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Lott DT. Thanato-technics: Temporal Horizons of Death and Dying. Cult Med Psychiatry 2024:10.1007/s11013-024-09877-1. [PMID: 39365496 DOI: 10.1007/s11013-024-09877-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/02/2024] [Indexed: 10/05/2024]
Abstract
Advances in end-of-life technologies increasingly destabilize received notions of personhood, identity, and ethics. As notions of personhood and identity within such systems are made to conform to discrete, binary and less fluid categories, some in the West have sought guidance in the techniques and views related to the dying process cultivated in other cultures, particularly Tibetan Buddhism. This article considers such dynamics as they unfolded in research focused on the postmortem bodies of Tibetan Buddhist practitioners in India. This article introduces the term thanato-technics to highlight the temporalities, imaginary or otherwise, evoked, enabled, and invested through the use of technologies to ascertain or conjecture about the intrasubjectivity of the dead and dying.
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Affiliation(s)
- Dylan T Lott
- Center for Healthy Minds, University of Wisconsin-Madison, Madison, USA.
- Comer Children's Hospital, The University of Chicago, Chicago, USA.
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2
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Bryan AF, Reich AJ, Norton AC, Campbell ML, Schwartzstein RM, Cooper Z, White DB, Mitchell SL, Fehnel CR. Process of Withdrawal of Mechanical Ventilation at End of Life in the ICU: Clinician Perceptions. CHEST CRITICAL CARE 2024; 2:100051. [PMID: 38957855 PMCID: PMC11218830 DOI: 10.1016/j.chstcc.2024.100051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Abstract
BACKGROUND Nearly one-quarter of all Americans die in the ICU. Many of their deaths are anticipated and occur following the withdrawal of mechanical ventilation (WMV). However, there are few data on which to base best practices for interdisciplinary ICU teams to conduct WMV. RESEARCH QUESTION What are the perceptions of current WMV practices among ICU clinicians, and what are their opinions of processes that might improve the practice of WMV at end of life in the ICU? STUDY DESIGN AND METHODS This prospective two-center observational study conducted in Boston, Massachusetts, the Observational Study of the Withdrawal of Mechanical Ventilation (OBSERVE-WMV) was designed to better understand the perspectives of clinicians and experience of patients undergoing WMV. This report focuses on analyses of qualitative data obtained from in-person surveys administered to the ICU clinicians (nurses, respiratory therapists, and physicians) caring for these patients. Surveys assessed a broad range of clinician perspectives on planning, as well as the key processes required for WMV. This analysis used independent open, inductive coding of responses to open-ended questions. Initial codes were reconciled iteratively and then organized and interpreted using a thematic analysis approach. Opinions were assessed on how WMV could be improved for individual patients and the ICU as a whole. RESULTS Among 456 eligible clinicians, 312 in-person surveys were completed by clinicians caring for 152 patients who underwent WMV. Qualitative analyses identified two main themes characterizing high-quality WMV processes: (1) good communication (eg, mutual understanding of family preferences) between the ICU team and family; and (2) medical management (eg, planning, availability of ICU team) that minimizes patient distress. Team member support was identified as an essential process component in both themes. INTERPRETATION Clinician perceptions of the appropriateness or success of WMV prioritize the quality of team and family communication and patient symptom management. Both are modifiable targets of interventions aimed at optimizing overall WMV.
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Affiliation(s)
- Ava Ferguson Bryan
- Department of Surgery (A. F. B.), The University of Chicago, Chicago, IL; Center for Surgery and Public Health, Brigham & Women's Hospital (A. F. B. and A. J. R.), Boston, MA; Beth Israel Deaconess Medical Center/Harvard Medical School (A. C. N., R. M. S., S. L. M., and C. R. F.), Boston, MA; Wayne State University (M. L. C.), Detroit, MI; Brigham and Women's Hospital/Harvard Medical School (Z. C.), Boston, MA; University of Pittsburgh School of Medicine (D. B. W.), Pittsburgh, PA; and the Marcus Institute for Aging Research (S. L. M. and C. R. F.), Hebrew Senior Life, Boston, MA
| | - Amanda J Reich
- Department of Surgery (A. F. B.), The University of Chicago, Chicago, IL; Center for Surgery and Public Health, Brigham & Women's Hospital (A. F. B. and A. J. R.), Boston, MA; Beth Israel Deaconess Medical Center/Harvard Medical School (A. C. N., R. M. S., S. L. M., and C. R. F.), Boston, MA; Wayne State University (M. L. C.), Detroit, MI; Brigham and Women's Hospital/Harvard Medical School (Z. C.), Boston, MA; University of Pittsburgh School of Medicine (D. B. W.), Pittsburgh, PA; and the Marcus Institute for Aging Research (S. L. M. and C. R. F.), Hebrew Senior Life, Boston, MA
| | - Andrea C Norton
- Department of Surgery (A. F. B.), The University of Chicago, Chicago, IL; Center for Surgery and Public Health, Brigham & Women's Hospital (A. F. B. and A. J. R.), Boston, MA; Beth Israel Deaconess Medical Center/Harvard Medical School (A. C. N., R. M. S., S. L. M., and C. R. F.), Boston, MA; Wayne State University (M. L. C.), Detroit, MI; Brigham and Women's Hospital/Harvard Medical School (Z. C.), Boston, MA; University of Pittsburgh School of Medicine (D. B. W.), Pittsburgh, PA; and the Marcus Institute for Aging Research (S. L. M. and C. R. F.), Hebrew Senior Life, Boston, MA
| | - Margaret L Campbell
- Department of Surgery (A. F. B.), The University of Chicago, Chicago, IL; Center for Surgery and Public Health, Brigham & Women's Hospital (A. F. B. and A. J. R.), Boston, MA; Beth Israel Deaconess Medical Center/Harvard Medical School (A. C. N., R. M. S., S. L. M., and C. R. F.), Boston, MA; Wayne State University (M. L. C.), Detroit, MI; Brigham and Women's Hospital/Harvard Medical School (Z. C.), Boston, MA; University of Pittsburgh School of Medicine (D. B. W.), Pittsburgh, PA; and the Marcus Institute for Aging Research (S. L. M. and C. R. F.), Hebrew Senior Life, Boston, MA
| | - Richard M Schwartzstein
- Department of Surgery (A. F. B.), The University of Chicago, Chicago, IL; Center for Surgery and Public Health, Brigham & Women's Hospital (A. F. B. and A. J. R.), Boston, MA; Beth Israel Deaconess Medical Center/Harvard Medical School (A. C. N., R. M. S., S. L. M., and C. R. F.), Boston, MA; Wayne State University (M. L. C.), Detroit, MI; Brigham and Women's Hospital/Harvard Medical School (Z. C.), Boston, MA; University of Pittsburgh School of Medicine (D. B. W.), Pittsburgh, PA; and the Marcus Institute for Aging Research (S. L. M. and C. R. F.), Hebrew Senior Life, Boston, MA
| | - Zara Cooper
- Department of Surgery (A. F. B.), The University of Chicago, Chicago, IL; Center for Surgery and Public Health, Brigham & Women's Hospital (A. F. B. and A. J. R.), Boston, MA; Beth Israel Deaconess Medical Center/Harvard Medical School (A. C. N., R. M. S., S. L. M., and C. R. F.), Boston, MA; Wayne State University (M. L. C.), Detroit, MI; Brigham and Women's Hospital/Harvard Medical School (Z. C.), Boston, MA; University of Pittsburgh School of Medicine (D. B. W.), Pittsburgh, PA; and the Marcus Institute for Aging Research (S. L. M. and C. R. F.), Hebrew Senior Life, Boston, MA
| | - Douglas B White
- Department of Surgery (A. F. B.), The University of Chicago, Chicago, IL; Center for Surgery and Public Health, Brigham & Women's Hospital (A. F. B. and A. J. R.), Boston, MA; Beth Israel Deaconess Medical Center/Harvard Medical School (A. C. N., R. M. S., S. L. M., and C. R. F.), Boston, MA; Wayne State University (M. L. C.), Detroit, MI; Brigham and Women's Hospital/Harvard Medical School (Z. C.), Boston, MA; University of Pittsburgh School of Medicine (D. B. W.), Pittsburgh, PA; and the Marcus Institute for Aging Research (S. L. M. and C. R. F.), Hebrew Senior Life, Boston, MA
| | - Susan L Mitchell
- Department of Surgery (A. F. B.), The University of Chicago, Chicago, IL; Center for Surgery and Public Health, Brigham & Women's Hospital (A. F. B. and A. J. R.), Boston, MA; Beth Israel Deaconess Medical Center/Harvard Medical School (A. C. N., R. M. S., S. L. M., and C. R. F.), Boston, MA; Wayne State University (M. L. C.), Detroit, MI; Brigham and Women's Hospital/Harvard Medical School (Z. C.), Boston, MA; University of Pittsburgh School of Medicine (D. B. W.), Pittsburgh, PA; and the Marcus Institute for Aging Research (S. L. M. and C. R. F.), Hebrew Senior Life, Boston, MA
| | - Corey R Fehnel
- Department of Surgery (A. F. B.), The University of Chicago, Chicago, IL; Center for Surgery and Public Health, Brigham & Women's Hospital (A. F. B. and A. J. R.), Boston, MA; Beth Israel Deaconess Medical Center/Harvard Medical School (A. C. N., R. M. S., S. L. M., and C. R. F.), Boston, MA; Wayne State University (M. L. C.), Detroit, MI; Brigham and Women's Hospital/Harvard Medical School (Z. C.), Boston, MA; University of Pittsburgh School of Medicine (D. B. W.), Pittsburgh, PA; and the Marcus Institute for Aging Research (S. L. M. and C. R. F.), Hebrew Senior Life, Boston, MA
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Murphy NB, Shemie SD, Capron A, Truog RD, Nakagawa T, Healey A, Gofton T, Bernat JL, Fenton K, Khush KK, Schwartz B, Wall SP. Advancing the Scientific Basis for Determining Death in Controlled Organ Donation After Circulatory Determination of Death. Transplantation 2024:00007890-990000000-00733. [PMID: 38637919 DOI: 10.1097/tp.0000000000005002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
In controlled organ donation after circulatory determination of death (cDCDD), accurate and timely death determination is critical, yet knowledge gaps persist. Further research to improve the science of defining and determining death by circulatory criteria is therefore warranted. In a workshop sponsored by the National Heart, Lung, and Blood Institute, experts identified research opportunities pertaining to scientific, conceptual, and ethical understandings of DCDD and associated technologies. This article identifies a research strategy to inform the biomedical definition of death, the criteria for its determination, and circulatory death determination in cDCDD. Highlighting knowledge gaps, we propose that further research is needed to inform the observation period following cessation of circulation in pediatric and neonatal populations, the temporal relationship between the cessation of brain and circulatory function after the withdrawal of life-sustaining measures in all patient populations, and the minimal pulse pressures that sustain brain blood flow, perfusion, activity, and function. Additionally, accurate predictive tools to estimate time to asystole following the withdrawal of treatment and alternative monitoring modalities to establish the cessation of circulatory, brainstem, and brain function are needed. The physiologic and conceptual implications of postmortem interventions that resume circulation in cDCDD donors likewise demand attention to inform organ recovery practices. Finally, because jurisdictionally variable definitions of death and the criteria for its determination may impede collaborative research efforts, further work is required to achieve consensus on the physiologic and conceptual rationale for defining and determining death after circulatory arrest.
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Affiliation(s)
- Nicholas B Murphy
- Departments of Medicine and Philosophy, Western University, London, ON, Canada
| | - Sam D Shemie
- Division of Critical Care Medicine, Montreal Children's Hospital, McGill University, Montreal, QC, Canada
- System Development, Canadian Blood Services, Ottawa, ON, Canada
| | - Alex Capron
- Gould School of Law and Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Robert D Truog
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA
| | - Thomas Nakagawa
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Florida College of Medicine-Jacksonville, Jacksonville, FL
| | - Andrew Healey
- Ontario Health (Trillium Gift of Life Network), Toronto, ON, Canada
- Divisions of Emergency and Critical Care Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Teneille Gofton
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - James L Bernat
- Department of Neurology, Dartmouth Geisel School of Medicine, Hanover, NH
| | - Kathleen Fenton
- Advanced Technologies and Surgery Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Department of Bioethics, Clinical Center, National Institutes of Health, Bethesda, MD
| | - Kiran K Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Bryanna Schwartz
- Heart Development and Structural Diseases Branch, Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
- Division of Cardiology, Children's National Hospital, Washington, DC
| | - Stephen P Wall
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY
- Department of Population Health, NYU Grossman School of Medicine, New York, NY
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Mazzu MA, Campbell ML, Schwartzstein RM, White DB, Mitchell SL, Fehnel CR. Evidence Guiding Withdrawal of Mechanical Ventilation at the End of Life: A Review. J Pain Symptom Manage 2023; 66:e399-e426. [PMID: 37244527 PMCID: PMC10527530 DOI: 10.1016/j.jpainsymman.2023.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 05/10/2023] [Accepted: 05/19/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVE Distress at the end of life in the intensive care unit (ICU) is common. We reviewed the evidence guiding symptom assessment, withdrawal of mechanical ventilation (WMV) process, support for the ICU team, and symptom management among adults, and specifically older adults, at end of life in the ICU. SETTING AND DESIGN Systematic search of published literature (January 1990-December 2021) pertaining to WMV at end of life among adults in the ICU setting using PubMed, Embase, and Web of Science. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed. PARTICIPANTS Adults (age 18 and over) undergoing WMV in the ICU. MEASUREMENTS Study quality was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. RESULTS Out of 574 articles screened, 130 underwent full text review, and 74 were reviewed and assessed for quality. The highest quality studies pertained to use of validated symptom scales during WMV. Studies of the WMV process itself were generally lower quality. Support for the ICU team best occurs via structured communication and social supports. Dyspnea is the most distressing symptom, and while high quality evidence supports the use of opiates, there is limited evidence to guide implementation of their use for specific patients. CONCLUSION High quality studies support some practices in palliative WMV, while gaps in evidence remain for the WMV process, supporting the ICU team, and medical management of distress. Future studies should rigorously compare WMV processes and symptom management to reduce distress at end of life.
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Affiliation(s)
- Maria A Mazzu
- University of New England College of Osteopathic Medicine (M.A.M.), Biddeford, Maine, USA
| | | | - Richard M Schwartzstein
- Beth Israel Deaconess Medical Center (R.M.S., S.L.M., C.R.F.), Boston, Massachusetts, USA; Harvard Medical School (R.M.S., S.L.M., C.R.F.), Boston, Massachusetts, USA
| | - Douglas B White
- University of Pittsburgh School of Medicine (D.B.W.), Pittsburgh, Pennsylvania, USA
| | - Susan L Mitchell
- Beth Israel Deaconess Medical Center (R.M.S., S.L.M., C.R.F.), Boston, Massachusetts, USA; Harvard Medical School (R.M.S., S.L.M., C.R.F.), Boston, Massachusetts, USA; Hebrew SeniorLife, Marcus Institute for Aging Research (S.L.M., C.R.F.), Boston, Massachusetts, USA
| | - Corey R Fehnel
- Beth Israel Deaconess Medical Center (R.M.S., S.L.M., C.R.F.), Boston, Massachusetts, USA; Harvard Medical School (R.M.S., S.L.M., C.R.F.), Boston, Massachusetts, USA; Hebrew SeniorLife, Marcus Institute for Aging Research (S.L.M., C.R.F.), Boston, Massachusetts, USA.
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Shahin J, Scales NB, Johara F, Hogue M, Hornby L, Shemie S, Schmidt M, Waldauf P, Duska F, Wind T, Van Mook WN, Dhanani S. Is the process of withdrawal of life-sustaining measures in the intensive care unit different for deceased organ donors compared with other dying patients? A secondary analysis of prospectively collected data. BMJ Open 2023; 13:e069536. [PMID: 37597867 PMCID: PMC10441082 DOI: 10.1136/bmjopen-2022-069536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 07/10/2023] [Indexed: 08/21/2023] Open
Abstract
OBJECTIVE To investigate whether observable differences exist between patterns of withdrawal of life-sustaining measures (WLSM) for patients eligible for donation after circulatory death (DCD) in whom donation was attempted compared with those patients in whom no donation attempts were made. SETTING Adult intensive care units from 20 centres in Canada, the Czech Republic and the Netherlands. DESIGN Secondary analysis of quantitative data collected as part of a large, prospective, cohort study (the Death Prediction and Physiology after Removal of Therapy study). PARTICIPANTS Patients ≥18 years of age who died after a controlled WLSM in an intensive care unit. Patients were classified as not DCD eligible, DCD eligible with DCD attempted or DCD eligible but DCD was not attempted. PRIMARY AND SECONDARY OUTCOME MEASURES The process of WLSM (timing and type and, if applicable, dosages of measures withdrawn, dosages of analgesics/sedatives) was compared between groups. RESULTS Of the 635 patients analysed, 85% had either cardiovascular support stopped or were extubated immediately on WLSM. Of the DCD eligible patients, more were immediately extubated at the initiation of WLSM when DCD was attempted compared with when DCD was not attempted (95% vs 61%, p<0.0001). Initiation of WLSM with the immediate cessation of cardiovascular measures or early extubation was associated with earlier time to death, even after adjusting for confounders (OR 2.94, 95% CI 1.39 to 6.23, at 30 min). Other than in a few patients who received propofol, analgesic and sedative dosing after WLSM between DCD attempted and DCD eligible but not attempted patients was not significantly different. All patients died. CONCLUSIONS Patients in whom DCD is attempted may receive a different process of WLSM. This highlights the need for a standardised and transparent process for end-of-life care across the spectrum of critically ill patients and potential organ donors.
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Affiliation(s)
- J Shahin
- Division of Critical Care, Respiratory Epidemiology and Clinical Research Unit, McGill University Faculty of Medicine, Montreal, Québec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Québec, Canada
| | | | - F Johara
- Research Institute of the McGill University Health Centre, Montreal, Québec, Canada
| | - M Hogue
- CHEO, Ottawa, Ontario, Canada
| | - Laura Hornby
- System Development, Canadian Blood Services Organ Donation and Transplantation, Ottawa, Ontario, Canada
| | - Sam Shemie
- Division of Critical Care, Department of Pediatrics, Montreal Childrens Hospital, Montreal, Québec, Canada
- System Development, Canadian Blood Services, Ottawa, Ontario, Canada
| | - M Schmidt
- Third Faculty of Medicine, Charles University, Praha, Czech Republic
- FNKV University Hospital, Prague, Czech Republic
| | - P Waldauf
- Third Faculty of Medicine, Charles University, Praha, Czech Republic
- FNKV University Hospital, Prague, Czech Republic
| | - F Duska
- Third Faculty of Medicine, Charles University, Praha, Czech Republic
- FNKV University Hospital, Prague, Czech Republic
| | - Tineke Wind
- Maastricht University Medical Centre, Maastricht, The Netherlands
- Heart and Vascular Center, Maastricht, The Netherlands
| | - W N Van Mook
- Deparment of Intensive Care Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Sonny Dhanani
- Critical Pediatric Critical Care Medicine, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
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Gofton T, Dhanani S, Meade M, Boyd JG, Chamberlain E, Chandler J, Chassé M, Scales NB, Choi YH, D'Aragon F, Debicki D, English S, Fantaneanu TA, Kramer AH, Kromm J, Murphy N, Norton L, Singh J, Smith MJ, Weijer C, Shemie S, Bentall TC, Campbell E, Slessarev M. Neurologic Physiology after Removal of Therapy (NeuPaRT) study: study protocol of a multicentre, prospective, observational, pilot feasibility study of neurophysiology after withdrawal of life-sustaining measures. BMJ Open 2023; 13:e073643. [PMID: 37105694 PMCID: PMC10152060 DOI: 10.1136/bmjopen-2023-073643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/29/2023] Open
Abstract
INTRODUCTION In donation after circulatory determination of death, death is declared 5 min after circulatory arrest. This practice assumes, but does not explicitly confirm, permanent loss of brain activity. While this assumption is rooted a strong physiological rationale, paucity of direct human data regarding temporal relationship between cessation of brain activity and circulatory arrest during the dying process threatens public and healthcare provider trust in deceased organ donation. METHODS AND ANALYSIS In this cohort study, we will prospectively record cerebral and brainstem electrical activity, cerebral blood flow velocity and arterial blood pressure using electroencephalography (EEG), brainstem evoked potentials, transcranial doppler and bedside haemodynamic monitors in adult patients undergoing planned withdrawal of life sustaining measures in the intensive care units at five hospital sites for 18 months. We will use MATLAB to synchronise waveform data and compute the time of cessation of each signal relative to circulatory arrest. Our primary outcome is the feasibility of patient accrual, while secondary outcomes are (a) proportion of patients with complete waveform recordings and data transfer to coordinating site and (b) time difference between cessation of neurophysiological signals and circulatory arrest. We expect to accrue 1 patient/site/month for a total of 90 patients. ETHICS AND DISSEMINATION We have ethics approval from Clinical Trials Ontario (protocol #3862, version 1.0, date 19 January 2022.) and the relevant Research Ethics Board for each site. We will obtain written informed consent from legal substitute decision makers. We will present study results at research conferences including donor family partner forum and in peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT05306327.
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Affiliation(s)
- Teneille Gofton
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Sonny Dhanani
- Pediatric Critical Care, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Maureen Meade
- Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - John Gordon Boyd
- Departments of Neurology and Critical Care, Queen's University, Kingston, Ontario, Canada
| | | | | | - Michaël Chassé
- Department of Medicine, Centre Hospitalier de Montréal, Montréal, Québec, Canada
| | - Nathan B Scales
- Dynamical Analysis Laboratory, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Yun-Hee Choi
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Frédérick D'Aragon
- Department of Anesthesiology, Universite de Sherbrooke Faculte de medecine et des sciences de la sante, Sherbrooke, Quebec, Canada
- Centre de recherche du CHUS, Sherbrooke, Quebec, Canada
| | - Derek Debicki
- Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada
| | - Shane English
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Tadeu A Fantaneanu
- Department of Medicine, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Andreas H Kramer
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Julie Kromm
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nicholas Murphy
- Philosophy and Medicine, Western University, London, Ontario, Canada
| | - Loretta Norton
- Department of Psychology, King's University College at Western University, London, Ontario, Canada
| | - Jeffrey Singh
- Interdepartmental Division of Critical Care Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
- Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Maxwell J Smith
- School of Health Studies, Faculty of Health Sciences and Rotman Institute of Philosophy, Western University, London, ON, Canada
| | - Charles Weijer
- Department of Philosophy, Western University, London, Ontario, Canada
| | - Sam Shemie
- Pediatric Intensive Care, McGill University, Montreal, Québec, Canada
| | - Tracey C Bentall
- Department of Medicine, London Health Sciences Centre, London, Ontario, Canada
| | - Eileen Campbell
- Department of Medicine, London Health Sciences Centre, London, Ontario, Canada
| | - Marat Slessarev
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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7
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Gofton TE, Norton L, Laforge G, Gibson R, Debicki D, Althenayan E, Scales N, Beinum AV, Hornby L, Shemie S, Dhanani S, Slessarev M. Cerebral cortical activity after withdrawal of life-sustaining measures in critically ill patients. Am J Transplant 2022; 22:3120-3129. [PMID: 35822321 DOI: 10.1111/ajt.17146] [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: 01/10/2022] [Revised: 06/09/2022] [Accepted: 07/04/2022] [Indexed: 01/25/2023]
Abstract
Establishing when cerebral cortical activity stops relative to circulatory arrest during the dying process will enhance trust in donation after circulatory determination of death. We used continuous electroencephalography and arterial blood pressure monitoring prior to withdrawal of life sustaining measures and for 30 min following circulatory arrest to explore the temporal relationship between cessation of cerebral cortical activity and circulatory arrest. Qualitative and quantitative EEG analyses were completed. Among 140 screened patients, 52 were eligible, 15 were enrolled, 11 completed the full study, and 8 (3 female, median age 68 years) were included in the analysis. Across participants, EEG activity stopped at a median of 78 (Q1 = -387, Q3 = 111) seconds before circulatory arrest. Following withdrawal of life sustaining measures there was a progressive reduction in electroencephalographic amplitude (p = .002), spectral power (p = .008), and coherence (p = .003). Prospective recording of cerebral cortical activity in imminently dying patients is feasible. Our results from this small cohort suggest that cerebral cortical activity does not persist after circulatory arrest. Confirmation of these findings in a larger multicenter study are needed to help promote stakeholder trust in donation after circulatory determination of death.
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Affiliation(s)
- Teneille E Gofton
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Western Institute for Neuroscience, Western University, London, Ontario, Canada
| | - Loretta Norton
- Department of Psychology, King's University College at Western University, London, Ontario, Canada
| | - Geoffrey Laforge
- Western Institute for Neuroscience, Western University, London, Ontario, Canada
| | - Raechelle Gibson
- Department of Psychiatry, University of Calgary, Calgary, Alberta, Canada
| | - Derek Debicki
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.,Western Institute for Neuroscience, Western University, London, Ontario, Canada
| | - Eyad Althenayan
- Department of Medicine/Critical Care, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Nathan Scales
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Laura Hornby
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Canadian Blood Services, Ottawa, Ontario, Canada
| | - Sam Shemie
- Canadian Blood Services, Ottawa, Ontario, Canada.,Pediatric Intensive Care, McGill University Health Centre & Research Institute, Montreal, Quebec, Canada
| | - Sonny Dhanani
- Pediatric Critical Care, Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Marat Slessarev
- Department of Psychology, King's University College at Western University, London, Ontario, Canada.,Department of Medicine/Critical Care, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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8
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Healey A, Hartwick M, Downar J, Keenan S, Lalani J, Mohr J, Appleby A, Spring J, Delaney JW, Wilson LC, Shemie S. Improving quality of withdrawal of life-sustaining measures in organ donation: a framework and implementation toolkit. Can J Anaesth 2020; 67:1549-1556. [PMID: 32918249 PMCID: PMC7546981 DOI: 10.1007/s12630-020-01774-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 05/07/2020] [Accepted: 05/14/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Donation after circulatory determination of death (DCD) is responsible for the largest increase in deceased donation over the past decade. When the Canadian DCD guideline was published in 2006, it included recommendations to create standard policies and procedures for withdrawal of life-sustaining measures (WLSM) as well as quality assurance frameworks for this practice. In 2016, the Canadian Critical Care Society produced a guideline for WLSM that requires modifications to facilitate implementation when DCD is part of the end-of-life care plan. METHODS A pan-Canadian multidisciplinary collaborative was convened to examine the existing guideline framework and to create tools to put the existing guideline into practice in centres that practice DCD. RESULTS A set of guiding principles for implementation of the guideline in DCD practice were produced using an iterative, consensus-based approach followed by development of four implementation tools and three quality assurance and audit tools. CONCLUSIONS The tools developed will aid DCD centres in fulsomely adapting the Canadian Critical Care Society Withdrawal of Life-Sustaining Measures guideline.
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Affiliation(s)
- Andrew Healey
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada.
- Trillium Gift of Life Network, Toronto, ON, Canada.
| | - Michael Hartwick
- Department of Critical Care, The Ottawa Hospital, Ottawa, ON, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - James Downar
- Department of Critical Care, The Ottawa Hospital, Ottawa, ON, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sean Keenan
- Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada
- Donation Services, BC Transplant, Vancouver, BC, Canada
| | - Jehan Lalani
- Donation and Transplantation, Canadian Blood Services, Ottawa, ON, Canada
| | - Jim Mohr
- Donation and Transplantation, Canadian Blood Services, Ottawa, ON, Canada
| | - Amber Appleby
- Donation and Transplantation, Canadian Blood Services, Ottawa, ON, Canada
| | - Jenna Spring
- Interdepartmental Division of Critical Care Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jesse W Delaney
- Departments of Critical Care and Medicine, Scarborough Health Network, Scarborough, ON, Canada
- Division of Palliative Care, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Lindsay C Wilson
- Donation and Transplantation, Canadian Blood Services, Ottawa, ON, Canada
| | - Sam Shemie
- Donation and Transplantation, Canadian Blood Services, Ottawa, ON, Canada
- Division of Critical Care, Montréal Children's Hospital, Montréal, QC, Canada
- McGill University Health Centre and Research Institute, Montréal, QC, Canada
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9
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Fehnel CR, Armengol de la Hoz M, Celi LA, Campbell ML, Hanafy K, Nozari A, White DB, Mitchell SL. Incidence and Risk Model Development for Severe Tachypnea Following Terminal Extubation. Chest 2020; 158:1456-1463. [PMID: 32360728 DOI: 10.1016/j.chest.2020.04.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 04/03/2020] [Accepted: 04/20/2020] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Palliative ventilator withdrawal (PVW) in the ICU is a common occurrence. RESEARCH QUESTION The goal of this study was to measure the rate of severe tachypnea as a proxy for dyspnea and to identify characteristics associated with episodes of tachypnea. STUDY DESIGN AND METHODS This study assessed a retrospective cohort of ICU patients from 2008 to 2012 mechanically ventilated at a single academic medical center who underwent PVW. The primary outcome of at least one episode of severe tachypnea (respiratory rate > 30 breaths/min) within 6 h after PVW was measured by using detailed physiologic and medical record data. Multivariable logistic regression was used to examine the association between patient and treatment characteristics with the occurrence of a severe episode of tachypnea post extubation. RESULTS Among 822 patients undergoing PVW, 19% and 30% had an episode of severe tachypnea during the 1-h and 6-h postextubation period, respectively. Within 1 h postextubation, patients with the following characteristics were more likely to experience tachypnea: no pre-extubation opiates (adjusted OR [aOR], 2.08; 95% CI, 1.03-4.19), lung injury (aOR, 3.33; 95% CI, 2.19-5.04), Glasgow Coma Scale score > 8 (aOR, 2.21; 95% CI, 1.30-3.77), and no postextubation opiates (aOR, 1.90; 95% CI, 1.19-3.00). INTERPRETATION Up to one-third of ICU patients undergoing PVW experience severe tachypnea. Administration of pre-extubation opiates (anticipatory dosing) represents a key modifiable factor that may reduce poor symptom control.
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Affiliation(s)
- Corey R Fehnel
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, MA; Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA.
| | - Miguel Armengol de la Hoz
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA; Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA; Biomedical Engineering and Telemedicine Group, Biomedical Technology Centre CTB, ETSI Telecomunicación, Universidad Politécnica de Madrid, Madrid, Spain
| | - Leo A Celi
- Department of Medicine, Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts Institute of Technology, Cambridge, MA
| | | | - Khalid Hanafy
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Ala Nozari
- Department of Medicine, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Douglas B White
- Department of Critical Care, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Susan L Mitchell
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, MA; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
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10
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Chang HT, Lin MH, Chen CK, Chen TJ, Hwang SJ. Aggressive End-of-Life Care and Symptom Relief Treatments in Terminally Ill Patients Who Had Discussed Withdrawal of Mechanical Ventilation: A Hospital-Based Observational Study. Am J Hosp Palliat Care 2020; 37:897-903. [PMID: 32115985 DOI: 10.1177/1049909120906612] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The aim of this study was to explore the status of aggressive end-of-life care and symptom relief treatments in terminally ill patients who had discussed the withdrawal of mechanical ventilation. METHODS This research is a retrospective observational study based on a chart review. Terminal patients aged ≥20 years, who were intubated with mechanical ventilation support, who underwent hospice-shared care, and who personally, or whose close relatives, had discussed the withdrawal of mechanical ventilation with hospice-shared care team members in a tertiary hospital in Taiwan during 2012 to 2015 were included. Demographics, medical conditions, and aggressive end-of-life care, including hospitalization, use of vasopressors, artificial nutrition, tube feeding, antibiotics, and symptom relief treatments including the use of opioids, steroids, and sedatives, were identified. The modes of care and treatments of patients by the status of withdrawal of mechanical ventilation were compared. RESULTS A total of 141 patients had discussed the withdrawal of mechanical ventilation, and 111 (78.7%) had been withdrawn. Aggressive end-of-life care was noted in all patients regardless of mechanical ventilation status. There were no significant differences in the number and pattern of aggressive end-of-life care measures between patients who had or had not been withdrawn. There were significantly higher rates of symptom relief treatments used in patients who had been withdrawn. CONCLUSIONS Aggressive end-of-life care is common for patients who have discussed the withdrawal of mechanical ventilation. There are significantly higher rates of symptom relief medications administered in patients who have been withdrawn from mechanical ventilation.
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Affiliation(s)
- Hsiao-Ting Chang
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei .,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei
| | - Ming-Hwai Lin
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei .,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei
| | - Chun-Ku Chen
- Department of Radiology, Taipei Veterans General Hospital, Taipei.,Faculty of Medicine, School of Medicine and Institute of Clinical Medicine, National Yang-Ming University, Taipei
| | - Tzeng-Ji Chen
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei .,Faculty of Medicine, School of Medicine and Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei
| | - Shinn-Jang Hwang
- Department of Family Medicine, Taipei Veterans General Hospital, Taipei .,Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei
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Nurses' Experiences and Factors Related to Their Attitudes Regarding Discussions with Patients and Family Members about Do-Not-Resuscitate Decisions and Life-Sustaining Treatment Withdrawal: A Hospital-Based Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17020557. [PMID: 31952305 PMCID: PMC7014028 DOI: 10.3390/ijerph17020557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 01/06/2020] [Accepted: 01/11/2020] [Indexed: 11/17/2022]
Abstract
This study aimed to evaluate nurses’ experiences and factors related to their attitudes regarding discussions of do-not-resuscitate (DNR) and withdrawal of life-sustaining treatment (LST) with patients and their families. A cross-sectional survey was conducted in a tertiary hospital in Taiwan. Nurses aged ≥ 20 years who were in charge of acute inpatient care were randomly recruited. A semi-structured questionnaire was used to evaluate participants’ experiences and attitudes regarding discussions of DNR and LST withdrawal for terminal patients. Logistic regression with adjustment for covariates was used to analyze factors related to participants’ attitudes toward discussions about DNR and LST withdrawal with patients and families in the future care of terminal patients. The participants were 132 nurses. They had significantly more discussions about DNR and LST withdrawal with patients’ families than with patients. Regression analysis showed that participants who had past experiences in actively initiating DNR discussions with patients or patients’ families were significantly more likely to discuss DNR with patients in the future care of terminal patients, but participants aged 40.0 to 60.0 years were significantly less likely to have DNR discussions than those aged 20.0 to 29.9 years. Experiences of actively initiated DNR or LST discussions with patients’ families were significantly more likely to discuss DNR with patients’ families, but those aged 40.0 to 60.0 years were also significantly less likely to have DNR discussions than those aged 20.0 to 29.9 years. Experience in actively initiating discussions about LST withdrawal with patients’ families, being male, and possessing an education level higher than university were significantly related to LST withdrawal discussions with terminal patients or their families in the future. In conclusion, there need to be more discussions about DNR and LST withdrawal with patients. To protect patients’ autonomy and their rights to make decisions about their DNR and LST, measures are needed to facilitate DNR and LST discussions with patients to ensure better end-of-life care.
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12
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Lesieur O, Herbland A, Cabasson S, Hoppe MA, Guillaume F, Leloup M. Changes in limitations of life-sustaining treatments over time in a French intensive care unit: A prospective observational study. J Crit Care 2018; 47:21-29. [DOI: 10.1016/j.jcrc.2018.05.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 05/29/2018] [Accepted: 05/30/2018] [Indexed: 01/31/2023]
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