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Papagiannopoulou A, Stergiannis P, Katsoulas T, Intas G, Myrianthefs P. Characteristics and Survival Rates in Ward Patients Requiring Evaluation by Intensivist in Greece. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1196:141-147. [DOI: 10.1007/978-3-030-32637-1_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bassford C, Griffiths F, Svantesson M, Ryan M, Krucien N, Dale J, Rees S, Rees K, Ignatowicz A, Parsons H, Flowers N, Fritz Z, Perkins G, Quinton S, Symons S, White C, Huang H, Turner J, Brooke M, McCreedy A, Blake C, Slowther A. Developing an intervention around referral and admissions to intensive care: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07390] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BackgroundIntensive care treatment can be life-saving, but it is invasive and distressing for patients receiving it and it is not always successful. Deciding whether or not a patient will benefit from intensive care is a difficult clinical and ethical challenge.ObjectivesTo explore the decision-making process for referral and admission to the intensive care unit and to develop and test an intervention to improve it.MethodsA mixed-methods study comprising (1) two systematic reviews investigating the factors associated with decisions to admit patients to the intensive care unit and the experiences of clinicians, patients and families; (2) observation of decisions and interviews with intensive care unit doctors, referring doctors, and patients and families in six NHS trusts in the Midlands, UK; (3) a choice experiment survey distributed to UK intensive care unit consultants and critical care outreach nurses, eliciting their preferences for factors used in decision-making for intensive care unit admission; (4) development of a decision-support intervention informed by the previous work streams, including an ethical framework for decision-making and supporting referral and decision-support forms and patient and family information leaflets. Implementation feasibility was tested in three NHS trusts; (5) development and testing of a tool to evaluate the ethical quality of decision-making related to intensive care unit admission, based on the assessment of patient records. The tool was tested for inter-rater and intersite reliability in 120 patient records.ResultsInfluences on decision-making identified in the systematic review and ethnographic study included age, presence of chronic illness, functional status, presence of a do not attempt cardiopulmonary resuscitation order, referring specialty, referrer seniority and intensive care unit bed availability. Intensive care unit doctors used a gestalt assessment of the patient when making decisions. The choice experiment showed that age was the most important factor in consultants’ and critical care outreach nurses’ preferences for admission. The ethnographic study illuminated the complexity of the decision-making process, and the importance of interprofessional relationships and good communication between teams and with patients and families. Doctors found it difficult to articulate and balance the benefits and burdens of intensive care unit treatment for a patient. There was low uptake of the decision-support intervention, although doctors who used it noted that it improved articulation of reasons for decisions and communication with patients.LimitationsLimitations existed in each of the component studies; for example, we had difficulty recruiting patients and families in our qualitative work. However, the project benefited from a mixed-method approach that mitigated the potential limitations of the component studies.ConclusionsDecision-making surrounding referral and admission to the intensive care unit is complex. This study has provided evidence and resources to help clinicians and organisations aiming to improve the decision-making for and, ultimately, the care of critically ill patients.Future workFurther research is needed into decision-making practices, particularly in how best to engage with patients and families during the decision process. The development and evaluation of training for clinicians involved in these decisions should be a priority for future work.Study registrationThe systematic reviews of this study are registered as PROSPERO CRD42016039054, CRD42015019711 and CRD42015019714.FundingThe National Institute for Health Research Health Services and Delivery Research programme. The University of Aberdeen and the Chief Scientist Office of the Scottish Government Health and Social Care Directorates fund the Health Economics Research Unit.
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Affiliation(s)
- Chris Bassford
- Warwick Medical School, University of Warwick, Coventry, UK
- Department of Anaesthesia, Critical Care and Pain, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Mia Svantesson
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Mandy Ryan
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Nicolas Krucien
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Sophie Rees
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Karen Rees
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Agnieszka Ignatowicz
- Warwick Medical School, University of Warwick, Coventry, UK
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Helen Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Nadine Flowers
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Zoe Fritz
- Warwick Medical School, University of Warwick, Coventry, UK
- Department of Acute Medicine, Cambridge University Hospitals NHS Trust, Cambridge, UK
- The Healthcare Improvement Studies (THIS) Institute, University of Cambridge, Cambridge, UK
| | - Gavin Perkins
- Warwick Medical School, University of Warwick, Coventry, UK
- Heartlands Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Sarah Quinton
- Warwick Medical School, University of Warwick, Coventry, UK
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | | | | - Huayi Huang
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Jake Turner
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Mike Brooke
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Aimee McCreedy
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Caroline Blake
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Anne Slowther
- Warwick Medical School, University of Warwick, Coventry, UK
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Oerlemans AJM, Wollersheim H, van Sluisveld N, van der Hoeven JG, Dekkers WJM, Zegers M. Rationing in the intensive care unit in case of full bed occupancy: a survey among intensive care unit physicians. BMC Anesthesiol 2016; 16:25. [PMID: 27142161 PMCID: PMC4855768 DOI: 10.1186/s12871-016-0190-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 04/27/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Internationally, there is no consensus on how to best deal with admission requests in cases of full ICU bed occupancy. Knowledge about the degree of dissension and insight into the reasons for this dissension is lacking. Information about the opinion of ICU physicians can be used to improve decision-making regarding allocation of ICU resources. The aim of this study was to: Assess which factors play a role in the decision-making process regarding the admission of ICU patients; Assess the adherence to a Dutch guideline pertaining to rationing of ICU resources; Investigate factors influencing the adherence to this guideline. METHODS In March 2013, an online questionnaire was sent to all ICU physician members (n = 761, in 90 hospitals) of the Dutch Society for Intensive Care. RESULTS 166 physicians (21.8 %) working in 64 different Dutch hospitals (71.1 %) completed the questionnaire. Factors associated with a patient's physical condition and quality of life were generally considered most important in admission decisions. Scenario-based adherence to the Dutch guideline "Admission request in case of full ICU bed occupancy" was found to be low (adherence rate 50.0 %). There were two main reasons for this poor compliance: unfamiliarity with the guideline and disagreement with the fundamental approach underlying the guideline. CONCLUSIONS Dutch ICU physicians disagree about how to deal with admission requests in cases of full ICU bed occupancy. The results of this study contribute to the discussion about the fundamental principles regarding admission of ICU patients in case of full bed occupancy.
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Affiliation(s)
- Anke J M Oerlemans
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Hub Wollersheim
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Nelleke van Sluisveld
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Johannes G van der Hoeven
- Radboud University Medical Center, Department of Intensive Care Medicine, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Wim J M Dekkers
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Marieke Zegers
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
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Bjørshol CA, Sollid S, Flaatten H, Hetland I, Mathiesen WT, Søreide E. Great variation between ICU physicians in the approach to making end-of-life decisions. Acta Anaesthesiol Scand 2016; 60:476-84. [PMID: 26941116 DOI: 10.1111/aas.12640] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 09/07/2015] [Accepted: 09/11/2015] [Indexed: 11/28/2022]
Abstract
INTRODUCTION End-of-life (EOL) decision-making in the intensive care unit (ICU) is difficult, but is rarely practiced in simulated settings. We wanted to explore different strategies ICU physicians use when making EOL decisions, and whether attitudes towards EOL decisions differ between a small-group simulation setting and a large-group plenary setting. METHODS The study took place during a Scandinavian anaesthesiology and intensive care conference. The simulated ICU patient had a cancer disease with a grave prognosis, had undergone surgery, suffered from severe co-morbidities and had a son present demanding all possible treatment. The participants were asked to make a decision regarding further ICU care. We presented the same case scenario in a plenary session with voting opportunities. RESULTS In the simulation group (n = 48), ICU physicians used various strategies to come to an EOL decision: patient-oriented, family-oriented, staff-oriented and regulatory-oriented. The simulation group was more willing than the plenary group (n = 47) to readmit the patient to the ICU if the patient again would need respiratory support (32% vs. 8%, P < 0.001). Still, fewer participants in the simulation group than in the plenary group (21% vs. 38%, P = 0.019) considered the patient's life expectancy of living an independent life to be over 10%. CONCLUSION There was great variation between ICU physicians in the approach to making EOL decisions, and large variations in their life expectancy estimates. Participants in the simulation group were more willing to admit and readmit the patient to the ICU, despite being more pessimistic towards life expectancies. We believe simulation can be used more extensively in EOL decision-making training.
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Affiliation(s)
- C. A. Bjørshol
- Department of Anaesthesiology and Intensive Care; Stavanger University Hospital; Stavanger Norway
- Stavanger Acute Medicine Foundation for Education and Research; Stavanger University Hospital; Stavanger Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
| | - S. Sollid
- Department of Research and Development; Norwegian Air Ambulance Foundation; Drøbak Norway
- Department of Health Care Sciences; University of Stavanger; Stavanger Norway
| | - H. Flaatten
- Department of Clinical Medicine; University of Bergen; Bergen Norway
- Department of Anaesthesiology and Intensive Care; Haukeland University Hospital; Bergen Norway
| | - I. Hetland
- Stavanger Acute Medicine Foundation for Education and Research; Stavanger University Hospital; Stavanger Norway
| | - W. T. Mathiesen
- Department of Anaesthesiology and Intensive Care; Stavanger University Hospital; Stavanger Norway
| | - E. Søreide
- Department of Anaesthesiology and Intensive Care; Stavanger University Hospital; Stavanger Norway
- Stavanger Acute Medicine Foundation for Education and Research; Stavanger University Hospital; Stavanger Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
- Department of Health Care Sciences; University of Stavanger; Stavanger Norway
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Abstract
Dignity is a key concept in contemporary health care ethics, but the practical meaning of dignity in care remains unclear. In this article, I show that in practice, different and possibly conflicting notions of what dignity means are engaged simultaneously in the care of critical patients. The empirical data is based on ethnographic fieldwork conducted in three separate intensive care units in three European countries, Spain, Norway, and France, in the spring of 2014. Four weeks were spent at each site. Using participant observations and semi-structured interviews with 24 intensive care unit staff, I illustrate how the ideal of patient dignity is carried out in practice in the daily life of these units.
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Affiliation(s)
- Gitte H Koksvik
- a Department of Social Anthropology , Norwegian University of Science and Technology , Trondheim , Norway
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Oerlemans AJM, van Sluisveld N, van Leeuwen ESJ, Wollersheim H, Dekkers WJM, Zegers M. Ethical problems in intensive care unit admission and discharge decisions: a qualitative study among physicians and nurses in the Netherlands. BMC Med Ethics 2015; 16:9. [PMID: 25880418 PMCID: PMC4344998 DOI: 10.1186/s12910-015-0001-4] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 01/27/2015] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND There have been few empirical studies into what non-medical factors influence physicians and nurses when deciding about admission and discharge of ICU patients. Information about the attitudes of healthcare professionals about this process can be used to improve decision-making about resource allocation in intensive care. To provide insight into ethical problems that influence the ICU admission and discharge process, we aimed to identify and explore ethical dilemmas healthcare professionals are faced with. METHODS This was an explorative, descriptive study using qualitative methods (individual and focus group interviews). We conducted 19 individual interviews and 4 focus group interviews with nurses and physicians working in the ICU or the general ward of 10 Dutch hospitals. RESULTS The ethical problems in the context of ICU admission and discharge can be divided into problems concerning full bed occupancy and problems related to treatment decisions. The gap between the high level of care the ICU can provide and the lower care level in the general ward sometimes leads to mutual misunderstandings. Our results indicate that when professionals of different wards feel there is a collective responsibility and effort to solve a problem, this helps to prevent or alleviate moral distress. ICU patients' wishes are often unknown, causing healthcare professionals to err on the side of more treatment. Additionally, the highly technological nature of intensive care appears to encourage over-treatment. CONCLUSIONS It is important for ICUs and general wards to communicate and cooperate well, since there is a mutual dependency for optimal patient flow between the different departments. Interventions that improve the understanding and cooperation between these wards may help mitigate ethical problems. The nature of the ICU environment makes it important for healthcare professionals to be aware of the risk of over-treatment, reflect on why they do what they do, and be mindful of a possible negative impact of over-treatment on their patients. Early discussion of a patient's wishes with regard to treatment options is important in preventing over-treatment.
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Affiliation(s)
- Anke J M Oerlemans
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, the Netherlands.
| | - Nelleke van Sluisveld
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, the Netherlands.
| | - Eric S J van Leeuwen
- Department of Intensive Care Medicine, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, the Netherlands.
| | - Hub Wollersheim
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, the Netherlands.
| | - Wim J M Dekkers
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, the Netherlands.
| | - Marieke Zegers
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, the Netherlands.
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Puro H, Pakarinen P, Korttila K, Tallgren M. Verbal information about anesthesia before scheduled surgery - contents and patient satisfaction. PATIENT EDUCATION AND COUNSELING 2013; 90:367-371. [PMID: 22104299 DOI: 10.1016/j.pec.2011.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Revised: 10/11/2011] [Accepted: 10/22/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVE The contents of information for patients before medical procedures are outlined by legislation and guidelines. The amount and form are less regulated. Our aim was to evaluate the contents of verbal information provided by anesthesiologists in a long-established preoperative clinic, and how satisfied patients are with it. METHODS A questionnaire based on legislation and the DISCERN quality criteria for information on treatment choices was sent to patients who recently had anesthesia for elective hysterectomy in our hospital (n=372), and to the anesthesiologists involved (n=24). RESULTS Preoperative information was regarded as sufficient by 82% of the patients and rated good by 65%. Information on the benefits of anesthesia, its risks, and effects on the quality of life was considered satisfactory by 74%, 49%, and 49%, respectively. Only 54% received enough information on lifestyle interventions to reduce their individual risks. Of the anesthesiologists, 33% had a policy to tell about risks on request only. CONCLUSION Verbal information was highly appreciated by the patients, but only two-thirds rated its quality as good, and half were satisfied with the information concerning risks. PRACTICE IMPLICATIONS More attention has to be focused on how to offer information on risks and self-help interventions to reduce them.
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Affiliation(s)
- Helena Puro
- Department of Anesthesia, Helsinki University Hospital, Helsinki, Finland
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Gysels M, Evans N, Meñaca A, Andrew E, Toscani F, Finetti S, Pasman HR, Higginson I, Harding R, Pool R. Culture and end of life care: a scoping exercise in seven European countries. PLoS One 2012; 7:e34188. [PMID: 22509278 PMCID: PMC3317929 DOI: 10.1371/journal.pone.0034188] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Accepted: 02/28/2012] [Indexed: 11/18/2022] Open
Abstract
AIM Culture is becoming increasingly important in relation to end of life (EoL) care in a context of globalization, migration and European integration. We explore and compare socio-cultural issues that shape EoL care in seven European countries and critically appraise the existing research evidence on cultural issues in EoL care generated in the different countries. METHODS We scoped the literature for Germany, Norway, Belgium, The Netherlands, Spain, Italy and Portugal, carrying out electronic searches in 16 international and country-specific databases and handsearches in 17 journals, bibliographies of relevant papers and webpages. We analysed the literature which was unearthed, in its entirety and by type (reviews, original studies, opinion pieces) and conducted quantitative analyses for each country and across countries. Qualitative techniques generated themes and sub-themes. RESULTS A total of 868 papers were reviewed. The following themes facilitated cross-country comparison: setting, caregivers, communication, medical EoL decisions, minority ethnic groups, and knowledge, attitudes and values of death and care. The frequencies of themes varied considerably between countries. Sub-themes reflected issues characteristic for specific countries (e.g. culture-specific disclosure in the southern European countries). The work from the seven European countries concentrates on cultural traditions and identities, and there was almost no evidence on ethnic minorities. CONCLUSION This scoping review is the first comparative exploration of the cultural differences in the understanding of EoL care in these countries. The diverse body of evidence that was identified on socio-cultural issues in EoL care, reflects clearly distinguishable national cultures of EoL care, with differences in meaning, priorities, and expertise in each country. The diverse ways that EoL care is understood and practised forms a necessary part of what constitutes best evidence for the improvement of EoL care in the future.
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Affiliation(s)
- Marjolein Gysels
- Barcelona Centre for International Health Research, Universitat de Barcelona, Barcelona, Spain.
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Lind R, Lorem GF, Nortvedt P, Hevrøy O. Family members' experiences of "wait and see" as a communication strategy in end-of-life decisions. Intensive Care Med 2011; 37:1143-50. [PMID: 21626240 PMCID: PMC3126999 DOI: 10.1007/s00134-011-2253-x] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Accepted: 04/01/2011] [Indexed: 11/02/2022]
Abstract
PURPOSE The aim of this study is to examine family members' experiences of end-of-life decision-making processes in Norwegian intensive care units (ICUs) to ascertain the degree to which they felt included in the decision-making process and whether they received necessary information. Were they asked about the patient's preferences, and how did they view their role as family members in the decision-making process? METHODS A constructivist interpretive approach to the grounded theory method of qualitative research was employed with interviews of 27 bereaved family members of former ICU patients 3-12 months after the patient's death. RESULTS The core finding is that relatives want a more active role in end-of-life decision-making in order to communicate the patient's wishes. However, many consider their role to be unclear, and few study participants experienced shared decision-making. The clinician's expression "wait and see" hides and delays the communication of honest and clear information. When physicians finally address their decision, there is no time for family participation. Our results also indicate that nurses should be more involved in family-physician communication. CONCLUSIONS Families are uncertain whether or how they can participate in the decision-making process. They need unambiguous communication and honest information to be able to take part in the decision-making process. We suggest that clinicians in Norwegian ICUs need more training in the knowledge and skills of effective communication with families of dying patients.
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Affiliation(s)
- Ranveig Lind
- Intensive Care Unit, University Hospital of Northern Norway, Opin-klin, Pb 6060, 9038 Tromsø, Norway
- Department of Care and Health Sciences, University of Tromsø, Tromsø, Norway
| | - Geir F. Lorem
- Department of Care and Health Sciences, University of Tromsø, Tromsø, Norway
| | - Per Nortvedt
- Section for Medical Ethics, University of Oslo, Oslo, Norway
| | - Olav Hevrøy
- Intensive Care Unit, Haukeland University Hospital, Bergen, Norway
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Schaden E, Herczeg P, Hacker S, Schopper A, Krenn CG. The role of advance directives in end-of-life decisions in Austria: survey of intensive care physicians. BMC Med Ethics 2010; 11:19. [PMID: 20964852 PMCID: PMC2976730 DOI: 10.1186/1472-6939-11-19] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2010] [Accepted: 10/21/2010] [Indexed: 11/26/2022] Open
Abstract
Background Currently, intensive care medicine strives to define a generally accepted way of dealing with end-of-life decisions, therapy limitation and therapy discontinuation. In 2006 a new advance directive legislation was enacted in Austria. Patients may now document their personal views regarding extension of treatment. The aim of this survey was to explore Austrian intensive care physicians' experiences with and their acceptance of the new advance directive legislation two years after enactment (2008). Methods Under the aegis of the OEGARI (Austrian Society of Anaesthesiology, Resuscitation and Intensive Care) an anonymised questionnaire was sent to the medical directors of all intensive care units in Austria. The questions focused on the physicians' experiences regarding advance directives and their level of knowledge about the underlying legislation. Results There were 241 questionnaires sent and 139 were turned, which was a response rate of 58%. About one third of the responders reported having had no experience with advance directives and only 9 directors of intensive care units had dealt with more than 10 advance directives in the previous two years. Life-supporting measures, resuscitation, and mechanical ventilation were the predominantly refused therapies, wishes were mainly expressed concerning pain therapy. Conclusion A response rate of almost 60% proves the great interest of intensive care professionals in making patient-oriented end-of-life decisions. However, as long as patients do not make use of their right of co-determination, the enactment of the new law can be considered only a first important step forward.
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Affiliation(s)
- Eva Schaden
- Department of Anaesthesiology, General Intensive Care and Pain Management Medical University of Vienna, Austria.
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Admission of incompetent patients to intensive care: Doctors’ responsiveness to family wishes*. Crit Care Med 2009; 37:528-32. [DOI: 10.1097/ccm.0b013e3181958409] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Halvorsen K, Førde R, Nortvedt P. Value choices and considerations when limiting intensive care treatment: a qualitative study. Acta Anaesthesiol Scand 2009; 53:10-7. [PMID: 19032565 DOI: 10.1111/j.1399-6576.2008.01793.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND To shed light on the values and considerations that affect the decision-making processes and the decisions to limit intensive care treatment. METHOD Qualitative methodology with participant observation and in-depth interviews, with an emphasis on eliciting the underlying rationale of the clinicians' actions and choices when limiting treatment. RESULTS Informants perceived over-treatment in intensive care medicine as a dilemma. One explanation was that the decision-making base was somewhat uncertain, complex and difficult. The informants claimed that those responsible for taking decisions from the admitting ward prolonged futile treatment because they may bear guilt or responsibility for something that had gone wrong during the course of treatment. The assessments of the patient's situation made by physicians from the admitting ward were often more organ-oriented and the expectations were less realistic than those of clinicians in the intensive care unit who frequently had a more balanced and overall perspective. Aspects such as the personality and the speciality of those involved, the culture of the unit and the degree of interdisciplinary cooperation were important issues in the decision-making processes. CONCLUSION Under-communicated considerations jeopardise the principle of equal treatment. If intensive care patients are to be ensured equal treatment, strategies for interdisciplinary, transparent and appropriate decision-making processes must be developed in which open and hidden values are rendered visible, power structures disclosed, employees respected and the various perspectives of the treatment given their legitimate place.
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Affiliation(s)
- K Halvorsen
- Faculty of Nursing Education, Akershus University College, Lillestrøm, Norway.
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Hynninen M, Klepstad P, Petersson J, Skram U, Tallgren M. Process of foregoing life-sustaining treatment: a survey among Scandinavian intensivists. Acta Anaesthesiol Scand 2008; 52:1081-5. [PMID: 18840108 DOI: 10.1111/j.1399-6576.2008.01636.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND How ethical issues are dealt with varies considerably depending on the geographic and religious background of individuals. The views of Scandinavian physicians on end-of-life care were studied using a survey. The aim of this study was to clarify the actual processes of foregoing life-sustaining treatment in Scandinavia. METHODS A questionnaire was developed and sent to 78 intensive care physicians working in Denmark, Finland, Norway and Sweden. RESULTS Forty-four responses were obtained (13 from Denmark, eight from Finland, 12 from Norway and 11 from Sweden); 89% of the respondents were from University Hospitals. Withholding and withdrawing of treatment were practiced in all intensive care units (ICUs) concerned, but written guidelines on end-of-life care existed in only one ICU. End-of-life care is usually arranged in the ICU. Religious support is available in most hospitals during office hours, but lacking in 26% of ICUs outside office hours. Vasoactive medication, renal replacement therapy, and artificial nutrition are among the therapies most likely to be discontinued during withdrawal of life support. Certain types of monitoring and organ support are still continued in many centers during end-of-life care. CONCLUSION Local written guidelines on end-of-life care are scarce in Scandinavian ICUs, which may explain the observed variability in the practices. Development of guidelines and monitoring how these instructions are carried out may help to improve the quality of care of dying ICU patients.
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Affiliation(s)
- M Hynninen
- Department of Anesthesia and Intensive Care Medicine, Helsinki University Central Hospital, Helsinki, Finland.
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Lifeboat ethics: considerations in the discharge of inpatients for the creation of hospital surge capacity. Disaster Med Public Health Prep 2008; 1:51-6. [PMID: 18388604 DOI: 10.1097/dmp.0b013e318065c4ca] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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How decisions are made to admit patients to medical intensive care units (MICUs): a survey of MICU directors at academic medical centers across the United States. Crit Care Med 2008; 36:414-20. [PMID: 18091539 DOI: 10.1097/01.ccm.0000299738.26888.37] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine how medical intensive care unit (MICU) admission decisions are made at U.S. academic MICUs and to learn how these practices compare with the recommendations of the Society of Critical Care Medicine and the American Thoracic Society. DESIGN A 22-question Web-based survey. SETTING University health sciences centers. SUBJECTS MICU directors at academic U.S. medical centers offering fellowship programs in pulmonary/critical care or critical care medicine. INTERVENTIONS The survey was sent by E-mail to 146 academic MICU directors. MEASUREMENTS AND MAIN RESULTS Survey response rate was 83% (121/146). MICU attendings were the primary decision-maker for patient admission to the intensive care unit (ICU) in 40% of the MICUs during daytime hours, in 36% on weekends, and in 27% overnight. Critical care fellows and resident house staff were often responsible for making MICU admission decisions, particularly overnight and on weekends. Of the MICUs surveyed, 88% had written admission guidelines, although only 25% used them on a regular basis. Written restriction guidelines were present in only 21% of these ICUs, although 53% of MICU directors believed that MICUs should have standardized criteria for restricting admission to the ICU. Finally, 29% of MICUs surveyed did not authorize MICU attendings to deny ICU admission on a case-by-case basis for futile or inadvisable care, thereby maintaining an open door policy for ICU admission. CONCLUSIONS Significant practice variability exists across U.S. academic MICUs regarding how decisions are made to admit patients to the ICU. The majority of academic MICUs in the United States do not strictly employ ICU admission and restriction guidelines, as recommended by the Society of Critical Care Medicine and the American Thoracic Society.
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Hawryluck L. Ethics review: position papers and policies--are they really helpful to front-line ICU teams? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2007; 10:242. [PMID: 17164011 PMCID: PMC1794463 DOI: 10.1186/cc5095] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
During the past few years the ethics sections of critical care societies have proposed a number of policies describing the goals of intensive care unit (ICU) care and providing broad guidance on the diagnoses and physiological criteria that would mandate using the specialized skill and technologies of an ICU environment. Discussions on what constitutes appropriate use of such scarce resources, incorporating cultural and religious beliefs and exploring how they interact with these medical criteria, remain vague. To date, these policies do not provide any definitive guidance in the difficult decision making faced by clinicians. Some argue that they were never meant to do so and yet they have served to guide the development of local hospital policies. Many have explored how critical care services are allocated without achieving consensus on the best way to achieve fair and equitable access to life-sustaining interventions. A consensus is needed though, one that is reflective of both individual and societal values and goals. Otherwise, increasing pressure to provide treatments with marginal benefits at best will threaten the ability of others to access treatments that may offer them very real benefits.
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Affiliation(s)
- Laura Hawryluck
- Critical Care Medicine, University health Network--Toronto General Hospital, University Ave, Toronto, Ontario M5G 2N2, Canada.
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Christian MD, Hawryluck L, Wax RS, Cook T, Lazar NM, Herridge MS, Muller MP, Gowans DR, Fortier W, Burkle FM. Development of a triage protocol for critical care during an influenza pandemic. CMAJ 2006; 175:1377-81. [PMID: 17116904 PMCID: PMC1635763 DOI: 10.1503/cmaj.060911] [Citation(s) in RCA: 216] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The recent outbreaks of avian influenza (H5N1) have placed a renewed emphasis on preparing for an influenza pandemic in humans. Of particular concern in this planning is the allocation of resources, such as ventilators and antiviral medications, which will likely become scarce during a pandemic. METHODS We applied a collaborative process using best evidence, expert panels, stakeholder consultations and ethical principles to develop a triage protocol for prioritizing access to critical care resources, including mechanical ventilation, during a pandemic. RESULTS The triage protocol uses the Sequential Organ Failure Assessment score and has 4 main components: inclusion criteria, exclusion criteria, minimum qualifications for survival and a prioritization tool. INTERPRETATION This protocol is intended to provide guidance for making triage decisions during the initial days to weeks of an influenza pandemic if the critical care system becomes overwhelmed. Although we designed this protocol for use during an influenza pandemic, the triage protocol would apply to patients both with and without influenza, since all patients must share a single pool of critical care resources.
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Affiliation(s)
- Michael D Christian
- Division of Infectious Diseases & Critical Care, Department of Postgraduate Medicine, McMaster University, Hamilton, Ont.
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Moselli NM, Debernardi F, Piovano F. Forgoing life sustaining treatments: differences and similarities between North America and Europe. Acta Anaesthesiol Scand 2006; 50:1177-86. [PMID: 17067320 DOI: 10.1111/j.1399-6576.2006.01150.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND As evidence exist that severe neurological damage or prolonged death after inappropriate CPR could occur, restraints and indications for CPR were perceived as necessary. The objective of this review is to examine policies and attitudes towards end-of-life decisions in Europe and North America and to outline differences and similarities. METHODS A bibliographic database search from 1990 to 2006 was performed using the following terms: do-not-resuscitate orders, end-of-life decisions, withholding/withdrawal of life-sustaining treatments, medical futility and advanced directives. Eighty-eight articles, out of 305 examined, were analyzed and their data systematically reported and compared where possible. They consisted of studies, questionnaires and surveys answering the following questions: percentage of deaths of critical patients preceded by do-not-resuscitate orders, factors affecting the decision for do-not-resuscitate orders, people involved in this decision (patient, surrogates and medical staff) and how it was performed. RESULTS There is an evident gap between the North American use of standard and formal procedures compared with Europe. Second, they diverge in the role acknowledged to surrogates in the decisional process, as in Europe, restraints and reserves to accept surrogates as decision makers seem still strong and a paternalistic approach at the end-of-life is still present. CONCLUSION Incidentally, despite the predictable differences between Europe and North America, concerns do exist about the actual extent of autonomy wished by patients and surrogates. It is important to highlight these findings, as the paternalistic attitude, too often negatively depicted, could be, according to the best medical practice, justified and more welcomed in some instances.
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Affiliation(s)
- N M Moselli
- Unit of Anaesthesiology, Intensive Care and Pain Therapy, Institute for Cancer Research and Treatment (IRCC), Candiolo (Torino), Italy.
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Giannini A. Effect of life-support decision tools on actual decisions in the intensive care unit. Crit Care Med 2006; 34:2699; author reply 2699-700. [PMID: 16983280 DOI: 10.1097/01.ccm.0000240785.54198.d0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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