-item Quality of Dying and Death Questionnaire (QODD) using a sample of caregivers of recently deceased older adults in China, and the validation of a shortened version (QODD-C) derived from the original scale. METHODS The translation was performed using a forward and back method. The full scale was tested with 212 caregivers of decedents in four regions of China. Confirmatory factor analysis tested the model fit between the full Chinese version and the original conceptual model and generated the QODD-C. The psychometric analysis was performed to evaluate the QODD-C's internal consistency, content validity, construct validity, and discriminant validity. RESULTS A five-domain, 18-item QODD-C was identified with excellent internal consistency reliability (Cronbach's α = 0.933; split-half Pearson's value = 0.855). The QODD-C total score was significantly associated with constructs related to five domains. The caregiver's relationship with the decedent, the decedent's age at death, death reason, and death place was significantly associated with the QODD-C total score. SIGNIFICANCE OF RESULTS The QODD-C is a valid and reliable instrument for assessing the quality of dying and death among the Chinese populations.
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Affiliation(s)
- Ying Wang
- School of Philosophy and Sociology, Lanzhou University, Lanzhou, China
| | - Mandong Liu
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA
- Edward R. Roybal Institute on Aging, University of Southern California, Los Angeles, CA
| | - Wallace Chi Ho Chan
- Department of Social Work, Chinese University of Hong Kong, New Territories, Hong Kong
| | - Jing Zhou
- School of Law, Shanghai Lixin University of Accounting and Finance, Shanghai, China
| | - Iris Chi
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA
- Edward R. Roybal Institute on Aging, University of Southern California, Los Angeles, CA
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Reinink H, Geurts M, Melis-Riemens C, Hollander A, Kappelle J, van der Worp B. Quality of dying after acute stroke. Eur Stroke J 2021; 6:268-275. [PMID: 34746423 PMCID: PMC8564161 DOI: 10.1177/23969873211041843] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 08/06/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction There is a lack of evidence concerning the palliative needs of patients with
acute stroke during end-of-life care. We interviewed relatives of patients
who deceased in our stroke unit about the quality of dying and compared
their experiences with those of nurses. Patients and Methods Relatives of 59 patients were interviewed approximately 6 weeks after the
patient had died. The primary outcome was a score assessing the overall
quality of dying on a scale ranging from 0 to 10, with 0 representing the
worst quality and 10 the best quality. We investigated the frequency and
appreciation of specific aspects of the dying phase with an adapted version
of the Quality of Death and Dying Questionnaire. The nurse who was most
frequently involved in the end-of-life care of the patient completed a
similar questionnaire. Results Family members were generally satisfied with the quality of dying (median
overall score 8; interquartile range, 6–9) as well as with the care provided
by nurses (9; 8–10) and doctors (8; 7–9). Breathing difficulties were
frequently reported (by 46% of the relatives), but pain was not.
Unsatisfactory experiences were related to feeding (69% unsatisfactory),
inability to say goodbye to loved ones (51%), appearing not to have control
(47%), and not retaining a sense of dignity (41%). Two-thirds of the
relatives reported that palliative medication adequately resolved
discomfort. There was a good correlation between the experiences of
relatives and nurses. Discussion and Conclusion Most relatives were satisfied with the overall quality of dying. Negative
experiences concerned feeding problems, not being able to say goodbye to
loved ones, sense of self control and dignity, and breathing difficulties.
Experiences of nurses may be a reasonable and practical option when
evaluating the quality of dying in acute stroke patients.
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Affiliation(s)
- Hendrik Reinink
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marjolein Geurts
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Neurology Erasmus Medical Center, Rotterdam, The Netherlands
| | - Constance Melis-Riemens
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Annemarie Hollander
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jaap Kappelle
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bart van der Worp
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Palliative care interventions in intensive care unit patients. Intensive Care Med 2021; 47:1415-1425. [PMID: 34652465 DOI: 10.1007/s00134-021-06544-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/21/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The integration of palliative care into intensive care units (ICUs) is advocated to mitigate physical and psychological burdens for patients and their families, and to improve end-of-life care. The most efficacious palliative care interventions, the optimal model of their delivery and the most appropriate outcome measures in ICU are not clear. METHODS We conducted a systematic review of randomised clinical trials and observational studies to evaluate the number and types of palliative care interventions implemented within the ICU setting, to assess their impact on ICU practice and to evaluate differences in palliative care approaches across different countries. RESULTS Fifty-eight full articles were identified, including 9 randomised trials and 49 cohort studies; all but 4 were conducted within North America. Interventions were categorised into five themes: communication (14, 24.6%), ethics consultations (5, 8.8%), educational (18, 31.6%), involvement of a palliative care team (28, 49.1%) and advance care planning or goals-of-care discussions (7, 12.3%). Thirty studies (51.7%) proposed an integrative model, whilst 28 (48.3%) reported a consultative one. The most frequently reported outcomes were ICU or hospital length of stay (33/55, 60%), limitation of life-sustaining treatment decisions (22/55, 40%) and mortality (15/55, 27.2%). Quantitative assessment of pooled data was not performed due to heterogeneity in interventions and outcomes between studies. CONCLUSION Beneficial effects on the most common outcomes were associated with strategies to enhance palliative care involvement, either with an integrative or a consultative approach. Few studies reported functional outcomes for ICU patients. Almost all studies were from North America, limiting the generalisability to other healthcare systems.
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Aslakson RA, Cox CE, Baggs JG, Curtis JR. Palliative and End-of-Life Care: Prioritizing Compassion Within the ICU and Beyond. Crit Care Med 2021; 49:1626-1637. [PMID: 34325446 DOI: 10.1097/ccm.0000000000005208] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Rebecca A Aslakson
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA
- Division of Primary Care and Population Health, Department of Medicine, Palliative Care Section, Stanford University, Stanford, CA
| | - Christopher E Cox
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Duke University, Durham, NC
- Program to Support People and Enhance Recovery (ProSPER), Duke University, Durham, NC
| | - Judith G Baggs
- School of Nursing, Oregon Health & Science University, Portland, OR
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA
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Han XP, Mei X, Zhang J, Zhang TT, Yin AN, Qiu F, Liu MJ. Validation of the Chinese Version of the Quality of Dying and Death Questionnaire for Family Members of ICU Patients. J Pain Symptom Manage 2021; 62:599-608. [PMID: 33388383 DOI: 10.1016/j.jpainsymman.2020.12.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/10/2020] [Accepted: 12/25/2020] [Indexed: 10/22/2022]
Abstract
CONTEXT The quality of end-of-life care services directly affects the end-of-life quality of life of patients and their families. At present, there are no standard tools in China for assessing the quality of dying and death (QODD) of critical intensive care unit (ICU) patients. OBJECTIVES This study aimed to introduce the Chinese version of the QODD questionnaire for family members of ICU patients, after transcultural adaptation and validation, to provide an effective instrument for assessing the quality of end-of-life care of ICU patients in China, fill the gap in the evaluation of the quality of end-of-life care of critical ICU patients in China, and offer a theoretical basis and practical guidance during purposeful intervention. METHODS This study involved the main adult caregivers or principal family members of 149 dying critically ill patients. The original QODD scale was translated using the double forward and backward method. Nine cultural adaptation experts adapted the Chinese version of the QODD scale for completion by family members of ICU patients. Then, we carried out content validity, structural validity, internal consistency, confirmatory factors, and item correlation analysis of the modified scale. RESULTS The Chinese version of the QODD for family members of ICU patients was developed after some items were deleted or modified. The content validity index was 0.93, indicating that all items were correlated with the measurement of death quality. The Kaiser-Meyer-Olkin value was 0.797, suggesting that the correlations between items were high. The Cronbach's α was 0.865, indicating good internal consistency. In confirmatory factor analysis, the fit indices were χ2 = 207.327, non-normed fit index = 0.916, root mean square error of approximation = 0.033, and comparative fit index = 0.93, indicating a good fit of the five-factor model of the Chinese version of the QODD questionnaire for family members of ICU patients. CONCLUSION The Chinese version of the QODD questionnaire for family members of ICU patients is a reliable and effective instrument for evaluating the quality of death among patients who die in the ICU and can be applied to clinical practice and research.
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Affiliation(s)
- Xing-Ping Han
- Department of Oncology, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Xu Mei
- School of Nursing, Southwest Medical University, Luzhou, Sichuan, China
| | - Jing Zhang
- Department of Thoracic Surgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital, Chengdu, Sichuan, China
| | - Ting-Ting Zhang
- School of Nursing, Southwest Medical University, Luzhou, Sichuan, China
| | - Ai-Ni Yin
- School of Nursing, Southwest Medical University, Luzhou, Sichuan, China
| | - Fang Qiu
- School of Nursing, Southwest Medical University, Luzhou, Sichuan, China
| | - Meng-Jie Liu
- Department of Nursing, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China.
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Aelbrecht-Meurisse C, Ryckewaert T, Pannier D, Gamblin V, Garcia V, Aelbrecht S, Penel N. [Withholding or withdrawing life-sustaining treatments in acute oncology situations: History and regulatory aspects in France]. Bull Cancer 2021; 108:415-423. [PMID: 33678409 DOI: 10.1016/j.bulcan.2020.11.020] [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: 07/02/2020] [Revised: 10/28/2020] [Accepted: 11/20/2020] [Indexed: 10/22/2022]
Abstract
The management of oncology patients, especially hospitalized patients, can lead to almost daily discussions regarding therapeutic limitations. Here, we review the history and propose a summary of the texts framing the notion of "withholding and withdrawing life-sustaining treatment" in oncology practice in France. This decision is regulated by the Claeys-Léonetti Law of February 2, 2016 recommending a collegial discussion and its documentation in the medical record. The decision to withhold or withdraw life-sustaining treatments is the subject of discussion between the patient, his physicians and his family and may take place at any time during his management. The work of intensive-care physicians provides many useful recommendations for acute oncology situations, however articles specific for oncology practice are scarce; this is a topic that oncologists must take up.
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Affiliation(s)
| | - Thomas Ryckewaert
- Centre Oscar Lambret, département d'oncologie médicale, 3, rue Frédéric Combemale, 59000 Lille, France
| | - Diane Pannier
- Centre Oscar Lambret, département d'oncologie médicale, 3, rue Frédéric Combemale, 59000 Lille, France
| | - Vincent Gamblin
- Centre Oscar Lambret, département de soins palliatifs, 3, rue Frédéric Combemale, 59000 Lille, France
| | - Vincent Garcia
- Centre Oscar Lambret, département d'anesthésie-réanimation, 3, rue Frédéric Combemale, 59000 Lille, France
| | - Stéphane Aelbrecht
- EHPAD Les Myosotis, 160, rue Augustin Tirmont, 59283 Raimbeaucourt, France
| | - Nicolas Penel
- Centre Oscar Lambret, département d'oncologie médicale, 3, rue Frédéric Combemale, 59000 Lille, France
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11
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Ghoshal A. Adapting and using the quality of dying and death questionnaire. Indian J Palliat Care 2020; 26:39-41. [PMID: 32132782 PMCID: PMC7017709 DOI: 10.4103/ijpc.ijpc_170_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 11/02/2019] [Indexed: 11/04/2022] Open
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Douplat M, Berthiller J, Schott AM, Potinet V, Le Coz P, Tazarourte K, Jacquin L. Difficulty of the decision-making process in emergency departments for end-of-life patients. J Eval Clin Pract 2019; 25:1193-1199. [PMID: 31287201 DOI: 10.1111/jep.13229] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 06/17/2019] [Accepted: 06/19/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND In emergency departments, for some patients, death is preceded by a decision of withholding or withdrawing life-sustaining treatments. This concerns mainly patients over 80, with many comorbidities. The decision-making process of these decisions in emergency departments has not been extensively studied, especially for noncommunicating patients. AIM The purpose of this study is to describe the decision-making process of withholding and withdrawing life-sustaining treatments in emergency departments for noncommunicating patients and the outcome of said patients. DESIGN We conducted a prospective multicenter study in three emergency departments of university hospitals from September 2015 to January 2017. RESULTS We included 109 patients in the study. Fifty-eight (53.2%) patients were coming from nursing homes and 52 (47.7%) patients had dementia. Decisions of withholding life-sustaining treatment concerned 93 patients (85.3%) and were more frequent when a surrogate decision maker was present 61 (65.6%) versus seven (43.8%) patients. The most relevant factors that lead to these decisions were previous functional limitation (71.6%) and age (69.7%). Decision was taken by two physicians for 80 patients (73.4%). The nursing staff and general practitioner were, respectively, involved in 31 (28.4%) and two (1.8%) patients. A majority of the patients had no advance directives (89.9%), and the relatives were implicated in the decision-making process for 96 patients (88.1%). Death in emergency departments occurred for 47 patients (43.1%), and after 21 days, 84 patients (77.1 %) died. CONCLUSION There is little anticipation in end-of-life decisions. Discussion with patients concerning their end-of-life wishes and the writing of advance directives, especially for patients with chronic diseases, must be encouraged early.
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Affiliation(s)
- Marion Douplat
- Hospices Civils de Lyon, Service d'Accueil des urgences, Hôpital Lyon Sud, 165 chemin du Grand Revoyet, Pierre Bénite, F-69495, France.,UMR 7268 ADéS, Faculté de Médecine, Aix-Marseille Université/EFS/CNRS, 27 boulevard Jean Moulin, Marseille, 13005, France
| | - Julien Berthiller
- Pôle Information Médicale Evaluation Recherche, Hospices Civils de Lyon, Lyon, France
| | - Anne-Marie Schott
- Pôle Information Médicale Evaluation Recherche, Hospices Civils de Lyon, Lyon, France
| | - Véronique Potinet
- Hospices Civils de Lyon, Service d'Accueil des urgences, Hôpital Lyon Sud, 165 chemin du Grand Revoyet, Pierre Bénite, F-69495, France
| | - Pierre Le Coz
- UMR 7268 ADéS, Faculté de Médecine, Aix-Marseille Université/EFS/CNRS, 27 boulevard Jean Moulin, Marseille, 13005, France
| | - Karim Tazarourte
- Hospices Civiles de Lyon, Hôpital Edouard Herriot, Service d'Accueil des urgences, 5 place d'Arsonval, Lyon, F-69003, France
| | - Laurent Jacquin
- Hospices Civiles de Lyon, Hôpital Edouard Herriot, Service d'Accueil des urgences, 5 place d'Arsonval, Lyon, F-69003, France
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13
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Short SR, Thienprayoon R. Pediatric palliative care in the intensive care unit and questions of quality: a review of the determinants and mechanisms of high-quality palliative care in the pediatric intensive care unit (PICU). Transl Pediatr 2018; 7:326-343. [PMID: 30460185 PMCID: PMC6212394 DOI: 10.21037/tp.2018.09.11] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
This article reviews the state and practice of pediatric palliative care (PC) within the pediatric intensive care unit (PICU) with specific consideration of quality issues. This includes defining PC and end of life (EOL) care. We will also describe PC as it pertains to alleviating children's suffering through the provision of "concurrent care" in the ICU environment. Modes of care, and attendant strengths, of both the consultant and integrated models will be presented. We will review salient issues related to the provision of PC in the PICU, barriers to optimal practice, parental, and staff perceptions. Opportunity areas for quality improvement and the role of initiatives and measures such as education, family-based initiatives, staff needs, symptom recognition, grief, and communication follow. To conclude, we will look to the literature for PC resources for pediatric intensivists and future directions of study.
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Mercadante S, Gregoretti C, Cortegiani A. Palliative care in intensive care units: why, where, what, who, when, how. BMC Anesthesiol 2018; 18:106. [PMID: 30111299 PMCID: PMC6094470 DOI: 10.1186/s12871-018-0574-9] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 08/03/2018] [Indexed: 12/15/2022] Open
Abstract
Palliative care is patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering when “curative” therapies are futile. In the Intensive Care Unit (ICU), critically ill patients receive life-sustaining therapies with the goal of restoring or maintaining organ function. Palliative Care in the ICU is a widely discussed topic and it is increasingly applied in clinics. It encompasses symptoms control and end-of-life management, communication with relatives and setting goals of care ensuring dignity in death and decision-making power. However, effective application of Palliative Care in ICU presupposes specific knowledge and training which anesthesiologists and critical care physicians may lack. Moreover, logistic issues such protocols for patients’ selection, application models and triggers for consultation of external experts are still matter of debate. The aim of this review is to provide the anesthesiologists and intensivists an overview of the aims, current evidence and practical advices about the application of palliative care in ICU.
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Affiliation(s)
- Sebastiano Mercadante
- Anesthesia and Intensive Care Unit and Pain Relief and Supportive-Palliative Care Unit, La Maddalena Cancer Center, Via san Lorenzo 312, 90145, Palermo, Italy
| | - Cesare Gregoretti
- Department of Biopathology and Medical Biotechnologies (DIBIMED). Section of Anestesia, Analgesia, Intensive Care and Emergency. Policlinico Paolo Giaccone, University of Palermo, Via del vespro 129, 90127, Palermo, Italy
| | - Andrea Cortegiani
- Department of Biopathology and Medical Biotechnologies (DIBIMED). Section of Anestesia, Analgesia, Intensive Care and Emergency. Policlinico Paolo Giaccone, University of Palermo, Via del vespro 129, 90127, Palermo, Italy.
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15
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Cho JY, Lee J, Lee SM, Park JH, Kim J, Kim Y, Lee SH, Park JS, Cho YJ, Yoon HI, Lee JH, Lee CT, Lee YJ. Transcultural Adaptation and Validation of Quality of Dying and Death Questionnaire in Medical Intensive Care Units in South Korea. Acute Crit Care 2018; 33:95-101. [PMID: 31723869 PMCID: PMC6849059 DOI: 10.4266/acc.2017.00612] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 03/30/2018] [Accepted: 05/03/2018] [Indexed: 01/04/2023] Open
Abstract
Background Providing palliative care to dying patients in the intensive care unit (ICU) has recently received much attention. Evaluating the quality of dying and death (QODD) is important for appropriate comfort care in the ICU. This study aimed to validate the Korean version of the QODD questionnaire. Methods This study included decedents in the ICUs of three tertiary teaching hospitals and one secondary hospital from June 2016 to May 2017. ICU staff members were asked to complete the translated QODD questionnaire and the visual analogue scale (VAS) questionnaire within 48 hours of patient death. The validation process consisted of evaluating construct validity, internal consistency, and interrater reliability. Results We obtained 416 completed questionnaires describing 255 decedents. The QODD score was positively correlated with the 100-VAS score (Pearson correlation coefficient, 0.348; P<0.001). An evaluation of the internal consistency presented favorable results (calculated Cronbach’s alpha if a given item exceeded 0.8 in all items). The interrater reliability revealed no concordance between doctors and nurses. Conclusions The QODD questionnaire was successfully translated and validated in Korean medical ICUs. We hope further studies that use this valuable instrument will be conducted in Korea.
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Affiliation(s)
- Jun Yeun Cho
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jinwoo Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sang-Min Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ju-Hee Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Junghyun Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Medical Center, Seoul, Korea
| | - Youlim Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang Hoon Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jong Sun Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young-Jae Cho
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ho Il Yoon
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae Ho Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Choon-Taek Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yeon Joo Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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16
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Hwang DY, El-Kareh R, Davidson JE. Implementing Intensive Care Unit Family-Centered Care: Resources to Identify and Address Gaps. AACN Adv Crit Care 2018; 28:148-154. [PMID: 28592474 DOI: 10.4037/aacnacc2017636] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
During creation of the 2017 Society of Critical Care Medicine Guidelines for Family-Centered Care in the Intensive Care Unit, 2 implementation tools were developed to assist intensive care unit clinicians in incorporating the new recommendations into local practice: a gap analysis tool and a work tools document. The gap analysis tool helps intensive care unit teams rapidly develop unit- or organization-specific recommendations to enhance family-centered care and assess local barriers to implementation. The work tools document identifies readily available and tested resources that may further assist with action planning for change. The goal of these implementation tools is to promote rapid translation of the SCCM Guideline recommendations into practice, thereby streamlining the process of enacting meaningful evidence-based practice change.
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Affiliation(s)
- David Y Hwang
- David Y. Hwang is Assistant Professor of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, P.O. Box 208018, New Haven, CT 06520 . Robert El-Kareh is Associate Professor of Medicine, Divisions of Biomedical Informatics and Hospital Medicine, University of California, San Diego Health, La Jolla, California. Judy E. Davidson is Evidence-Based Practice and Research Nurse Liaison, University of California, San Diego Health, San Diego, California
| | - Robert El-Kareh
- David Y. Hwang is Assistant Professor of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, P.O. Box 208018, New Haven, CT 06520 . Robert El-Kareh is Associate Professor of Medicine, Divisions of Biomedical Informatics and Hospital Medicine, University of California, San Diego Health, La Jolla, California. Judy E. Davidson is Evidence-Based Practice and Research Nurse Liaison, University of California, San Diego Health, San Diego, California
| | - Judy E Davidson
- David Y. Hwang is Assistant Professor of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, P.O. Box 208018, New Haven, CT 06520 . Robert El-Kareh is Associate Professor of Medicine, Divisions of Biomedical Informatics and Hospital Medicine, University of California, San Diego Health, La Jolla, California. Judy E. Davidson is Evidence-Based Practice and Research Nurse Liaison, University of California, San Diego Health, San Diego, California
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17
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Coombs M, Puntillo KA, Franck LS, Scruth EA, Harvey MA, Swoboda SM, Davidson JE. Implementing the SCCM Family-Centered Care Guidelines in Critical Care Nursing Practice. AACN Adv Crit Care 2018; 28:138-147. [PMID: 28592473 DOI: 10.4037/aacnacc2017766] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Family-centered care is an important component of holistic nursing practice, particularly in critical care, where the impact on families of admitted patients can be physiologically and psychologically burdensome. Family-centered care guidelines, developed by an international group of nursing, medical, and academic experts for the American College of Critical Care Medicine/Society of Critical Care Medicine, explore the evidence base in 5 key areas of family-centered care. Evidence in each of the guideline areas is outlined and recommendations are made about how critical care nurses can use this information in family-centered care practice.
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Affiliation(s)
- Maureen Coombs
- Maureen Coombs is Professor, Clinical Nursing, The Graduate School of Nursing Midwifery and Health, Victoria University, Wellington, New Zealand . Kathleen A. Puntillo is Professor Emeritus and Research Scientist, Department of Physiological Nursing, University of California, San Francisco, California. Linda S. Franck is Jack and Elaine Koehn Endowed Chair in Pediatric Nursing, Department of Family Health Care Nursing, University of California, San Francisco, California. Elizabeth A. Scruth is Clinical Practice Consultant, Regional Quality and Regulatory Services, Kaiser Permanente, Oakland, California. Maurene A. Harvey is a Critical Care Educator and Consultant, Lake Tahoe, Nevada. Sandra M. Swoboda is Research Program Coordinator/Simulation Educator, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland. Judy E. Davidson is Evidence-Based Practice and Research Nurse Liaison, University of California San Diego Health, San Diego, California
| | - Kathleen A Puntillo
- Maureen Coombs is Professor, Clinical Nursing, The Graduate School of Nursing Midwifery and Health, Victoria University, Wellington, New Zealand . Kathleen A. Puntillo is Professor Emeritus and Research Scientist, Department of Physiological Nursing, University of California, San Francisco, California. Linda S. Franck is Jack and Elaine Koehn Endowed Chair in Pediatric Nursing, Department of Family Health Care Nursing, University of California, San Francisco, California. Elizabeth A. Scruth is Clinical Practice Consultant, Regional Quality and Regulatory Services, Kaiser Permanente, Oakland, California. Maurene A. Harvey is a Critical Care Educator and Consultant, Lake Tahoe, Nevada. Sandra M. Swoboda is Research Program Coordinator/Simulation Educator, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland. Judy E. Davidson is Evidence-Based Practice and Research Nurse Liaison, University of California San Diego Health, San Diego, California
| | - Linda S Franck
- Maureen Coombs is Professor, Clinical Nursing, The Graduate School of Nursing Midwifery and Health, Victoria University, Wellington, New Zealand . Kathleen A. Puntillo is Professor Emeritus and Research Scientist, Department of Physiological Nursing, University of California, San Francisco, California. Linda S. Franck is Jack and Elaine Koehn Endowed Chair in Pediatric Nursing, Department of Family Health Care Nursing, University of California, San Francisco, California. Elizabeth A. Scruth is Clinical Practice Consultant, Regional Quality and Regulatory Services, Kaiser Permanente, Oakland, California. Maurene A. Harvey is a Critical Care Educator and Consultant, Lake Tahoe, Nevada. Sandra M. Swoboda is Research Program Coordinator/Simulation Educator, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland. Judy E. Davidson is Evidence-Based Practice and Research Nurse Liaison, University of California San Diego Health, San Diego, California
| | - Elizabeth A Scruth
- Maureen Coombs is Professor, Clinical Nursing, The Graduate School of Nursing Midwifery and Health, Victoria University, Wellington, New Zealand . Kathleen A. Puntillo is Professor Emeritus and Research Scientist, Department of Physiological Nursing, University of California, San Francisco, California. Linda S. Franck is Jack and Elaine Koehn Endowed Chair in Pediatric Nursing, Department of Family Health Care Nursing, University of California, San Francisco, California. Elizabeth A. Scruth is Clinical Practice Consultant, Regional Quality and Regulatory Services, Kaiser Permanente, Oakland, California. Maurene A. Harvey is a Critical Care Educator and Consultant, Lake Tahoe, Nevada. Sandra M. Swoboda is Research Program Coordinator/Simulation Educator, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland. Judy E. Davidson is Evidence-Based Practice and Research Nurse Liaison, University of California San Diego Health, San Diego, California
| | - Maurene A Harvey
- Maureen Coombs is Professor, Clinical Nursing, The Graduate School of Nursing Midwifery and Health, Victoria University, Wellington, New Zealand . Kathleen A. Puntillo is Professor Emeritus and Research Scientist, Department of Physiological Nursing, University of California, San Francisco, California. Linda S. Franck is Jack and Elaine Koehn Endowed Chair in Pediatric Nursing, Department of Family Health Care Nursing, University of California, San Francisco, California. Elizabeth A. Scruth is Clinical Practice Consultant, Regional Quality and Regulatory Services, Kaiser Permanente, Oakland, California. Maurene A. Harvey is a Critical Care Educator and Consultant, Lake Tahoe, Nevada. Sandra M. Swoboda is Research Program Coordinator/Simulation Educator, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland. Judy E. Davidson is Evidence-Based Practice and Research Nurse Liaison, University of California San Diego Health, San Diego, California
| | - Sandra M Swoboda
- Maureen Coombs is Professor, Clinical Nursing, The Graduate School of Nursing Midwifery and Health, Victoria University, Wellington, New Zealand . Kathleen A. Puntillo is Professor Emeritus and Research Scientist, Department of Physiological Nursing, University of California, San Francisco, California. Linda S. Franck is Jack and Elaine Koehn Endowed Chair in Pediatric Nursing, Department of Family Health Care Nursing, University of California, San Francisco, California. Elizabeth A. Scruth is Clinical Practice Consultant, Regional Quality and Regulatory Services, Kaiser Permanente, Oakland, California. Maurene A. Harvey is a Critical Care Educator and Consultant, Lake Tahoe, Nevada. Sandra M. Swoboda is Research Program Coordinator/Simulation Educator, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland. Judy E. Davidson is Evidence-Based Practice and Research Nurse Liaison, University of California San Diego Health, San Diego, California
| | - Judy E Davidson
- Maureen Coombs is Professor, Clinical Nursing, The Graduate School of Nursing Midwifery and Health, Victoria University, Wellington, New Zealand . Kathleen A. Puntillo is Professor Emeritus and Research Scientist, Department of Physiological Nursing, University of California, San Francisco, California. Linda S. Franck is Jack and Elaine Koehn Endowed Chair in Pediatric Nursing, Department of Family Health Care Nursing, University of California, San Francisco, California. Elizabeth A. Scruth is Clinical Practice Consultant, Regional Quality and Regulatory Services, Kaiser Permanente, Oakland, California. Maurene A. Harvey is a Critical Care Educator and Consultant, Lake Tahoe, Nevada. Sandra M. Swoboda is Research Program Coordinator/Simulation Educator, Johns Hopkins University Schools of Medicine and Nursing, Baltimore, Maryland. Judy E. Davidson is Evidence-Based Practice and Research Nurse Liaison, University of California San Diego Health, San Diego, California
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18
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Aslakson RA, Reinke LF, Cox C, Kross EK, Benzo RP, Curtis JR. Developing a Research Agenda for Integrating Palliative Care into Critical Care and Pulmonary Practice To Improve Patient and Family Outcomes. J Palliat Med 2018; 20:329-343. [PMID: 28379812 DOI: 10.1089/jpm.2016.0567] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Palliative care is a medical specialty and philosophy of care that focuses on reducing suffering among patients with serious illness and their family members, regardless of disease diagnosis or prognosis. As critical illness or moderate to severe pulmonary disease confers significant disease-related symptom burdens, palliative care and palliative care specialists can aid in reducing symptom burden and improving quality of life among these patients and their family members. OBJECTIVE The objective of this article is to review the existing gaps in evidence for palliative care in pulmonary disease and critical illness and to use an interdisciplinary working group convened by the National Institutes of Health and the National Palliative Care Research Center to develop a research agenda to address these gaps. METHODS We completed a narrative review of the literature concerning the integration of palliative care into pulmonary and/or critical care. The review was based on recent systematic reviews on these topics as well as a summary of relevant articles identified through hand search. We used this review to identify gaps in current knowledge and develop a research agenda for the future. RESULTS We identified key areas of need and knowledge gaps that should be addressed to improve palliative care for patients with pulmonary and critical illness. These areas include developing and validating patient- and family-centered outcomes, identifying the key components of palliative care that are effective and cost-effective, developing and evaluating different models of palliative care delivery, and determining the effectiveness and cost-effectiveness of palliative care interventions. CONCLUSIONS The goal of this research agenda is to encourage researchers, clinicians, healthcare systems, and research funders to identify research that can address these gaps and improve the lives of patients with pulmonary and critical illness and their family members.
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Affiliation(s)
- Rebecca A Aslakson
- 1 Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins School of Medicine , Baltimore, Maryland.,2 Department of Oncology and Palliative Care Program in the Kimmel Comprehensive Cancer Center at Johns Hopkins , Baltimore, Maryland.,3 Department of Health, Behavior and Society, The Johns Hopkins Bloomberg School of Public Health , Baltimore, Maryland
| | - Lynn F Reinke
- 4 Department of Veterans Affairs, Puget Sound Healthcare System , Seattle, Washington.,5 Department of Biobehavioral Nursing and Health Systems, University of Washington , Seattle, Washington
| | - Christopher Cox
- 6 Department of Medicine, Duke University , Durham, North Carolina
| | - Erin K Kross
- 7 Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington , Seattle, Washington.,8 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington
| | - Roberto P Benzo
- 9 Mindful Breathing Laboratory, Division of Pulmonary and Critical Care Medicine, Mayo Clinic , Rochester, Minnesota
| | - J Randall Curtis
- 7 Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington , Seattle, Washington.,8 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington
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19
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Bender MA, Hurd C, Solvang N, Colagrossi K, Matsuwaka D, Curtis JR. A New Generation of Comfort Care Order Sets: Aligning Protocols with Current Principles. J Palliat Med 2017; 20:922-929. [PMID: 28537773 DOI: 10.1089/jpm.2016.0549] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND There are few published comfort care order sets for end-of-life symptom management, contributing to variability in treatment of common symptoms. At our academic medical centers, we have observed that rapid titration of opioid infusions using our original comfort care order set's titration algorithm causes increased discomfort from opioid toxicity. OBJECTIVE The aim of this study was to describe the process and outcomes of a multiyear revision of a standardized comfort care order set for clinicians to treat end-of-life symptoms in hospitalized patients. DESIGN Our revision process included interdisciplinary group meetings, literature review and expert consultation, beta testing protocols with end users, and soliciting feedback from key committees at our institutions. We focused on opioid dosing and embedding treatment algorithms and guidelines within the order set for clinicians. SETTING The study was conducted at two large academic medical centers. RESULTS We developed and implemented a comfort care order set with opioid dosing that reflects current pharmacologic principles and expert recommendations. Educational tools and reference materials are embedded within the order set in the electronic medical record. There are prompts for improved collaboration between ordering clinicians, nurses, and palliative care. CONCLUSIONS We successfully developed a new comfort care order set at our institutions that can serve as a resource for others. Further evaluation of this order set is needed.
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Affiliation(s)
- Melissa A Bender
- 1 University of Washington School of Medicine, University of Washington Medical Center , Seattle, Washington
| | - Caroline Hurd
- 2 Harborview Medical Center, University of Washington School of Medicine , Seattle, Washington
| | - Nicole Solvang
- 3 University of Washington Medical Center , Seattle, Washington
| | - Kathy Colagrossi
- 2 Harborview Medical Center, University of Washington School of Medicine , Seattle, Washington
| | - Diane Matsuwaka
- 4 Pharmacy Informatics, University of Washington , Seattle, Washington
| | - J Randall Curtis
- 2 Harborview Medical Center, University of Washington School of Medicine , Seattle, Washington
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20
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21
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Family Members’ and Intensive Care Unit Nurses’ Response to the ECG Memento© During the Bereavement Period. Dimens Crit Care Nurs 2017; 36:317-326. [DOI: 10.1097/dcc.0000000000000269] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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22
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Van Scoy LJ, Reading JM, Howrylak JA, Tamhane A, Sherman MS. Low quality of dying and death in patients with septic shock as perceived by nurses and resident physicians. DEATH STUDIES 2016; 40:486-493. [PMID: 27192058 DOI: 10.1080/07481187.2016.1181121] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Septic shock is a disease with both high prevalence and mortality. Few studies have evaluated the quality of dying and death (QODD) in patients with septic shock. The authors compared the QODD of patients who died of septic shock versus other causes. They prospectively collected QODD surveys from nurses and residents caring for 196 patients who died in the medical intensive care unit (ICU) at an urban, university hospital. Patients were included in the analysis if either a nurse or resident returned a survey. Chart review established cause of death. The authors compared total QODD scores (on a scale of 0-100) and a single-item score (QODD-1; on a scale of 0-10) of patients who died of septic shock versus other causes. Survey response rates were 59% (n = 155) for residents and 49% (n = 129) for nurses. Nurses rated patients as having lower total QODD and QODD-1 scores for septic (Δ 7.5 points, p = 0.03, and 0.9 points, p = 0.05, respectively). Residents rated septic patients with lower QODD-1 scores than nonseptic patients (Δ 0.8 points, p = 0.03). This study shows that nurses rate patients with septic shock as having lower QODD than patients dying of other causes. These findings are important for clinicians who counsel families of patients dying of septic shock.
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Affiliation(s)
- Lauren Jodi Van Scoy
- a Division of Pulmonary, Critical Care, & Sleep Medicine , Drexel University College of Medicine , Philadelphia , Pennsylvania , USA
| | - Jean M Reading
- a Division of Pulmonary, Critical Care, & Sleep Medicine , Drexel University College of Medicine , Philadelphia , Pennsylvania , USA
| | - Judie A Howrylak
- a Division of Pulmonary, Critical Care, & Sleep Medicine , Drexel University College of Medicine , Philadelphia , Pennsylvania , USA
| | - Apurva Tamhane
- b Department of Medicine , Drexel University College of Medicine , Philadelphia , Pennsylvania , USA
| | - Michael S Sherman
- a Division of Pulmonary, Critical Care, & Sleep Medicine , Drexel University College of Medicine , Philadelphia , Pennsylvania , USA
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23
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Edwards JD, Voigt LP, Nelson JE. Ten key points about ICU palliative care. Intensive Care Med 2016; 43:83-85. [PMID: 27506756 DOI: 10.1007/s00134-016-4481-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 07/30/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Jeffrey D Edwards
- Division of Pediatric Critical Care, Columbia University College of Physician and Surgeons, 3959 Broadway, CHN 10-24, New York, NY, 10032, USA.
| | - Louis P Voigt
- Critical Care Service, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, USA
| | - Judith E Nelson
- Critical Care Service, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, USA.,Palliative Medicine Service, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, USA
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24
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Heckel M, Bussmann S, Stiel S, Ostgathe C, Weber M. Validation of the German Version of the Quality of Dying and Death Questionnaire for Health Professionals. Am J Hosp Palliat Care 2016; 33:760-9. [DOI: 10.1177/1049909115606075] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Purpose: To validate the Quality of Dying and Death (QoDD) instrument for health professionals (QoDD-D-MA) and to test its feasibility in 2 German palliative care units (PCUs). Methods: The QoDD was translated from English to German and then retranslated following European Organisation for Research and Treatment of Cancer (EORTC) guidelines. Data were collected in 2 German PCUs to calculate aspects of validity and reliability. Results: Mean total score was 83.05 (range 49-100; N = 232). The QoDD-D-MA showed satisfactory psychometric properties, Cronbach α = .830; interrater reliability r = .245 ( P < .01). The QoDD-D-MA was independent of patients’ demographic and clinical aspects. Some challenges occurred when applying the instrument. Conclusions: Feasibility could be improved by adapting the QoDD-D-MA to create a self-assessment version and finding a solution for items that result in many missing data. Future research should validate the QoDD-D-MA in other care settings.
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Affiliation(s)
- Maria Heckel
- Department of Palliative Medicine, Comprehensive Cancer Center CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Sonja Bussmann
- Interdisciplinary Palliative Care Unit, III. Department of Medicine, University Medical Centre of the Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Stephanie Stiel
- Department of Palliative Medicine, Comprehensive Cancer Center CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Christoph Ostgathe
- Department of Palliative Medicine, Comprehensive Cancer Center CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Germany
| | - Martin Weber
- Interdisciplinary Palliative Care Unit, III. Department of Medicine, University Medical Centre of the Johannes Gutenberg University of Mainz, Mainz, Germany
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Witsch J, Frey HP, Patel S, Park S, Lahiri S, Schmidt JM, Agarwal S, Falo MC, Velazquez A, Jaja B, Macdonald RL, Connolly ES, Claassen J. Prognostication of long-term outcomes after subarachnoid hemorrhage: The FRESH score. Ann Neurol 2016; 80:46-58. [PMID: 27129898 DOI: 10.1002/ana.24675] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 04/19/2016] [Accepted: 04/19/2016] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To create a multidimensional tool to prognosticate long-term functional, cognitive, and quality of life outcomes after spontaneous subarachnoid hemorrhage (SAH) using data up to 48 hours after admission. METHODS Data were prospectively collected for 1,619 consecutive patients enrolled in the SAH outcome project July 1996 to March 2014. Linear models (LMs) were applied to identify factors associated with outcome in 1,526 patients with complete data. Twelve-month functional, cognitive, and quality of life outcomes were measured using the modified Rankin scale (mRS), Telephone Interview for Cognitive Status, and Sickness Impact Profile. Based on the LM residuals, we constructed the FRESH score (Functional Recovery Expected after Subarachnoid Hemorrhage). Score performance, discrimination, and internal validity were tested using the area under the receiver operating characteristic curve (AUC), Nagelkerke and Cox/Snell R(2) , and bootstrapping. For external validation, we used a control population of SAH patients from the CONSCIOUS-1 study (n = 413). RESULTS The FRESH score was composed of Hunt & Hess and APACHE-II physiologic scores on admission, age, and aneurysmal rebleed within 48 hours. Separate scores to prognosticate 1-year cognition (FRESH-cog) and quality of life (FRESH-quol) were developed controlling for education and premorbid disability. Poor functional outcome (mRS = 4-6) for score levels 1 through 9 respectively was present in 3, 6, 12, 38, 61, 83, 92, 98, and 100% at 1-year follow-up. Performance of FRESH (AUC = 0.90), FRESH-cog (AUC = 0.80), and FRESH-quol (AUC = 0.78) was high. External validation of our cohort using mRS as endpoint showed satisfactory results (AUC = 0.77). To allow for convenient score calculation, we built a smartphone app available for free download. INTERPRETATION FRESH is the first clinical tool to prognosticate long-term outcome after spontaneous SAH in a multidimensional manner. Ann Neurol 2016;80:46-58.
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Affiliation(s)
- Jens Witsch
- Division of Critical Care Neurology, Department of Neurology, Columbia University, College of Physicians and Surgeons, New York, NY
| | - Hans-Peter Frey
- Division of Critical Care Neurology, Department of Neurology, Columbia University, College of Physicians and Surgeons, New York, NY
| | - Sweta Patel
- Division of Critical Care Neurology, Department of Neurology, Columbia University, College of Physicians and Surgeons, New York, NY
| | - Soojin Park
- Division of Critical Care Neurology, Department of Neurology, Columbia University, College of Physicians and Surgeons, New York, NY
| | - Shouri Lahiri
- Division of Critical Care Neurology, Department of Neurology, Columbia University, College of Physicians and Surgeons, New York, NY
| | - J Michael Schmidt
- Division of Critical Care Neurology, Department of Neurology, Columbia University, College of Physicians and Surgeons, New York, NY
| | - Sachin Agarwal
- Division of Critical Care Neurology, Department of Neurology, Columbia University, College of Physicians and Surgeons, New York, NY
| | - Maria Cristina Falo
- Division of Critical Care Neurology, Department of Neurology, Columbia University, College of Physicians and Surgeons, New York, NY
| | - Angela Velazquez
- Division of Critical Care Neurology, Department of Neurology, Columbia University, College of Physicians and Surgeons, New York, NY
| | - Blessing Jaja
- Division of Neurosurgery, St Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, Institute of Medical Science, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - R Loch Macdonald
- Division of Neurosurgery, St Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St Michael's Hospital, Institute of Medical Science, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - E Sander Connolly
- Department of Neurosurgery, Columbia University, College of Physicians and Surgeons, New York, NY
| | - Jan Claassen
- Division of Critical Care Neurology, Department of Neurology, Columbia University, College of Physicians and Surgeons, New York, NY
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Delaney JW, Downar J. How is life support withdrawn in intensive care units: A narrative review. J Crit Care 2016; 35:12-8. [PMID: 27481730 DOI: 10.1016/j.jcrc.2016.04.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 03/17/2016] [Accepted: 04/03/2016] [Indexed: 01/20/2023]
Abstract
PURPOSE Decisions to withdraw life-sustaining therapy (WDLS) are relatively common in intensive care units across Canada. As part of preliminary work to develop guidelines for WDLS, we performed a narrative review of the literature to identify published studies of WDLS. MATERIALS AND METHODS A search of MEDLINE and EMBASE databases was performed. The results were reviewed and only articles relevant to WDLS were included. Any references within these articles deemed to be relevant were subsequently included. RESULTS The initial search identified 3687 articles. A total of 100 articles of interest were identified from the initial search and a review of their references. The articles were primarily composed of observational data and expert opinion. The information from the literature was organized into 6 themes: preparation for WDLS, monitoring parameters, pharmacologic symptom management, withdrawing life-sustaining therapies, withdrawal of mechanical ventilation, and bereavement. CONCLUSIONS This review describes current practices and opinions about WDLS, and also demonstrates the significant practice variation that currently exists. We believe that the development of guidelines to help increase transparency and standardize the process will be an important step to ensuring high quality care during WDLS.
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Affiliation(s)
| | - James Downar
- Division of Palliative Care, University of Toronto, Toronto, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
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Guidelines for the withdrawal of life-sustaining measures. Intensive Care Med 2016; 42:1003-17. [PMID: 27059793 DOI: 10.1007/s00134-016-4330-7] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 03/11/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Withdrawal of life-sustaining measures is a common event in the intensive care unit yet it involves a complex balance of medical, legal and ethical considerations. Very few healthcare providers have been specifically trained to withdraw life-sustaining measures, and no comprehensive guidelines exist to help ensure clinicians deliver the highest quality of care to patients and families. Hence, we sought to develop guidelines for the process of withdrawing life-sustaining measures in the clinical setting. METHODS We convened an interdisciplinary group of ICU care providers from the Canadian Critical Care Society and the Canadian Association of Critical Care Nurses, and used a modified Delphi process to answer key clinical and ethical questions identified in the literature. RESULTS A total of 39 experienced clinicians completed the initial workshop, and 36 were involved in the subsequent Delphi rounds. The group developed a series of guidelines to address (1) preparing for withdrawal of life-sustaining measures; (2) assessment of distress; (3) pharmaceutical management of distress; and (4) discontinuation of life-sustaining measures and monitoring. The group achieved consensus on all aspects of the guidelines after the third Delphi round. CONCLUSION We present these guidelines to help physicians provide high-quality end of life (EOL) care in the ICU. Future studies should address their effectiveness from both critical care team and family perspectives.
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Centofanti J, Swinton M, Dionne J, Barefah A, Boyle A, Woods A, Shears M, Heels-Ansdell D, Cook D. Resident reflections on end-of-life education: a mixed-methods study of the 3 Wishes Project. BMJ Open 2016; 6:e010626. [PMID: 27033962 PMCID: PMC4823392 DOI: 10.1136/bmjopen-2015-010626] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 02/22/2016] [Accepted: 03/09/2016] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE The objectives of this study were to describe residents' experiences with end-of-life (EOL) education during a rotation in the intensive care unit (ICU), and to understand the possible influence of the 3 Wishes Project. DESIGN We enrolled dying patients, their families and 1-3 of their clinicians in the 3 Wishes Project, eliciting and honouring a set of 3 wishes to bring peace to the final days of a critically ill patient's life, and ease the grieving process for families. We conducted semistructured interviews with 33 residents who had cared for 50 dying patients to understand their experiences with the project. Interviews were recorded, transcribed verbatim, then analysed using a qualitative descriptive approach. SETTING 21-bed medical surgical ICU in a tertiary care, university-affiliated hospital. RESULTS 33 residents participated from internal medicine (24, 72.7%), anaesthesia (8, 24.2%) and laboratory medicine (1, 3.0%) programmes in postgraduate years 1-3. 3 categories and associated themes emerged. (1) EOL care is a challenging component of training in that (a) death in the ICU can invoke helplessness, (b) EOL education is inadequate, (c) personal connections with dying patients is difficult in the ICU and (d) EOL skills are valued by residents. (2) The project reframes the dying process for residents by (a) humanising this aspect of practice, (b) identifying that family engagement is central to the dying process, (c) increasing emotional responsiveness and (d) showing that care shifts, not stops. (3) The project offers experiential education by (a) intentional role modelling, (b) facilitating EOL dialogue, (c) empowering residents to care in a tangible way and (d) encouraging reflection. CONCLUSIONS For residents, the 3 Wishes Project integrated many forms of active learning for residents. Practice-based rather than classroom-based programmes may engage trainees to develop EOL skills transferable to other settings.
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Affiliation(s)
- J Centofanti
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
- Department of Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - M Swinton
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - J Dionne
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - A Barefah
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - A Boyle
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine and Critical Care, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - A Woods
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine and Critical Care, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - M Shears
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - D Heels-Ansdell
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - D Cook
- Department of Critical Care, McMaster University, Hamilton, Ontario, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine and Critical Care, St. Joseph's Healthcare, Hamilton, Ontario, Canada
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An exploration of the role of religion/spirituality in the promotion of physicians' wellbeing in Emergency Medicine. Prev Med Rep 2016; 3:189-95. [PMID: 27419014 PMCID: PMC4929145 DOI: 10.1016/j.pmedr.2016.01.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Background: Burnout is highly prevalent among Emergency Medicine (EM) physicians and has significant impact on quality of care and workforce retention. The objective of this study was to determine whether higher religion/spirituality (R/S) is associated with a lower prevalence of burnout among EM physicians (primary outcome). A history of malpractice lawsuits and maladaptive behaviors were the secondary outcomes. Methods: This was a cross-sectional, survey-based study conducted among a random sample of physicians from the Massachusetts College of Emergency Physicians mailing list. Burnout was measured using a validated 2-item version of the Maslach Burnout Inventory. Maladaptive behaviors (smoking, drinking, and substance use) and medical malpractice were self-reported. R/S measures included organized religiosity, religious affiliation, private R/S practice, self-rated spirituality, religious rest, and religious commitment. Logistic regression was used to model study outcomes as a function of R/S predictors. Results: Of 422 EM physicians who received the invitation to participate, 138 completed the survey (32.7%). The prevalence of burnout was 27%. No significant associations were observed between burnout and R/S indicators. Maladaptive behaviors (adjusted OR = 0.42, CI: 0.19 to 0.96; p = 0.039) and history of medical malpractice (adjusted OR = 0.32; CI: 0.11 to 0.93; p = 0.037) were less likely among physicians reporting to be more involved in organized religious activity and to observe a day of rest for religious reasons, respectively. Conclusion: This study provides preliminary evidence for a possible protective association of certain dimensions of R/S on maladaptive behaviors and medical malpractice among EM physicians. Religiously/spiritually involved Emergency Medicine doctors reported lower burnout. Associations were consistent but non-significant due to low sample size. Doctors observing religious rest day were less likely to report malpractice claims. Physicians attending services were less likely to report maladaptive behaviors. These cross-sectional findings need to be replicated in large prospective studies.
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Abstract
OBJECTIVE The process of withdrawal of life-sustaining therapy remains poorly described in the current literature despite its importance for patient comfort and optimal end-of-life care. We conducted a structured review of the published literature to summarize patterns of withdrawal of life-sustaining therapy processes in adult ICUs. DATA SOURCES Electronic journal databases were searched from date of first issue until April 2014. STUDY SELECTION Original research articles describing processes of life-support therapy withdrawal in North American, European, and Australian ICUs were included. DATA EXTRACTION From each article, we extracted definitions of withdrawal of life-sustaining therapy, descriptions and order of interventions withdrawn, drugs administered, and timing from withdrawal of life-sustaining therapy until death. DATA SYNTHESIS Fifteen articles met inclusion criteria. Definitions of withdrawal of life-sustaining therapy varied and focused on withdrawal of mechanical ventilation; two studies did not present operational definitions. All studies described different aspects of process of life-support therapy withdrawal and measured different time periods prior to death. Staggered patterns of withdrawal of life-support therapy were reported in all studies describing order of interventions withdrawn, with vasoactive drugs withdrawn first followed by gradual withdrawal of mechanical ventilation. Processes of withdrawal of life-sustaining therapy did not seem to influence time to death. CONCLUSIONS Further description of the operational processes of life-sustaining therapy withdrawal in a more structured manner with standardized definitions and regular inclusion of measures of patient comfort and family satisfaction with care is needed to identify which patterns and processes are associated with greatest perceived patient comfort and family satisfaction with care.
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Integrating Palliative Care Into the Care of Neurocritically Ill Patients: A Report From the Improving Palliative Care in the ICU Project Advisory Board and the Center to Advance Palliative Care. Crit Care Med 2015; 43:1964-77. [PMID: 26154929 DOI: 10.1097/ccm.0000000000001131] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To describe unique features of neurocritical illness that are relevant to provision of high-quality palliative care; to discuss key prognostic aids and their limitations for neurocritical illnesses; to review challenges and strategies for establishing realistic goals of care for patients in the neuro-ICU; and to describe elements of best practice concerning symptom management, limitation of life support, and organ donation for the neurocritically ill. DATA SOURCES A search of PubMed and MEDLINE was conducted from inception through January 2015 for all English-language articles using the term "palliative care," "supportive care," "end-of-life care," "withdrawal of life-sustaining therapy," "limitation of life support," "prognosis," or "goals of care" together with "neurocritical care," "neurointensive care," "neurological," "stroke," "subarachnoid hemorrhage," "intracerebral hemorrhage," or "brain injury." DATA EXTRACTION AND SYNTHESIS We reviewed the existing literature on delivery of palliative care in the neurointensive care unit setting, focusing on challenges and strategies for establishing realistic and appropriate goals of care, symptom management, organ donation, and other considerations related to use and limitation of life-sustaining therapies for neurocritically ill patients. Based on review of these articles and the experiences of our interdisciplinary/interprofessional expert advisory board, this report was prepared to guide critical care staff, palliative care specialists, and others who practice in this setting. CONCLUSIONS Most neurocritically ill patients and their families face the sudden onset of devastating cognitive and functional changes that challenge clinicians to provide patient-centered palliative care within a complex and often uncertain prognostic environment. Application of palliative care principles concerning symptom relief, goal setting, and family emotional support will provide clinicians a framework to address decision making at a time of crisis that enhances patient/family autonomy and clinician professionalism.
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Heckel M, Bussmann S, Stiel S, Weber M, Ostgathe C. Validation of the German Version of the Quality of Dying and Death Questionnaire for Informal Caregivers (QODD-D-Ang). J Pain Symptom Manage 2015; 50:402-13. [PMID: 26079825 DOI: 10.1016/j.jpainsymman.2015.03.020] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 02/20/2015] [Accepted: 03/05/2015] [Indexed: 12/18/2022]
Abstract
CONTEXT The quality of dying and death (QOD) influences end-of-life care for patients and their relatives. To the best of our knowledge, there are currently no validated standard instruments for evaluating the QOD of patients in palliative care units (PCUs) in Germany. OBJECTIVES This study aimed to validate the German version of the multidimensional questionnaire "Quality of Dying and Death" for informal caregivers (QODD-Deutsch-Angehörige [QODD-D-Ang]) and provide a detailed report on its validity and reliability. METHODS The QODD was forward/backward translated following the European Organization for Research and Treatment of Cancer guidelines. Data collected in two German palliative care units (N = 226) with the QODD-D-Ang were used to calculate the QODD-D-Ang total score (TS) and to define reliability and validity, as well as acceptance and burden for informal caregivers. Frequencies, means, and SDs of various patient data related to care and disease were calculated to describe the study population and to look at group differences. RESULTS The mean TS of 175 participants was 75.72 (range 38-99; minimum 0 to maximum 100; higher scores indicate better QOD). The QODD-D-Ang showed good internal consistency for 27 items (Cronbach's alpha 0.852). Factors extracted by factor analysis could not be usefully interpreted. The TS of the QODD-D-Ang correlated substantially with the Palliative care Outcome Scale (r = 0.540), indicating good convergent validity. The QODD-D-Ang TS was stable for various demographic and clinical dimensions except for the amount of days on which informal caregivers visited patients, and, therefore, provided good discriminant validity. CONCLUSION Analyses of validity and reliability of the QODD-D-Ang showed satisfactory to good psychometric properties, meaning that the QODD can be recommended for standard implementation in German hospices and palliative care institutions to measure the QOD. Feasibility could be improved by adapting the instrument so that it may be administered with minimal demands on staff. When interpreting the results, it should be kept in mind that the QODD-D-Ang does not measure quality of care but the quality of the dying process as estimated by bereaved relatives.
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Affiliation(s)
- Maria Heckel
- Department of Palliative Medicine, Comprehensive Cancer Center CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany.
| | - Sonja Bussmann
- Interdisciplinary Palliative Care Unit, III. Department of Medicine, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Stephanie Stiel
- Department of Palliative Medicine, Comprehensive Cancer Center CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
| | - Martin Weber
- Interdisciplinary Palliative Care Unit, III. Department of Medicine, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Christoph Ostgathe
- Department of Palliative Medicine, Comprehensive Cancer Center CCC Erlangen-EMN, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Erlangen, Germany
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Campbell ML, Yarandi HN, Mendez M. A Two-Group Trial of a Terminal Ventilator Withdrawal Algorithm: Pilot Testing. J Palliat Med 2015; 18:781-5. [DOI: 10.1089/jpm.2015.0111] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | - Michael Mendez
- School of Medicine, Wayne State University, Detroit, Michigan
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Lundy JB, Chung KK, Pamplin JC, Ainsworth CR, Jeng JC, Friedman BC. Update on Severe Burn Management for the Intensivist. J Intensive Care Med 2015; 31:499-510. [PMID: 26112758 DOI: 10.1177/0885066615592346] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Accepted: 06/01/2015] [Indexed: 11/15/2022]
Abstract
Thermal injury of humans causes arguably the most severe perturbations in physiology that can be experienced. These physiologic derangements start immediately and can persist in some form until months or even years after the burn wounds are healed. Burn shock, marked activation of the systemic inflammatory response, multiple-organ failure, infection, and wound failure are just a few of the insults that may require management by the intensivist. The purpose of this article is to review recent advances in the critical care management of thermally injured patients.
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Affiliation(s)
- Jonathan B Lundy
- Burn Center, United States Army Institute of Surgical Research, Fort Sam Houston, TX, USA Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Kevin K Chung
- Burn Center, United States Army Institute of Surgical Research, Fort Sam Houston, TX, USA Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Jeremy C Pamplin
- Burn Center, United States Army Institute of Surgical Research, Fort Sam Houston, TX, USA Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Craig R Ainsworth
- Department of Medicine, William Beaumont Army Medical Center, Fort Bliss, TX, USA
| | - James C Jeng
- Department of Surgery, Mount Sinai Beth Israel Medical Center, New York, NY, USA
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Rajamani A, Barrett E, Weisbrodt L, Bourne J, Palejs P, Gresham R, Huang S. Protocolised Approach to End-of-Life Care in the ICU—The ICU PALCare Pilot Project. Anaesth Intensive Care 2015; 43:335-40. [DOI: 10.1177/0310057x1504300309] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
International literature on end-of-life care in intensive care units (ICUs) supports the use of ‘protocol bundles’, which is not common practice in our 18-bed adult general ICU in Sydney, New South Wales. We conducted a prospective observational study to identify problems related to end-of-life care practices and to determine whether there was a need to develop protocol bundles. Any ICU patient who had ‘withdrawal’ of life-sustaining treatment to facilitate a comfortable death was eligible. Exclusion criteria included organ donors, unsuitable family dynamics and lack of availability of research staff to obtain family consent. Process-of-care measures were collected using a standardised form. Satisfaction ratings were obtained using de-identified questionnaire surveys given to the healthcare staff shortly after the withdrawal of therapy and to the families 30 days later. Twenty-three patients were enrolled between June 2011 and July 2012. Survey questionnaires were given to 25 family members and 30 healthcare staff, with a high completion rate (24 family members [96%] and 28 staff [93.3%]). Problems identified included poor documentation of family meetings (39%) and symptom management. Emotional/spiritual support was not offered to families (39.1%) or ICU staff (0%). The overall level of end-of-life care was good. The overwhelming majority of families and healthcare staff were highly satisfied with the care provided. Problems identified related to communication documentation and lack of spiritual/emotional support. To address these problems, targeted measures would be more useful than the adoption of protocol bundles. Alternate models of satisfaction surveys may be needed.
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Affiliation(s)
- A. Rajamani
- Intensive Care Unit, Nepean Hospital, Kingswood, New South Wales
| | - E. Barrett
- Intensive Care Unit, Nepean Hospital, Kingswood, New South Wales
| | - L. Weisbrodt
- Intensive Care Nursing and Clinical Research Management, Nepean Hospital, Kingswood, New South Wales
| | - J. Bourne
- Intensive Care Unit, Nepean Hospital, Kingswood, New South Wales
| | - P. Palejs
- Intensive Care Unit, Nepean Hospital, Kingswood, New South Wales
| | - R. Gresham
- Intensive Care Unit, Nepean Hospital, Kingswood, New South Wales
| | - S. Huang
- Nepean Hospital, Kingswood, New South Wales
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Aslakson R, Cheng J, Vollenweider D, Galusca D, Smith TJ, Pronovost PJ. Evidence-based palliative care in the intensive care unit: a systematic review of interventions. J Palliat Med 2015; 17:219-35. [PMID: 24517300 DOI: 10.1089/jpm.2013.0409] [Citation(s) in RCA: 168] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Over the last 20 years, multiple interventions to better integrate palliative care and intensive care unit (ICU) care have been evaluated. This systematic review summarizes these studies and their outcomes. METHODS We searched MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Library, and the Web of Science; performed a search of articles published by opinion leaders in the field; and reviewed hand-search articles as of August 13, 2012. The terms "palliative care" and "intensive care unit" were mapped to MeSH subject headings and "exploded." We included trials of adult patients that evaluated an ICU intervention and addressed Robert Wood Johnson group-identified domains of high-quality end-of-life care in the ICU. We excluded case series, editorials, and review articles. We compared two types of interventions, integrative and consultative, focusing on the outcomes of patient and family satisfaction, mortality, and ICU and hospital length of stay (LOS), because these were most prevalent among studies. RESULTS Our search strategy yielded 3328 references, of which we included 37 publications detailing 30 unique interventions. Interventions and outcome measures were heterogeneous, and many studies were underpowered and/or subject to multiple biases. Most of the interventions resulted in a decrease in hospital and ICU LOS. Few interventions significantly affected satisfaction. With one exception, the interventions decreased or had no effect on mortality. There was no evidence of harm from any intervention. CONCLUSIONS Heterogeneity of interventions made comparison of ICU-based palliative care interventions difficult. However, existing evidence suggests proactive palliative care in the ICU, using either consultative or integrative palliative care interventions, decrease hospital and ICU LOS, do not affect satisfaction, and either decrease or do not affect mortality.
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Affiliation(s)
- Rebecca Aslakson
- 1 Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins School of Medicine , Baltimore, Maryland
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Kok VC. Compassionate extubation for a peaceful death in the setting of a community hospital: a case-series study. Clin Interv Aging 2015; 10:679-85. [PMID: 25897214 PMCID: PMC4396346 DOI: 10.2147/cia.s82760] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The use of compassionate extubation (CE) to alleviate suffering by terminating mechanical ventilation and withdrawing the endotracheal tube requires professional adherence and efficiency. The Hospice Palliative Care Act, amended on January 9, 2013, legalizes the CE procedure in Taiwan. METHODS From September 20, 2013 to September 2, 2014, the hospice palliative care team at a community hospital received 20 consultations for CE. Eight cases were excluded because of non-qualification. Following approval from the Ethics Committee, the medical records of the remaining 12 patients were reviewed and grouped by the underlying disease: A, "terminal-stage cancer"; B, "non-cancer out-of-hospital cardiac arrest"; and C, "non-cancer organ failure". Time to extubation using a cut-off at 48 hours was assessed. RESULTS The mean ages of patients (standard deviation) in groups A, B, and C were 66.3 (14.9) years, 72 (19.1) years, and 80.3 (4.0) years, respectively. The mean number of days of intubation at consultation were 6.8 (4.9), 7.3 (4.9), and 179.3 (271.6), respectively. The mean total doses of opioids (as morphine-equivalent dose) in the 24 hours preceding CE were 76 (87.5) mg, 3.3 (5.8) mg, and 43.3 (15.3) mg. The median times from extubation (range) to death were 97 (0.2-245) hours, 0.3 (0.2-0.4) hours, and 6.1 (3.6-71.8) hours. Compared to those requiring <48-hour preparatory time, patients requiring >48 hours to the moment of CE were younger (62.8 years vs 75.5 years), required a mean time of 122 hours (vs 30 hours) to CE (P=0.004), had shorter length of stay (33.3 days vs 77.8 days), required specialist social worker intervention in 75% of cases (vs 37.5%), and had a median duration of intubation of 11.5 days (vs 5.5 days). CONCLUSION CE was carried out according to protocol, and the median time from extubation to death varies determined by the underlying disease which was 0.3 hour in patients admitted after out-of-hospital cardiac arrest and 97 hours in patients with advanced cancer.
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Affiliation(s)
- Victor C Kok
- Division of Palliative Medicine and Hospice Palliative Care Team, Kuang Tien General Hospital, Asia University Taiwan, Taichung, Taiwan
- Department of Biomedical Informatics, Asia University Taiwan, Taichung, Taiwan
- Correspondence: Victor C Kok, Division of Palliative Medicine and Hospice Palliative Care Team, Kuang Tien General Hospital, Taichung 43303, Taiwan, Email
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Sellers DE, Dawson R, Cohen-Bearak A, Solomond MZ, Truog RD. Measuring the quality of dying and death in the pediatric intensive care setting: the clinician PICU-QODD. J Pain Symptom Manage 2015; 49:66-78. [PMID: 24878067 PMCID: PMC4247362 DOI: 10.1016/j.jpainsymman.2014.05.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Revised: 04/21/2014] [Accepted: 05/06/2014] [Indexed: 12/25/2022]
Abstract
CONTEXT In the pediatric intensive care setting, an accurate measure of the dying and death experience holds promise for illuminating how critical care nurses, physicians, and allied psychosocial staff can better manage end-of-life care for the benefit of children and their families, as well as the caregivers. OBJECTIVES The aim was to assess the reliability and validity of a clinician measure of the quality of dying and death (Pediatric Intensive Care Unit-Quality of Dying and Death 20 [PICU-QODD-20]) in the pediatric intensive care setting. METHODS In a retrospective cohort study, five types of clinicians (primary nurse, bedside nurse, attending physician, and the psychosocial clinician and critical care fellow most involved in the case) were asked to complete a survey for each of the 94 children who died over a 12 month period in the pediatric intensive care units of two children's hospitals in the northeast U.S. Analyses were conducted within type of clinician. RESULTS In total, 300 surveys were completed by 159 clinicians. Standard item analyses and substantive review led to the selection of 20 items for inclusion in the PICU-QODD-20. Cronbach alpha for the PICU-QODD-20 ranged from 0.891 for bedside nurses to 0.959 for attending physicians. For each type of clinician, the PICU-QODD-20 was significantly correlated with the quality of end-of-life care and with meeting the family's needs. In addition, when patient/family or team barriers were encountered, the PICU-QODD-20 score tended to be significantly lower than for cases in which the barrier was not encountered. CONCLUSION The PICU-QODD-20 shows promise as a valid and reliable measure of the quality of dying and death in pediatric intensive care.
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Affiliation(s)
- Deborah E Sellers
- Bronfenbrenner Center for Translational Research, Cornell University, Ithaca, New York, USA
| | - Ree Dawson
- Frontier Science and Technology Research Foundation, Boston, Massachusetts, USA
| | | | - Mildred Z Solomond
- The Hastings Center, Garrison, New York, USA; Division of Critical Care Medicine, Department of Anesthesiology, Boston Children's Hospital, Boston, Massachusetts, USA; Institute for Professionalism and Ethical Practice, Boston Children's Hospital, Boston, Massachusetts, USA; Division of Medical Ethics, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert D Truog
- Division of Critical Care Medicine, Department of Anesthesiology, Boston Children's Hospital, Boston, Massachusetts, USA; Institute for Professionalism and Ethical Practice, Boston Children's Hospital, Boston, Massachusetts, USA; Division of Medical Ethics, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.
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Abstract
OBJECTIVES Palliative care is an interprofessional specialty as well as an approach to care by all clinicians caring for patients with serious and complex illness. Unlike hospice, palliative care is based not on prognosis but on need and is an essential component of comprehensive care for critically ill patients from the time of ICU admission. In this clinically focused article, we review evidence of opportunities to improve palliative care for critically ill adults, summarize strategies for ICU palliative care improvement, and identify resources to support implementation. DATA SOURCES We searched the MEDLINE database from inception through January 2014. We also searched the Reference Library of The Improving Palliative Care in the ICU Project website sponsored by the National Institutes of Health and the Center to Advance Palliative Care, which is updated monthly. We hand-searched reference lists and author files. STUDY SELECTION Selected studies included all English-language articles concerning adult patients using the search terms 'intensive care' or 'critical care' with 'palliative care,' 'supportive care,' 'end-of-life care,' or 'ethics.' DATA EXTRACTION : After examination of peer-reviewed original scientific articles, consensus statements, guidelines, and reviews resulting from our literature search, we made final selections based on author consensus. DATA SYNTHESIS Existing evidence is organized to address: 1) opportunities to alleviate physical and emotional symptoms, improve communication, and provide support for patients and families; 2) models and specific interventions for improving ICU palliative care; 3) available resources for ICU palliative care improvement; and 4) ongoing challenges and targets for future research. Key domains of ICU palliative care have been defined and operationalized as measures of quality. There is increasing recognition that effective integration of palliative care during acute and chronic critical illness may help patients and families face challenges after discharge from intensive care. CONCLUSIONS Palliative care is increasingly accepted as an essential component of comprehensive care for critically ill patients, regardless of diagnosis or prognosis. A variety of strategies to improve ICU palliative care appear to be effective, and resources including technical assistance and tools are available to support improvement efforts. As the longer-term impact of intensive care on those surviving acute critical illness is increasingly documented, palliative care can help prepare and support patients and families for challenges after ICU discharge. Further research is needed to inform efforts to integrate palliative care with intensive care more effectively and efficiently in and after the ICU and to document improvement using valid and responsive outcome measures.
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Affiliation(s)
- Rebecca A Aslakson
- 1Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, MD. 2The Palliative Care Program at the Kimmel Cancer Center at Johns Hopkins, The Johns Hopkins School of Medicine, Baltimore, MD. 3Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, WA. 4Division of Pulmonary, Critical Care and Sleep Medicine and Hertzberg Palliative Care Institute, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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Lam KW, Yeung KWA, Lai KY, Cheng F. Changes in the Attitude and Practice Toward End-of-Life Care: Perspective of Chinese Physicians in Medical Department. Am J Hosp Palliat Care 2014; 32:549-54. [PMID: 24819729 DOI: 10.1177/1049909114531645] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION End-of-life care is affected by the attitude and cultural influence of doctors. METHODS To investigate the attitudes and practices of doctors on end-of-life care by questionnaire survey in 2004 and 2008. RESULTS In 2004, 31.7% of the respondents agreed that they "do not attempt resuscitation" (DNAR) form was useful and it rose to 54.4% in 2008. A higher proportion of respondents in 2008 claimed that they signed the DNAR form for documentation and accepted withholding noninvasive life-sustaining treatment compared to 2004. In 2004, 50% of the respondents regarded their training and education on handling DNAR issue as inadequate. CONCLUSION Documentation by DNAR form is gaining wider acceptance. Many doctors are expected to have more training and coaching on communication for handling such sensitive issues.
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Affiliation(s)
- K W Lam
- Intensive Care Unit, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - K W Au Yeung
- Intensive Care Unit, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - K Y Lai
- Intensive Care Unit, Queen Elizabeth Hospital, Kowloon, Hong Kong
| | - F Cheng
- Intensive Care Unit, Queen Elizabeth Hospital, Kowloon, Hong Kong
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Saft HL, Richman PS, Berman AR, Mularski RA, Kvale PA, Ray DE, Selecky P, Ford DW, Asch SM. Impact of critical care medicine training programs' palliative care education and bedside tools on ICU use at the end of life. J Grad Med Educ 2014; 6:44-9. [PMID: 24701309 PMCID: PMC3963793 DOI: 10.4300/jgme-06-01-38] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Revised: 07/17/2013] [Accepted: 07/30/2013] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Intensive care unit (ICU) use at the end of life is rising. Little research has focused on associations among critical care fellows' training, institutional support, and bedside tools with ICU use at the end of life. OBJECTIVE We evaluated whether hospital and critical care medicine program interventions were associated with ICU use in the last 6 months of life for patients with chronic illness. METHODS Our observational, retrospective study explored associations between results from a survey of critical care program directors and hospital-level Medicare data on ICU use in the last 6 months of life. Program directors evaluated quality of palliative care education in their critical care fellowships and reported on the number of bedside tools and the presence or absence of an inpatient palliative care consultation service. RESULTS For the 89 hospitals and 71 affiliated training programs analyzed, there were statistically significant relationships between 2 of the explanatory variables-the quality of palliative care education and the number of bedside tools-in ICU use. Each level of increased educational quality (1-5 Likert scale) was associated with a 0.57-day decrease in ICU days, whereas, for each additional, evidence-based bedside tool, there was a 0.31-day decrease. The presence of an inpatient palliative care program was not a significant predictor of ICU use. CONCLUSIONS We found that the quality of palliative care training in critical care medicine programs and the use of bedside tools were independently associated with reduced ICU use at the end of life.
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Kramer AH, Zygun DA. Donation after Circulatory Determination of Death: We Need to Respect and Protect Brain-injured Patients. Am J Respir Crit Care Med 2014; 189:504-5. [DOI: 10.1164/rccm.201308-1524le] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Masood UR, Said A, Faris C, Al Mussady M, Al Jundi A. Limiting intensive care therapy in dying critically Ill patients: Experience from a tertiary care center in United Arab Emirates. Int J Crit Illn Inj Sci 2014; 3:200-5. [PMID: 24404458 PMCID: PMC3883199 DOI: 10.4103/2229-5151.119201] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Limitations of life-support interventions, by either withholding or withdrawing support, are integrated parts of intensive care unit (ICU) activities and are ethically acceptable. The end-of-life legal aspects and practices in United Arab Emirates ICUs are rarely mentioned in the medical literature. The objective of this study was to examine the current practice of limiting futile life-sustaining therapies in our ICU, modalities for implementing of these decisions, and documentations in dying critically ill patients. Materials and Methods: This was a retrospective observational study conducted at our ICU. We studied all ICU patients who died from September 2008 to February 2009. Patients’ baseline demo-graphics, past medical problems, diagnosis on admission to ICU, and decision to withhold, withdraw and their modalities were collected. Methods: This was a retrospective observational study conducted at our ICU. We studied all ICU patients who died from September 2008 to February 2009. Patients’ baseline demo-graphics, past medical problems, diagnosis on admission to ICU, and decision to withhold, withdraw and their modalities were collected. Results: The electronic medical records of 67 patients were reviewed. The commonest method of limiting therapy was no escalation 53.6%. Interventions were withheld in 41.5%. “Do not resuscitate” order was documented in only 16.3%. The commonest method of documenting limitation of therapy was discussion with the family and documenting the prognosis and futility of additional therapy (73.3%). Patients who died early (<48 hrs) compared to patients who died late (>48 hrs) of ICU admission received terminal cardiopulmonary resuscitation more frequently (P < 0.007), had less frequent prognosis documentation (P < 0.009), and had more vasopressors administered (P < 0.006). Conclusion: Withholding therapy after discussion with the family was the preferred mode of limiting therapy in a dying patient.
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Affiliation(s)
- Ur Rahman Masood
- Department of Critical Care Medicine, Tawam Hospital, P.O. Box 15258, Al Ain, Dubai, United Arab Emirates
| | - Abuhasna Said
- Department of Critical Care Medicine, Tawam Hospital, P.O. Box 15258, Al Ain, Dubai, United Arab Emirates
| | - Chedid Faris
- Department of Neonatal Intensive Care Medicine, Tawam Hospital, P.O. Box 15258, Al Ain, Dubai, United Arab Emirates
| | - Mousab Al Mussady
- Department of Critical Care Medicine, Tawam Hospital, P.O. Box 15258, Al Ain, Dubai, United Arab Emirates
| | - Amer Al Jundi
- Department of Pharmacy, Tawam Hospital, P.O. Box 15258, Al Ain, Dubai, United Arab Emirates
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Hashmi ZG, Haider AH, Zafar SN, Kisat M, Moosa A, Siddiqui F, Pardhan A, Latif A, Zafar H. Hospital-based trauma quality improvement initiatives: first step toward improving trauma outcomes in the developing world. J Trauma Acute Care Surg 2013; 75:60-8; discussion 68. [PMID: 23778440 DOI: 10.1097/ta.0b013e31829880a0] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Injuries remain a leading cause of death in the developing world. Whereas new investments are welcome, quality improvement (QI) at the currently available trauma care facilities is essential. The objective of this study was to determine the effect and long-term sustainability of trauma QI initiatives on in-hospital mortality and complications at a large tertiary hospital in a developing country. METHODS In 2002, a specialized trauma team was formed (members trained using advanced trauma life support), and a western style trauma program established including a registry and quality assurance program. Patients from 1998 onward were entered in to this registry, enabling a preimplementation and postimplementation study. Adults (>15 years) with blunt or penetrating trauma were analyzed. The main outcomes of interest were (1) in-hospital mortality and (2) occurrence of any complication. Multiple logistic regression was performed to assess the impact of formalized trauma care on outcomes, controlling for covariates reaching significance in the bivariate analyses. RESULTS A total of 1,227 patient records were analyzed. Patient demographics and injury characteristics are described in Table 1. Overall in-hospital mortality rate was 6.4%, and the complication rate was 11.1%. On multivariate analysis, patients admitted during the trauma service years were 4.9 times less likely to die (95% confidence interval, 1.77-13.57) and 2.60 times (odds ratio; 95% confidence interval, 1.29-5.21) less likely to have a complication compared with those treated in the pretrauma service years. CONCLUSION Despite significant delays in hospital transit and lack of prehospital trauma care, hospital level implementation of trauma QI program greatly decreases mortality and complication rates in the developing world. LEVEL OF EVIDENCE Care management study, level IV.
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Affiliation(s)
- Zain G Hashmi
- Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
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Cox CE, Govert JA, Shanawani H, Abernethy AP. Providing palliative care for patients receiving mechanical ventilation in an intensive care unit Part 2: Withdrawing ventilation. PROGRESS IN PALLIATIVE CARE 2013. [DOI: 10.1179/096992605x48642] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Abstract
OBJECTIVES Order sets are widely used in hospitals to enter diagnosis and treatment orders. To determine the effectiveness of order sets in improving guideline adherence, treatment outcomes, processes of care, efficiency, and cost, we conducted a systematic review of the literature. METHODS A comprehensive literature search was performed in various databases for studies published between January 1, 1990, and April 18, 2009. A total of eighteen studies met inclusion criteria. No randomized controlled trials were found. RESULTS Outcomes of the included studies were summarized qualitatively due to variations in study population, intervention type, and outcome measures. There were no important inconsistencies between the results reported by studies involving different types of order sets. While the studies generally suggested positive outcomes, they were typically of low quality, with simple before-after designs and other methodological limitations. CONCLUSIONS The benefits of order sets remain eminently plausible, but given the paucity of high quality evidence, further investigations to formally evaluate the effectiveness of order sets would be highly valuable.
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Abstract
Withdrawal of life support is an option for patients with prolonged mechanical ventilation when all attempts at weaning have failed and it is deemed futile to continue the therapy, when quality of life is unacceptable, or when it is perceived that the patient is suffering. The purpose of this article is to present the nursing aspects of managing an adult patient undergoing the withdrawal of mechanical ventilation as an end-of-life procedure. Withdrawal of mechanical ventilation is a complex and difficult process that requires meticulous planning and management. Conferences with the patient and the patient's family are critical to addressing emotional support and ensuring that everyone understands the process and is provided an opportunity to gather information. Clear communication with patients and their families can ensure that the process goes smoothly. Having an organized approach can ensure that patients experience a peaceful death and staff experience closure regarding the event.
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Affiliation(s)
- Kathleen M Stacy
- Intermediate Care Unit, Palomar Medical Center, 555 Valley Parkway, Escondido, CA 92025, USA.
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Papadimos TJ, Maldonado Y, Tripathi RS, Kothari DS, Rosenberg AL. An overview of end-of-life issues in the intensive care unit. Int J Crit Illn Inj Sci 2012; 1:138-46. [PMID: 22229139 PMCID: PMC3249847 DOI: 10.4103/2229-5151.84801] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The population of the earth is aging, and as medical techniques, pharmaceuticals, and devices push the boundaries of human physiological capabilities, more humans will go on to live longer. However, this prolonged existence may involve incapacities, particularly at the end-of-life, and especially in the intensive care unit. This arena involves not only patients and families, but also care givers. It involves topics from economics to existentialism, and surgery to spiritualism. It requires education, communication, acceptance of diversity, and an ultimate acquiescence to the inevitable. Here, we present a comprehensive overview of issues in the care of patients at the end-of-life stage that may cause physicians and other healthcare providers, medical, ethical, social, and philosophical concerns in the intensive care unit.
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Affiliation(s)
- Thomas J Papadimos
- Department of Anesthesiology, Division of Critical Care Medicine, The Ohio State University Medical Center, Columbus OH 43210, USA
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Damghi N, Belayachi J, Aggoug B, Dendane T, Abidi K, Madani N, Zekraoui A, Belabes AB, Zeggwagh AA, Abouqal R. Withholding and withdrawing life-sustaining therapy in a Moroccan Emergency Department: an observational study. BMC Emerg Med 2011; 11:12. [PMID: 21838861 PMCID: PMC3199862 DOI: 10.1186/1471-227x-11-12] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2011] [Accepted: 08/12/2011] [Indexed: 11/18/2022] Open
Abstract
Background Withdrawing and withholding life-support therapy (WH/WD) are undeniably integrated parts of medical activity. However, Emergency Department (ED) might not be the most appropriate place to give end-of life (EOL) care; the legal aspects and practices of the EOL care in emergency rooms are rarely mentioned in the medical literature and should be studied. The aims of this study were to assess frequency of situations where life-support therapies were withheld or withdrawn and modalities for implement of these decisions. Method A survey of patients who died in a Moroccan ED was performed. Confounding variables examined were: Age, gender, chronic underlying diseases, acute medical disorders, APACHE II score, Charlson Comorbidities Index, and Length of stay. If a decision of WH/WD was taken, additional data were collected: Type of decision; reasons supporting the decision, modalities of WH/WD, moment, time from ED admission to decision, and time from processing to withhold or withdrawal life-sustaining treatment to death. Individuals who initiated (single emergency physician, medical staff), and were involved in the decision (nursing staff, patients, and families), and documentation of the decision in the medical record. Results 177 patients who died in ED between November 2009 and March 2010 were included. Withholding and withdrawing life-sustaining treatment was applied to 30.5% of all patients who died. Therapies were withheld in 24.2% and were withdrawn in 6.2%. The most reasons for making these decisions were; absence of improvement following a period of active treatment (61.1%), and expected irreversibility of acute disorder in the first 24 h (42.6%). The most common modalities withheld or withdrawn life-support therapy were mechanical ventilation (17%), vasopressor and inotrops infusion (15.8%). Factors associated with WH/WD decisions were older age (OR = 1.1; 95%IC = 1.01-1.07; P = 0.001), neurological acute medical disorders (OR = 4.1; 95%IC = 1.48-11.68; P = 0.007), malignancy (OR = 7.7; 95%IC = 1.38-8.54; P = 0.002) and cardiovascular (OR = 3.4;95%IC = 2.06-28.5;P = 0.008) chronic underlying diseases. Conclusion Life-sustaining treatment were frequently withheld or withdrawn from elderly patients with underlying chronic cardiovascular disease or metastatic cancer or patients with acute neurological medical disorders in a Moroccan ED. Religious beliefs and the lack of guidelines and official Moroccan laws could explain the ethical limitations of the decision-making process recorded in this study.
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Affiliation(s)
- Nada Damghi
- Medical Emergency Department, Ibn Sina University Hospital, 10000, Rabat, Morocco
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Aslakson R, Pronovost PJ. Health care quality in end-of-life care: promoting palliative care in the intensive care unit. Anesthesiol Clin 2011; 29:111-22. [PMID: 21295756 DOI: 10.1016/j.anclin.2010.11.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Seminal articles published in the late 1990s instigated not only an intense interest in health care quality but also a new era of research into quality end-of-life care, particularly in intensive care units (ICUs). ICUs can improve health care quality at the end of life by better using palliative care services and palliative care-related principles. This article details how the interest in health care quality has spurred a similar interest in end-of-life and palliative care in ICUs, defines palliative care and describes how it improves health care quality, and highlights barriers to the incorporation of palliative care in ICUs.
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Affiliation(s)
- Rebecca Aslakson
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins School of Medicine, 600 North Wolfe Street, Meyer 297A, Baltimore, MD 21287, USA
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