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Schaefer SL, Thompson CH, Gluck S, Booth AEC, Dignam CM. A Retrospective Analysis of Characteristics Favouring In-Hospital Resuscitation Plan Completion, Their Timing, and Associated Outcomes. J Clin Med 2024; 13:4098. [PMID: 39064138 PMCID: PMC11277889 DOI: 10.3390/jcm13144098] [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: 06/10/2024] [Revised: 07/04/2024] [Accepted: 07/07/2024] [Indexed: 07/28/2024] Open
Abstract
Background: Comprehensive resuscitation plans document treatment recommendations, such as 'Not for cardiopulmonary resuscitation'. When created early in admission as a shared decision-making process, these plans support patient autonomy and guide future treatment. The characteristics of patients who have resuscitation plans documented, their timing, and associations with clinical outcomes remain unclear. Objectives: To characterise factors associated with resuscitation plan completion, early completion, and differences in mortality rates and Intensive Care Unit (ICU) admissions based on resuscitation plan status. Methods: This retrospective study analysed non-elective admissions to an Australian tertiary centre from January to June 2021, examining plan completion timing (early < 48 h, late > 48 h) and associations with mortality and ICU admission. Results: Of 13,718 admissions, 5745 (42%) had a resuscitation plan recorded. Most plans (89%) were completed early. Furthermore, 9% of patients died during admission, and 8.2% were admitted to the ICU. For those without resuscitation plans, 0.5% died (p < 0.001), and 9.7% were admitted to the ICU (p = 0.002). Factors associated with plan completion included a medical unit, in-hours admission, older age, female gender, limited English proficiency, and non-Indigenous status. Plans completed late (>48 h) correlated with a higher mortality (14% vs. 9%; p < 0.001) and more ICU admissions (25% vs. 6%; p < 0.001). Aboriginal and/or Torres Strait Islander patients were often overlooked for resuscitation documentation before death. No resuscitation plans were documented for 62% of ICU admissions. Conclusions: Important disparities exist in resuscitation plan completion rates across highly relevant inpatient and demographic groups.
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Affiliation(s)
- Sara L. Schaefer
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, 4 North Terrace, Adelaide, SA 5000, Australia
- Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
| | - Campbell H. Thompson
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, 4 North Terrace, Adelaide, SA 5000, Australia
- Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
| | - Samuel Gluck
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, 4 North Terrace, Adelaide, SA 5000, Australia
- Northern Adelaide Local Health Network, Adelaide, SA 5092, Australia
| | - Andrew E. C. Booth
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, 4 North Terrace, Adelaide, SA 5000, Australia
- Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
| | - Colette M. Dignam
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, 4 North Terrace, Adelaide, SA 5000, Australia
- Central Adelaide Local Health Network, Adelaide, SA 5000, Australia
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Adams SY, Redford K, Li R, Malfa A, Tucker R, Lechner BE. Utility of do-not-resuscitate orders for critically ill infants in the NICU. Pediatr Res 2024:10.1038/s41390-024-03367-1. [PMID: 38969816 DOI: 10.1038/s41390-024-03367-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 04/10/2024] [Accepted: 05/07/2024] [Indexed: 07/07/2024]
Abstract
OBJECTIVE To better understand the value of DNR orders for critically ill infants in the NICU. METHODS A prospective mixed-methods approach was utilized including chart review of infants who died in a regional NICU over a twenty-six-month period and surveys of their neonatologists, neonatal fellows, and nurses. RESULTS 40 infants died during the study period and 120 staff surveys were completed. Infants with DNR orders were of a higher gestational age at birth and a higher chronological age at death. Nurses were more likely to perceive benefit from DNR orders than physicians. Medical staff recollection of the existence of DNR orders was not always accurate. Time and fear of adding unnecessary emotional burden to parents were identified as barriers to DNR order implementation. An advanced care planning model built on open communication instead of DNR order documentation was deemed the best approach. CONCLUSION Though DNR orders are beneficial for a subset of infants, DNR orders are likely not applicable for all infants who die in the NICU. More important is supportive, individualized communication between families and the medical team to ensure quality end-of-life care. IMPACT In the adult and pediatric ICU literature, DNR orders are associated with improved qualitative "good death" assessments and decreased familial decision regret. In the NICU, rates of DNR usage aren't well reported and their overall utility is unclear. Though DNR orders can help guide clinical decision making in the NICU and may be associated with higher quality ethical discussion, our data suggest that they are not applicable in all patient cases. We hope that this work will help guide approaches to end-of-life care in the NICU and underscore the importance of frequent, open communication between families and their medical team.
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Affiliation(s)
- Shannon Y Adams
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Katherine Redford
- Department of Pediatrics, Women & Infants Hospital of Rhode Island, Providence, RI, USA
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Randall Li
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Ana Malfa
- Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Richard Tucker
- Department of Pediatrics, Women & Infants Hospital of Rhode Island, Providence, RI, USA
| | - Beatrice E Lechner
- Department of Pediatrics, Women & Infants Hospital of Rhode Island, Providence, RI, USA
- Warren Alpert Medical School of Brown University, Providence, RI, USA
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Hernández-Zambrano SM, Carrillo-Algarra AJ, Manotas-Solano OE, Ibáñez-Gamboa SE, Mejia-Mendez LM, Martínez-Montoya OH, Fernández-Alcántara M, Hueso-Montoro C. Interprofessional interventions and factors that improve end-of-life care in intensive care units: An integratory review. ENFERMERIA INTENSIVA 2024:S2529-9840(23)00069-1. [PMID: 38910066 DOI: 10.1016/j.enfie.2023.08.009] [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: 06/18/2023] [Accepted: 08/24/2023] [Indexed: 06/25/2024]
Abstract
INTRODUCTION The changes in health dynamics, caused by the SARS-COVD-2 pandemic and its consequences, generated a greater need to integrate palliative care in the ICU to promote a dignified death. OBJECTIVE Identify interprofessional interventions and factors that improve the care of patients at the end of life. METHODOLOGY Integrative review, including experimental, quasi-experimental, observational, analytical, and descriptive studies with correlation of variables, published from 2010 to 2021, identified in COCHRANE, CINAHL, CUIDEN, LILACS, SCIELO, Dialnet, PsychInfo, PubMed, PROQUES, PSYCHOLOGY, JOURNALS, SCIENCEDIRECT, with MeSH/DECS terms: "Critical Care", "IntensiveCare" "Life support care", "Palliative care", "Life Quality", "Right to die". 36,271 were identified, after excluding duplicate title, abstract, year of publication, design, theme, methodological quality, objectives, and content, 31 studies were found. RESULTS It included 31 articles, 16.7% experimental, 3.3% quasi-experimental, 80% observational, analytical, and descriptive with correlation of variables, 38% published in the United States, 38%, and 19% in Brazil. The pooled sample was 24,779 participants. 32.2% of the studies had level of evidence 1 recommendation (c), and 25.8% level of evidence 2 recommendation (c). This paper synthesises evidence to promote Interprofessional Collaborative Practice in the ICU, improve end-of-life care, and interventions to achieve established therapeutic goals, implement effective care policies, plans, and programmes for critically ill patients and their families; factors that affect palliative care and improve with training and continuing education for health personnel. CONCLUSION There are interventions to manage physical and emotional symptoms, training strategies and emotional support aimed at health personnel and family members to improve the quality of death and reduce stays in the ICU. The interdisciplinary team requires training on palliative and end-of-life care to improve care.
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Affiliation(s)
- S M Hernández-Zambrano
- Grupo Perspectivas del Cuidado, Fundación Universitaria de Ciencias de la Salud, Facultad de Enfermería, Bogotá, Colombia.
| | - A J Carrillo-Algarra
- Grupo Perspectivas del Cuidado, Fundación Universitaria de Ciencias de la Salud, Facultad de Enfermería, Bogotá, Colombia
| | - O E Manotas-Solano
- Especialización de Enfermería en cuidado crítico del adulto, Fundación Universitaria de Ciencias de la Salud, Facultad de Enfermería, Bogotá, Colombia
| | - S E Ibáñez-Gamboa
- Especialización de Enfermería en cuidado crítico del adulto, Fundación Universitaria de Ciencias de la Salud, Facultad de Enfermería, Bogotá, Colombia
| | - L M Mejia-Mendez
- Especialización de Enfermería en cuidado crítico del adulto, Fundación Universitaria de Ciencias de la Salud, Facultad de Enfermería, Bogotá, Colombia
| | - O H Martínez-Montoya
- Especialización de Enfermería en cuidado crítico del adulto, Fundación Universitaria de Ciencias de la Salud, Facultad de Enfermería, Bogotá, Colombia
| | | | - C Hueso-Montoro
- Departamento de Enfermería, Facultad de Ciencias de la Salud, Universidad de Jaén, Instituto de Investigación Biosanitaria de Granada (Ibs.GRANADA), Centro de Investigación Mente, Cerebro y Comportamiento (CIMCYC), Jaén, Spain
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Margalit I, Yahav D, Hoffman T, Tabah A, Ruckly S, Barbier F, Singer P, Timsit JF, Prendki V, Buetti N. Presentation, management, and outcomes of older compared to younger adults with hospital-acquired bloodstream infections in the intensive care unit: a multicenter cohort study. Infection 2024:10.1007/s15010-024-02304-y. [PMID: 38869773 DOI: 10.1007/s15010-024-02304-y] [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: 03/18/2024] [Accepted: 05/20/2024] [Indexed: 06/14/2024]
Abstract
PURPOSE Older adults admitted to the intensive care unit (ICU) usually have fair baseline functional capacity, yet their age and frailty may compromise their management. We compared the characteristics and management of older (≥ 75 years) versus younger adults hospitalized in ICU with hospital-acquired bloodstream infection (HA-BSI). METHODS Nested cohort study within the EUROBACT-2 database, a multinational prospective cohort study including adults (≥ 18 years) hospitalized in the ICU during 2019-2021. We compared older versus younger adults in terms of infection characteristics (clinical signs and symptoms, source, and microbiological data), management (imaging, source control, antimicrobial therapy), and outcomes (28-day mortality and hospital discharge). RESULTS Among 2111 individuals hospitalized in 219 ICUs with HA-BSI, 563 (27%) were ≥ 75 years old. Compared to younger patients, these individuals had higher comorbidity score and lower functional capacity; presented more often with a pulmonary, urinary, or unknown HA-BSI source; and had lower heart rate, blood pressure and temperature at presentation. Pathogens and resistance rates were similar in both groups. Differences in management included mainly lower rates of effective source control achievement among aged individuals. Older adults also had significantly higher day-28 mortality (50% versus 34%, p < 0.001), and lower rates of discharge from hospital (12% versus 20%, p < 0.001) by this time. CONCLUSIONS Older adults with HA-BSI hospitalized in ICU have different baseline characteristics and source of infection compared to younger patients. Management of older adults differs mainly by lower probability to achieve source control. This should be targeted to improve outcomes among older ICU patients.
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Affiliation(s)
- Ili Margalit
- Infectious Diseases Unit, Sheba Medical Center, Ramat-Gan, Israel.
- Faculty of Medical & Health Sciences, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel.
| | - Dafna Yahav
- Infectious Diseases Unit, Sheba Medical Center, Ramat-Gan, Israel
- Faculty of Medical & Health Sciences, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel
| | - Tomer Hoffman
- Infectious Diseases Unit, Sheba Medical Center, Ramat-Gan, Israel
- Faculty of Medical & Health Sciences, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel
| | - Alexis Tabah
- Intensive Care Unit, Redclife Hospital, Brisbane, QLD, Australia
- Queensland University of Technology, Brisbane, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Stéphane Ruckly
- IAME UMR 1137, INSERM, Université de Paris, 75018, Paris, France
- ICUREsearch, Biometry, 38600, Fontaine, France
| | - François Barbier
- Service de Médecine Intensive‑Réanimation, Centre Hospitalier Régional d'Orléans, 14, Avenue de L'Hôpital, 45100, Orléans, France
| | - Pierre Singer
- Faculty of Medical & Health Sciences, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel
- Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Jean-François Timsit
- IAME UMR 1137, INSERM, Université de Paris, 75018, Paris, France
- Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat-Claude Bernard University Hospital, 46 Omdurman Maternity Hospital Rue Henri Huchard, 75877, Paris, France
| | - Virginie Prendki
- Division of Internal Medicine for the Aged, Department of Rehabilitation and Geriatrics, Geneva University Hospitals, Geneva, Switzerland
- Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
- Infection Control Programme and World Health Organization Collaborating Center, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Niccolò Buetti
- IAME UMR 1137, INSERM, Université de Paris, 75018, Paris, France
- Infection Control Programme and World Health Organization Collaborating Center, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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López-Ávila A, Rivas-Riveros E, Campillay-Campillay M. Do not resuscitate orders and limitation of therapeutic effort: Ethical challenges in healthcare teams in Chile. Salud Colect 2024; 20:e4821. [PMID: 38961602 DOI: 10.18294/sc.2024.4821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 05/30/2024] [Indexed: 07/05/2024] Open
Abstract
The purpose of this paper is to delve into the ethical aspects experienced by the healthcare team when they receive the directive to limit therapeutic effort or a do-not-resuscitate order. From an interpretative, qualitative paradigm with a content analysis approach, a process based on three phases was conducted: pre-analysis in which categories were identified, the projection of the analysis, and inductive analysis. During 2023, interviews were conducted in the clinical setting of a high-complexity hospital in Chile with 56 members of the healthcare teams from critical and emergency units, from which four categories emerged: a) the risk of violating patients' rights by using do-not-resuscitate orders and limiting therapeutic effort; b) the gap in the interpretation of the legal framework addressing the care and attention of patients at the end of life or with terminal illnesses by the healthcare team; c) ethical conflicts in end-of-life care; and d) efficient care versus holistic care in patients with terminal illness. There are significant gaps in bioethics training and aspects of a good death in healthcare teams facing the directive to limit therapeutic effort and not resuscitate. It is suggested to train personnel and work on a consensus guide to address the ethical aspects of a good death.
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Affiliation(s)
- Ana López-Ávila
- Magíster en Epidemiología Clínica. Enfermera clínica, Hospital Regional de Talca, Chile
| | - Edith Rivas-Riveros
- Doctora en Enfermería. Directora, Maestría en Enfermería, Universidad de La Frontera, Temuco, Chile
| | - Maggie Campillay-Campillay
- Doctora en Enfermería. Coordinadora, Maestría de Investigación en Metodologías Cualitativas para la Salud, Universidad de Atacama, Copiapó, Chile
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Ramadan OE, Mady AF, Al-Odat MA, Balshi AN, Aletreby AW, Stephen TJ, Diolaso SR, Gano JQ, Aletreby WT. Diagnostic accuracy of ePOS score in predicting DNR labeling after ICU admission: A prospective observational study (ePOS-DNR). JOURNAL OF INTENSIVE MEDICINE 2024; 4:216-221. [PMID: 38681789 PMCID: PMC11043627 DOI: 10.1016/j.jointm.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/28/2023] [Accepted: 09/14/2023] [Indexed: 05/01/2024]
Abstract
Background Resuscitation can sometimes be futile and making a do-not-resuscitate (DNR) decision is in the best interest of the patient. The electronic poor outcome screening (ePOS) score was developed to predict 6-month poor outcomes of critically ill patients. We explored the diagnostic accuracy of the ePOS score in predicting DNR decisions in the intensive care unit (ICU). Methods This study was conducted at the ICU of a tertiary referral hospital in Saudi Arabia between March and May 2023. Prospectively, we calculated ePOS scores for all eligible consecutive admissions after 48 h in the ICU and recorded the DNR orders. The ability of the score to predict DNR was explored using logistic regression. Youden's ideal cut-off value was calculated using the DeLong method, and different diagnostic accuracy measures were generated with corresponding 95 % confidence intervals (CIs). Results We enrolled 857 patients, 125 received a DNR order and 732 did not. The average ePOS score of DNR and non-DNR patients was 28.2±10.7 and 15.2±9.7, respectively. ePOS score, as a predictor of DNR order, had an area under receiver operator characteristic (AUROC) curve of 81.8 % (95% CI: 79.0 to 84.3, P <0.001). Youden's ideal cut-off value >17 was associated with a sensitivity of 87.2 (95% CI: 80.0 to 92.5, P <0.001), specificity of 63.9 (95% CI: 60.3 to 67.4, P <0.001), positive predictive value of 29.2 (95% CI: 24.6 to 33.8, P <0.001), negative predictive value of 96.7 (95% CI: 95.1 to 98.3, P <0.001), and diagnostic odds ratio 12.1 (95% CI: 7.0 to 20.8, P <0.001). Conclusions In this study, the ePOS score performed well as a diagnostic test for patients who will be labeled as DNR during their ICU stay. A cut-off score >17 may help guide clinical decisions to withhold or commence resuscitative measures.
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Affiliation(s)
- Omar E. Ramadan
- Department of Critical Care, King Saud Medical City, Riyadh, Saudi Arabia
- Anesthesia Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ahmed F. Mady
- Department of Critical Care, King Saud Medical City, Riyadh, Saudi Arabia
- Anesthesia Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | | | - Ahmed N. Balshi
- Department of Critical Care, King Saud Medical City, Riyadh, Saudi Arabia
| | | | - Taisy J. Stephen
- Department of Critical Care, King Saud Medical City, Riyadh, Saudi Arabia
- Nursing Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Sheena R. Diolaso
- Department of Critical Care, King Saud Medical City, Riyadh, Saudi Arabia
- Nursing Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Jennifer Q. Gano
- Department of Critical Care, King Saud Medical City, Riyadh, Saudi Arabia
- Nursing Department, King Saud Medical City, Riyadh, Saudi Arabia
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Sheehan MM, Zilberberg MD, Lindenauer PK, Higgins TL, Imrey PB, Guo N, Deshpande A, Haessler SD, Rothberg MB. Associations between Present-on-Admission Do-Not-Resuscitate Orders and Short-Term Outcomes in Patients with Pneumonia. South Med J 2024; 117:165-171. [PMID: 38428939 PMCID: PMC10914325 DOI: 10.14423/smj.0000000000001663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Abstract
OBJECTIVES Do-not-resuscitate (DNR) orders are used to express patient preferences for cardiopulmonary resuscitation. This study examined whether early DNR orders are associated with differences in treatments and outcomes among patients hospitalized with pneumonia. METHODS This is a retrospective cohort study of 768,015 adult patients hospitalized with pneumonia from 2010 to 2015 in 646 US hospitals. The exposure was DNR orders present on admission. Secondary analyses stratified patients by predicted in-hospital mortality. Main outcomes included in-hospital mortality, length of stay, cost, intensive care admission, invasive mechanical ventilation, noninvasive ventilation, vasopressors, and dialysis initiation. RESULTS Of 768,015 patients, 94,155 (12.3%) had an early DNR order. Compared with those without, patients with DNR orders were older (mean age 80.1 ± 10.6 years vs 67.8 ± 16.4 years), with higher comorbidity burden, intensive care use (31.6% vs 30.6%), and in-hospital mortality (28.2% vs 8.5%). After adjustment via propensity score weighting, these patients had higher mortality (odds ratio [OR] 2.39, 95% confidence interval [CI] 2.33-2.45) and lower use of intensive therapies such as vasopressors (OR 0.83, 95% CI 0.81-0.85) and invasive mechanical ventilation (OR 0.68, 95% CI 0.66-0.70). Although there was little relationship between predicted mortality and DNR orders, among those with highest predicted mortality, DNR orders were associated with lower intensive care use compared with those without (66.7% vs 80.8%). CONCLUSIONS Patients with early DNR orders have higher in-hospital mortality rates than those without, but often receive intensive care. These orders have the most impact on the care of patients with the highest mortality risk.
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Affiliation(s)
| | | | - Peter K. Lindenauer
- Departments of Healthcare Delivery and Population Sciences and Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester
| | - Thomas L. Higgins
- The Center for Case Management, Natick, Massachusetts
- Departments of Medicine and Anesthesiology, Division of Pulmonary and Critical Care Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield
| | - Peter B. Imrey
- Department of Quantitative Health Sciences, Cleveland, Ohio
| | - Ning Guo
- Department of Quantitative Health Sciences, Cleveland, Ohio
| | | | - Sarah D. Haessler
- Department of Medicine, Division of Infectious Diseases, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts
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Koutsouki S, Kosmidis D, Nagy EO, Tsaroucha A, Anastasopoulos G, Pnevmatikos I, Papaioannou V. Limitation of Non-Beneficial Interventions and their Impact on the Intensive Care Unit Costs. J Crit Care Med (Targu Mures) 2023; 9:230-238. [PMID: 37969880 PMCID: PMC10644299 DOI: 10.2478/jccm-2023-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 09/30/2023] [Indexed: 11/17/2023] Open
Abstract
Introduction Using a plan to limit non-beneficial life support interventions has significantly reduced harm and loss of dignity for patients at the end of life. The association of these limitations with patients' clinical characteristics and health care costs in the intensive care unit (ICU) needs further scientific evidence. Aim of the study To explore decisions to limit non-beneficial life support interventions, their correlation with patients' clinical data, and their effect on the cost of care in the ICU. Material and Methods We included all patients admitted to the general ICU of a hospital in Greece in a two-year (2019-2021) prospective study. Data collection included patient demographic and clinical variables, data related to decisions to limit (withholding, withdrawing) non-beneficial interventions (NBIs), and economic data. Comparisons were made between patients with and without limitation decisions. Results NBIs were limited in 164 of 454 patients (36.12%). Patients with limitation decisions were associated with older age (70y vs. 62y; p<0,001), greater disease severity score (APACHE IV, 71 vs. 50; p<0,001), longer length of stay (7d vs. 4.5d; p<0,001), and worse prognosis of death (APACHE IV PDR, 48.9 vs. 17.35; p<0,001). All cost categories and total cost per patient were also higher than the patient without limitation of NBIs (9247,79€ vs. 8029,46€, p<0,004). The mean daily cost has not differed between the groups (831,24€ vs. 832,59€; p<0,716). However, in the group of patients with limitations, all cost categories, including the average daily cost (767.31€ vs. 649.12€) after the limitation of NBIs, were reduced to a statistically significant degree (p<0.001). Conclusions Limiting NBIs in the ICU reduces healthcare costs and may lead to better management of ICU resource use.
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Affiliation(s)
| | - Dimitrios Kosmidis
- Nursing Department, International Hellenic University, Didymoteicho, Greece
| | | | - Alexandra Tsaroucha
- Postgraduate program on Bioethics, Laboratory of Bioethics, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
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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: 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: 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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Suresh S, Au A, Mohan S, Huang J, Guthrie C, Lee JT, Aggarwal G. Advance care and resuscitation plans in a tertiary hospital: a multimodal approach. BMJ Support Palliat Care 2023:spcare-2023-004476. [PMID: 37553202 DOI: 10.1136/spcare-2023-004476] [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: 07/05/2023] [Accepted: 07/07/2023] [Indexed: 08/10/2023]
Abstract
OBJECTIVES Advance care planning (ACP) is the process of documenting a person's preference for medical treatment in the event of future deterioration. This audit aimed to improve discussion and documentation of ACP in patients who die during a hospital admission. METHODS We performed a clinical audit in 2021 of inpatients at a tertiary hospital in Sydney, Australia to evaluate the benefit of multimodal interventions to improve ACP compared with previous audits from 2016 and 2011. RESULTS In 2021, 97% of audited patients had a documented ACP prior to death compared with 80% in the 2016 audit. The completion of NFR documentation on admission in 2016 was 33%, while in 2021 65% of ACPs were completed within 24 hours of admission.In 2021, 94% of patients had a paper resuscitation form filled; however, identification stickers, which are associated with risk of error, were used in 64%; and 25% of forms were only partially completed. Palliative care was consulted for 44% of patients prior to death; 33% on the day of or prior to death. CONCLUSIONS Improvement in prevalence and timing of ACP prior to death is seen in the postintervention audit. A repeat audit in 5 years will be conducted, with interventions focused on improving documentation of ACP.
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Affiliation(s)
- Sarika Suresh
- Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Angela Au
- Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Sharanya Mohan
- Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Johnny Huang
- Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Christiana Guthrie
- Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Jessica Tsuann Lee
- Concord Repatriation General Hospital, Concord, New South Wales, Australia
- Concord Centre for Palliative Care, Sydney, NSW, Australia
- IMPACCT, University of Technology Sydney, Sydney, NSW, Australia
- Concord Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Ghauri Aggarwal
- Concord Centre for Palliative Care, Sydney, NSW, Australia
- Concord Hospital, Sydney, NSW, Australia
- Department of Medicine, University of Sydney, Sydney, NSW, Australia
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Heung Y, Zhukovsky D, Hui D, Lu Z, Andersen C, Bruera E. Quality of End-of-Life Care during the COVID-19 Pandemic at a Comprehensive Cancer Center. Cancers (Basel) 2023; 15:2201. [PMID: 37190130 PMCID: PMC10136926 DOI: 10.3390/cancers15082201] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/01/2023] [Accepted: 04/06/2023] [Indexed: 05/17/2023] Open
Abstract
To evaluate how the COVID-19 pandemic impacted the quality of end-of-life care for patients with advanced cancer, we compared a random sample of 250 inpatient deaths from 1 April 2019, to 31 July 2019, with 250 consecutive inpatient deaths from 1 April 2020, to 31 July 2020, at a comprehensive cancer center. Sociodemographic and clinical characteristics, the timing of palliative care referral, timing of do-not-resuscitate (DNR) orders, location of death, and pre-admission out-of-hospital DNR documentation were included. During the COVID-19 pandemic, DNR orders occurred earlier (2.9 vs. 1.7 days before death, p = 0.028), and palliative care referrals also occurred earlier (3.5 vs. 2.5 days before death, p = 0.041). During the pandemic, 36% of inpatient deaths occurred in the Intensive Care Unit (ICU) and 36% in the Palliative Care Unit, compared to 48 and 29%, respectively, before the pandemic (p = 0.001). Earlier DNR orders, earlier palliative care referrals, and fewer ICU deaths suggest an improvement in the quality of end-of-life care in response to the COVID-19 pandemic. These encouraging findings may have future implications for maintaining quality end-of-life care post-pandemic.
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Affiliation(s)
- Yvonne Heung
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (Y.H.)
| | - Donna Zhukovsky
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (Y.H.)
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (Y.H.)
| | - Zhanni Lu
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (Y.H.)
| | - Clark Andersen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (Y.H.)
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12
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Callahan K, Acharya Y, Hollenbeak CS. The affordable care act and do-not-resuscitate orders: Differences by race and ethnicity. Heart Lung 2023; 59:16-22. [PMID: 36669442 DOI: 10.1016/j.hrtlng.2023.01.009] [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: 11/18/2022] [Revised: 01/05/2023] [Accepted: 01/15/2023] [Indexed: 01/20/2023]
Abstract
BACKGROUND The Affordable Care Act (ACA) created new payment rules that provided reimbursement for physicians to engage in advance care planning (ACP) conversations with patients. This reimbursement policy has the potential to increase ACP participation, including among racial and ethnic minority groups that have had lower ACP participation. OBJECTIVES To examine whether the ACP payment rules were associated with an increase in use of do-not-resuscitate (DNR) orders, particularly among racial and ethnic minority groups, among patients diagnosed with heart failure (HF) in California. METHODS The California Office of Statewide Health Planning and Development (OSHPD) Patient Discharge Data Set was used to identify a cohort of elderly patients with a principal diagnosis of HF. This study included 432,520 hospital admissions of patients over the age of 65 with a primary diagnosis of HF between 2012 and 2018. DNR status was identified using International Classification of Diseases, Clinical Modification Ninth and Tenth Revision, codes. RESULTS There was a small increase in the utilization of DNR orders overall after the ACA reimbursement policy, but the change was not significantly different for all racial and ethnic groups when compared to white non-Hispanic patients. CONCLUSIONS ACP payment rules provided in the ACA were associated with increased utilization of DNR, but the effect was not significantly different for racial and ethnic minorities hospitalized with HF in CA. Additional efforts are needed to increase ACP participation among racial and ethnic minorities.
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Affiliation(s)
- Katherine Callahan
- Department of Health Policy and Administration, College of Health and Human Development, The Pennsylvania State University, University Park, PA 16802 USA.
| | - Yubraj Acharya
- Department of Health Policy and Administration, College of Health and Human Development, The Pennsylvania State University, University Park, PA 16802 USA
| | - Christopher S Hollenbeak
- Department of Health Policy and Administration, College of Health and Human Development, The Pennsylvania State University, University Park, PA 16802 USA
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13
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Prigerson HG, Viola M, Maciejewski PK, Falzarano F. Advance care planning (ACP) to promote receipt of value-concordant care: Results vary according to patient priorities. PLoS One 2023; 18:e0280197. [PMID: 36630471 PMCID: PMC9833543 DOI: 10.1371/journal.pone.0280197] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 12/22/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Benefits of advance care planning (ACP) have recently been questioned by experts, but ACP is comprised of discrete activities. Little is known about which, if any, ACP activities are associated with patients' greater likelihood of receiving value-concordant end-of-life (EoL) care. OBJECTIVES To determine which ACP activities [Do-Not-Resuscitate (DNR) order completion, designation of a healthcare proxy (HCP), and/or EoL discussions with physicians], individually and in combination, are associated with the greatest likelihood of receiving value-concordant care, and how results may vary based on patient-reported EoL care priorities. METHODS Data from 2 federally-funded, multisite, prospective cohort studies of EoL cancer care from 2002-2019 were analyzed. Cancer patients (N = 278) with metastatic disease refractory to chemotherapy were interviewed for a baseline assessment and followed prospectively until death. Interviews regarding patient priorities occurred a median of 111 days prior to death; data regarding EoL medical care were collected post-mortem from caregiver interviews and medical record abstraction. Patients who 1) prioritized life-extending care, and then received life-extending care (or avoided hospice care), or 2) prioritized comfort-focused care, and then avoided life-extending care (or received hospice care) in the last week of life, were coded as receiving value-concordant care. RESULTS After inverse propensity score weighting, the ACP combination associated with the largest proportion of patients receiving value-concordant care was DNR, HCP, and EoL discussions (87% vs. 64% for no ACP activities; OR = 3.91, p = 0.006). In weighted analyses examining each ACP activity individually, DNR orders were associated with decreased likelihood of life-extending care (89% vs. 75%; p = 0.005) and EoL discussions were associated with increased likelihood of hospice care (77% vs. 55%; p = 0.002) among patients prioritizing comfort. ACP activities were not significantly associated with increased likelihood of receiving value-concordant care among patients prioritizing life-extension. CONCLUSIONS AND RELEVANCE For patients who prioritize comfort, EoL discussions with physicians and completion of DNR orders may improve odds of receiving value-concordant EoL care. For patients who prioritize life-extension, ACP does not appear to improve odds of receiving value-concordant EoL care.
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Affiliation(s)
- Holly G. Prigerson
- Cornell Center for Research on End-of Life Care, Department of Medicine, Weill Cornell Medicine, New York, New York, United States of America
| | - Martin Viola
- Cornell Center for Research on End-of Life Care, Department of Medicine, Weill Cornell Medicine, New York, New York, United States of America
| | - Paul K. Maciejewski
- Cornell Center for Research on End-of Life Care, Department of Medicine, Weill Cornell Medicine, New York, New York, United States of America
| | - Francesca Falzarano
- Cornell Center for Research on End-of Life Care, Department of Medicine, Weill Cornell Medicine, New York, New York, United States of America
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The Impact of Signing Do-Not-Resuscitate Orders on the Use of Non-Beneficial Life-Sustaining Treatments for Intensive Care Unit Patients: A Retrospective Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19159521. [PMID: 35954876 PMCID: PMC9367818 DOI: 10.3390/ijerph19159521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 07/14/2022] [Accepted: 07/30/2022] [Indexed: 02/06/2023]
Abstract
Background: Intensive care medical technology increases the survival rate of critically ill patients. However, life-sustaining treatments also increase the probability of non-beneficial medical treatments given to patients at the end of life. Objective: This study aimed to analyse whether patients with a do-not-resuscitate (DNR) order were more likely to be subject to the withholding of cardiac resuscitation and withdrawal of life-sustaining treatment in the ICU. Methods: This retrospective study collected data regarding the demographics, illness conditions, and life-sustaining treatments of ICU patients who were last admitted to the ICU between 1 January 2016 and 31 December 2017, as determined by the hospital’s electronic medical dataset. Results: We identified and collected data on 386 patients over the two years; 319 (82.6%) signed a DNR before the end. The study found that DNR patients were less likely to receive cardiac resuscitation before death than non-DNR patients. The cardiac resuscitation treatments included chest compressions, electric shock, and cardiotonic drug injections (p < 0.001). However, the life-sustaining treatments were withdrawn for only a few patients before death. The study highlights that an early-documented DNR order is essential. However, it needs to be considered that promoting discussions of time-limited trials might be the solution to helping ICU terminal patients withdraw from non-beneficial life-sustaining treatments.
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15
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Incidence and Outcomes of Cardiopulmonary Resuscitation in ICUs: Retrospective Cohort Analysis. Crit Care Med 2022; 50:1503-1512. [PMID: 35834661 DOI: 10.1097/ccm.0000000000005624] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES We aim to describe incidence and outcomes of cardiopulmonary resuscitation (CPR) efforts and their outcomes in ICUs and their changes over time. DESIGN Retrospective cohort analysis. SETTING Patient data documented in the Austrian Center for Documentation and Quality Assurance in Intensive Care database. PATIENTS Adult patients (age ≥ 18 yr) admitted to Austrian ICUs between 2005 and 2019. INTERVENTIONS None. MEASUREMENTS ANDN MAIN RESULTS Information on CPR was deduced from the Therapeutic Intervention Scoring System. End points were overall occurrence rate of CPR in the ICU and CPR for unexpected cardiac arrest after the first day of ICU stay as well as survival to discharge from the ICU and the hospital. Incidence and outcomes of ICU-CPR were compared between 2005 and 2009, 2010 and 2014, and 2015 and 2019 using chi-square test. A total of 525,518 first admissions and readmissions to ICU of 494,555 individual patients were included; of these, 72,585 patients (14.7%) died in hospital. ICU-CPR was performed in 20,668 (3.9%) admissions at least once; first events occurred on the first day of ICU admission in 15,266 cases (73.9%). ICU-CPR was first performed later during ICU stay in 5,402 admissions (1.0%). The incidence of ICU-CPR decreased slightly from 4.4% between 2005 and 2009, 3.9% between 2010 and 2014, and 3.7% between 2015 and 2019 (p < 0.001). A total of 7,078 (34.5%) of 20,499 patients who received ICU-CPR survived until hospital discharge. Survival rates varied slightly over the observation period; 59,164 (12.0%) of all patients died during hospital stay without ever receiving CPR in the ICU. CONCLUSIONS The incidence of ICU-CPR is approximately 40 in 1,000 admissions overall and approximately 10 in 1,000 admissions after the day of ICU admission. Short-term survival is approximately four out of 10 patients who receive ICU-CPR.
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16
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Bentin F, Van Den Noortgate N, Piers R. In-hospital end-of-life care in the old: a retrospective study of intensive care unit use and do-not-resuscitate forms in patients deceased in a Belgian university hospital. Acta Clin Belg 2022; 78:185-191. [PMID: 35816019 DOI: 10.1080/17843286.2022.2097408] [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: 10/17/2022]
Abstract
OBJECTIVES To explore the quality of in-hospital end-of-life care in adult patients with special attention to those 75 years and older and to make a comparison with the situation 10 years ago. METHODS Data were retrospectively collected on adult patients who deceased at Ghent University Hospital between September 2018 and December 2019. The main outcome measures were 'ICU use' and 'presence of DNR forms on non-ICU units' in the final hospitalization. In order to identify possible risk factors for ICU use, logistic regression was performed. RESULTS In total, 762 people died, of whom 35% were 75 or older. Just as 10 years ago, one-third (31%) died in the ICU versus 49% of those younger than 75 years (p < 0.001). Of people ≥75 years, 38%, compared to 42% 10 years ago, received an ICU treatment during their final hospitalization. The median length of an ICU stay was 4 versus 3 days 10 years ago. After adjusting for gender, comorbidities and the Charlson Comorbidity Index, factors associated with less ICU use were higher age, active malignancy and dementia (OR 0.838, 0.116 and 0.098 respectively). Seventy-nine percent of older patients on non-ICU wards died with a DNR form (versus 87% 10 years ago). CONCLUSION Although there was an increase in the presence of DNR forms in the final hospitalization, no significant differences were seen in actual ICU use compared to 10 years ago. Factors associated with less ICU use were higher age, active malignancy and dementia.
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Affiliation(s)
- Felicia Bentin
- Department of Geriatrics, University Hospital Ghent, Ghent, Belgium
| | | | - Ruth Piers
- Department of Geriatrics, University Hospital Ghent, Ghent, Belgium
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17
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Factors associated with limitation of care after fatal injury. J Trauma Acute Care Surg 2022; 92:974-983. [PMID: 35609288 DOI: 10.1097/ta.0000000000003495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is variability in end-of-life care of trauma patients. Many survive resuscitation but die after limitation of care (LoC). This study investigated LoC at a level I center. METHODS Adult trauma deaths between January 2016 and June 2020 were reviewed. Patients were stratified into "full code" versus any LoC (i.e., do not resuscitate, no escalation, or withdrawal of care) and by timing to LoC. Emergency department and "brain" deaths were excluded. Unadjusted logistic regression and Cox proportional hazards were used for analyses. Results include n (%) and odds ratios (ORs) with 95% confidence intervals (CIs), with α = 0.05. RESULTS A total of 173 patients were included; 15 patients (8%) died full code and 158 (91%) died after LoC. Seventy-seven patients (48%) underwent incremental LoC. Age (OR, 1.05; 95% CI, 1.02-1.08; p = 0.0010) and female sex (OR, 3.71; 95% CI, 1.01-13.64; p = 0.0487) increased the odds of LoC; number of anatomic injuries (OR, 0.91; 95% CI, 0.85-0.98; p = 0.0146), chest injuries (Abbreviated Injury Scale [AIS] score chest, >3) (OR, 0.02; 95% CI, 0.01-0.26; p = 0.0021), extremity injury (AIS score, >3) (OR, 0.08; 95% CI, 0.01-0.64; p = 0.0170), and hospital complications equal to 1 (OR, 0.21; 95% CI, 0.06-0.78; p = 0.0201) or ≥2 (OR, 0.19; 95% CI, 0.04-0.87; p = 0.0319) decreased the odds of LoC. For those having LoC, final limitations were implemented in <14 days for 83% of patients; markers of injury severity (e.g., Injury Severity Score, Glasgow Coma Scale score, and AIS score) increased the odds of early LoC implementation. CONCLUSION Most patients died after LoC was implemented in a timely fashion. Significant head injury increased the odds of LoC. The number of injuries, severe chest and extremity injuries, and increasing number of complications decreased the odds of LoC, presumably because patients died before LoCs were initiated. Understanding factors contributing to end-of-life care could help guide discussions regarding LoCs. LEVEL OF EVIDENCE Prognostic and Epidemiologic; Level III.
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18
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Im H, Choe HW, Oh SY, Ryu HG, Lee H. Changes in the incidence of cardiopulmonary resuscitation before and after implementation of the Life-Sustaining Treatment Decisions Act. Acute Crit Care 2022; 37:237-246. [PMID: 35280036 PMCID: PMC9184988 DOI: 10.4266/acc.2021.01095] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 11/13/2021] [Indexed: 11/30/2022] Open
Abstract
Background Methods Results Conclusions
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19
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Fan R, Yang S, Bu X, Chen Y, Wang Y, Shen B, Qiu C, Li X. Symptomatic Features and Factors Associated With Do-Not-Resuscitate Consent in Advanced Cancer Patients Admitted to Palliative Care Ward. Am J Hosp Palliat Care 2022; 39:1312-1324. [PMID: 35041534 DOI: 10.1177/10499091211068824] [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: 11/15/2022] Open
Abstract
This study aimed to conduct a retrospective cross-sectional study to investigate the prevalence of symptoms and symptom clusters on sociodemographic and disease characteristics, as well as factors associated with Do-Not-Resuscitate (DNR) consent. Advanced cancer patients were enrolled between 2018 and 2020 with available data. Demographic and clinical data were obtained for analysis from Hospital Information System (HIS) in China. Symptom clusters were extracted by hierarchical cluster analysis. Chi-square test and multiple logistic regression were conducted to investigate the prevalence characteristics of symptoms and influencing factors of DNR consent, respectively. 798 advanced cancer patients were enrolled. The most prevalent symptoms were pain (93%), anorexia (36.5%), and sleep disorders (34.2%). High heart rate was associated with poor performance status and more symptoms. Three clusters were extracted: fatigue-related, respiratory-circulatory system, and digestive system symptom clusters. The incidence of symptoms was statistically significant in age, gender, education level, residence, BMI, performance status, distress score, ADL, and primary pain level. The DNR signature rate was 15.5%. Female, distant metastasis, in-ward rescue, and appearance of dyspnea were independent influencing factors of DNR signature.Chinese hospitalized cancer patients had more symptoms burden that were influenced by various demographic characteristics, especially pain and fatigue-related symptoms. Concerning the trajectory of vital signs is important among advanced cancer patients. The DNR signature rate was lower and our finding indicating an urgency to accurately assess the prognosis and give more palliative care education to enhance DNR rates and early signing in Chinese context.
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Affiliation(s)
- Rongrong Fan
- 117924Hunan Cancer Hospital/Affiliated Cancer Hospital of Xiangya Nursing School of Central South University, Changsha, China
| | - Siyu Yang
- 117924Hunan Cancer Hospital/Affiliated Cancer Hospital of Xiangya Nursing School of Central South University, Changsha, China
| | - Xiaofan Bu
- 12570Xiangya Nursing School of Central South University, Changsha, China
| | - Yongyi Chen
- 117924Hunan Cancer Hospital/Affiliated Cancer Hospital of Xiangya Nursing School of Central South University, Changsha, China
| | - Ying Wang
- 117924Hunan Cancer Hospital/Affiliated Cancer Hospital of Xiangya Nursing School of Central South University, Changsha, China
| | - Boyong Shen
- 117924Hunan Cancer Hospital/Affiliated Cancer Hospital of Xiangya Nursing School of Central South University, Changsha, China
| | - Cuiling Qiu
- 117924Hunan Cancer Hospital/Affiliated Cancer Hospital of Xiangya Nursing School of Central South University, Changsha, China
| | - Xuying Li
- 117924Hunan Cancer Hospital/Affiliated Cancer Hospital of Xiangya Nursing School of Central South University, Changsha, China
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20
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Aletreby W, Mady A, Al-Odat M, Balshi A, Mady A, Al-Odat A, Elshayeb A, Mostafa A, Abd Elsalam S, Odchigue K. Early versus late DNR orders and its predictors in a Saudi Arabian ICU: A descriptive study. SAUDI JOURNAL OF MEDICINE AND MEDICAL SCIENCES 2022; 10:192-197. [PMID: 36247060 PMCID: PMC9555038 DOI: 10.4103/sjmms.sjmms_141_22] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/24/2022] [Accepted: 06/22/2022] [Indexed: 11/04/2022] Open
Abstract
Background Objective: Methods: Results: Conclusion:
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21
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Rice DR, Hyer JM, Tsilimigras D, Pawlik TM. Implications of intensive care unit admissions among medicare beneficiaries following resection of pancreatic cancer. J Surg Oncol 2021; 125:405-413. [PMID: 34608989 DOI: 10.1002/jso.26710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/24/2021] [Accepted: 09/28/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Intensive care unit (ICU) use has increased among patients with cancer. We sought to define factors associated with ICU admissions among patients with pancreatic cancer and characterize trends in mortality among hospital survivors. METHODS The Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database was used to identify patients with pancreatic cancer who underwent resection. Multivariable analyses were conducted to identify factors associated with ICU admission and mortality among hospital survivors. RESULTS Among 6422 Medicare beneficiaries who underwent resection of pancreatic cancer, 2386 (37.1%) had an ICU admission. Patients with ICU admissions were more likely to be younger (10-year increase odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.77-0.89), male (OR: 1.17, 95% CI 1.05-1.30) and undergo resection at a teaching hospital (OR: 1.19, 95% CI: 1.05-1.36). While the majority of patients survived to hospital discharge (n = 2106; 88.3%), a majority of patients (n = 1296; 54.3%) died within 6 months. Among patients who had subsequent ICU admissions, 1- and 5-year survival was only 31.8% and 11.0%, respectively. CONCLUSIONS Over one-third of patients with pancreatic cancer had an ICU admission. While most patients survived hospitalization, more than one-half of patients died within 6 months of discharge and two-thirds died within 1 year. These data should serve to guide patient-provider discussions around prognosis relative to ICU utilization.
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Affiliation(s)
- Daniel R Rice
- The Ohio State Wexner Medical Center, James Cancer Center, Columbus, Ohio, USA
| | - J Madison Hyer
- The Ohio State Wexner Medical Center, James Cancer Center, Columbus, Ohio, USA
| | | | - Timothy M Pawlik
- The Ohio State Wexner Medical Center, James Cancer Center, Columbus, Ohio, USA
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22
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Lin MY, Li CC, Lin PH, Wang JL, Chan MC, Wu CL, Chao WC. Explainable Machine Learning to Predict Successful Weaning Among Patients Requiring Prolonged Mechanical Ventilation: A Retrospective Cohort Study in Central Taiwan. Front Med (Lausanne) 2021; 8:663739. [PMID: 33968967 PMCID: PMC8104124 DOI: 10.3389/fmed.2021.663739] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/04/2021] [Indexed: 11/26/2022] Open
Abstract
Objective: The number of patients requiring prolonged mechanical ventilation (PMV) is increasing worldwide, but the weaning outcome prediction model in these patients is still lacking. We hence aimed to develop an explainable machine learning (ML) model to predict successful weaning in patients requiring PMV using a real-world dataset. Methods: This retrospective study used the electronic medical records of patients admitted to a 12-bed respiratory care center in central Taiwan between 2013 and 2018. We used three ML models, namely, extreme gradient boosting (XGBoost), random forest (RF), and logistic regression (LR), to establish the prediction model. We further illustrated the feature importance categorized by clinical domains and provided visualized interpretation by using SHapley Additive exPlanations (SHAP) as well as local interpretable model-agnostic explanations (LIME). Results: The dataset contained data of 963 patients requiring PMV, and 56.0% (539/963) of them were successfully weaned from mechanical ventilation. The XGBoost model (area under the curve [AUC]: 0.908; 95% confidence interval [CI] 0.864-0.943) and RF model (AUC: 0.888; 95% CI 0.844-0.934) outperformed the LR model (AUC: 0.762; 95% CI 0.687-0.830) in predicting successful weaning in patients requiring PMV. To give the physician an intuitive understanding of the model, we stratified the feature importance by clinical domains. The cumulative feature importance in the ventilation domain, fluid domain, physiology domain, and laboratory data domain was 0.310, 0.201, 0.265, and 0.182, respectively. We further used the SHAP plot and partial dependence plot to illustrate associations between features and the weaning outcome at the feature level. Moreover, we used LIME plots to illustrate the prediction model at the individual level. Additionally, we addressed the weekly performance of the three ML models and found that the accuracy of XGBoost/RF was ~0.7 between weeks 4 and week 7 and slightly declined to 0.6 on weeks 8 and 9. Conclusion: We used an ML approach, mainly XGBoost, SHAP plot, and LIME plot to establish an explainable weaning prediction ML model in patients requiring PMV. We believe these approaches should largely mitigate the concern of the black-box issue of artificial intelligence, and future studies are warranted for the landing of the proposed model.
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Affiliation(s)
- Ming-Yen Lin
- Department of Information Engineering and Computer Science, Feng Chia University, Taichung, Taiwan
| | - Chi-Chun Li
- Department of Information Engineering and Computer Science, Feng Chia University, Taichung, Taiwan
| | - Pin-Hsiu Lin
- Department of Information Engineering and Computer Science, Feng Chia University, Taichung, Taiwan
| | - Jiun-Long Wang
- Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Life Sciences, National Chung-Hsing University, Taichung, Taiwan
| | - Ming-Cheng Chan
- Division of Critical Care and Respiratory Therapy, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Central Taiwan University of Science and Technology, Taichung, Taiwan
- The College of Science, Tunghai University, Taichung, Taiwan
| | - Chieh-Liang Wu
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Computer Science, Tunghai University, Taichung, Taiwan
| | - Wen-Cheng Chao
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Computer Science, Tunghai University, Taichung, Taiwan
- Department of Automatic Control Engineering, Feng Chia University, Taichung, Taiwan
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Erath A, Shipley K, Walker LA, Burrell E, Weavind L. Code status at time of rapid response activation - Impact on escalation of care? Resusc Plus 2021; 6:100102. [PMID: 34223364 PMCID: PMC8244475 DOI: 10.1016/j.resplu.2021.100102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 01/23/2021] [Accepted: 02/22/2021] [Indexed: 11/15/2022] Open
Abstract
Background A code status documents the decision to receive or forgo cardiopulmonary resuscitation in the event of cardiac arrest. For patients who undergo a rapid response team activation (RRT) for possible escalation to an intensive care unit (ICU), the presence or absence of a code status represents a critical inflection point for guiding care decisions and resource utilization. This study characterizes the prevalence of code status at the time of RRT and how code status at RRT affects rates of intensive treatments in the ICU. Methods We conducted a single-center retrospective cohort study of 895 rapid response activations occurring over six months. The study included all rapid response team activations for non-obstetric adult inpatients documented in the patient chart. All data was obtained through retrospective chart review. STROBE reporting guidelines were followed. Results At the time of RRT activation, 56% of patients had a documented code status. Code status prevalence was much higher among medical rather than surgical services (74% vs. 13%). For patients escalated to the ICU, having a DNR code status at RRT was not associated with decreased odds of receiving cardioactive medications or advanced respiratory support. Before RRT activation, palliative care utilization was low (9%) but more than doubled after RRT (24% before discharge). Conclusions Barely half of the patients had an active code status at the time of RRT activation. Similar rates of invasive ICU treatments among full code and DNR patients suggest that documented code statuses do not reflect in-depth goals of care discussions, nor does it guide medical teams caring for the patient at times of decompensation.
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Affiliation(s)
- Alexandra Erath
- School of Medicine, Vanderbilt University, Nashville, TN, United States
| | - Kipp Shipley
- Pulmonary & Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | | | - Erin Burrell
- Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Liza Weavind
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37212, United States
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Differences in Characteristics, Hospital Care and Outcomes between Acute Critically Ill Emergency Department Patients with Early and Late Do-Not-Resuscitate Orders. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18031028. [PMID: 33503811 PMCID: PMC7908360 DOI: 10.3390/ijerph18031028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/20/2021] [Accepted: 01/21/2021] [Indexed: 11/27/2022]
Abstract
Background: A do-not-resuscitate (DNR) order is associated with an increased risk of death among emergency department (ED) patients. Little is known about patient characteristics, hospital care, and outcomes associated with the timing of the DNR order. Aim: Determine patient characteristics, hospital care, survival, and resource utilization between patients with early DNR (EDNR: signed within 24 h of ED presentation) and late DNR orders. Design: Retrospective observational study. Setting/Participants: We enrolled consecutive, acute, critically ill patients admitted to the emergency intensive care unit (EICU) at Taipei Veterans General Hospital from 1 February 2018, to 31 January 2020. Results: Of the 1064 patients admitted to the EICU, 619 (58.2%) had EDNR and 445 (41.8%) LDNR. EDNR predictors were age >85 years (adjusted odd ratios (AOR) 1.700, 1.027–2.814), living in long-term care facilities (AOR 1.880, 1.066–3.319), having advanced cardiovascular diseases (AOR 2.128, 1.039–4.358), “medical staff would not be surprised if the patient died within 12 months” (AOR 1.725, 1.193–2.496), and patients’ family requesting palliative care (AOR 2.420, 1.187–4.935). EDNR patients underwent lesser endotracheal tube (ET) intubation (15.6% vs. 39.9%, p < 0.001) and had reduced epinephrine injection (19.9% vs. 30.3%, p = 0.009), ventilator support (16.7% vs. 37.9%, p < 0.001), and narcotic use (51.1% vs. 62.6%, p = 0.012). EDNR patients had significantly lower 7-day (p < 0.001), 30-day (p < 0.001), and 90-day (p = 0.023) survival. Conclusions: EDNR patients underwent decreased ET intubation and had reduced epinephrine injection, ventilator support, and narcotic use during EOL as well as decreased length of hospital stay, hospital expenditure, and survival compared to LDNR patients.
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Luth EA, Pan CX, Viola M, Prigerson HG. Dementia and Early Do-Not-Resuscitate Orders Associated With Less Intensive of End-of-Life Care: A Retrospective Cohort Study. Am J Hosp Palliat Care 2021; 38:1417-1425. [PMID: 33467864 DOI: 10.1177/1049909121989020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Dementia is a leading cause of death among US older adults. Little is known about end-of-life care intensity and do-not-resuscitate orders (DNRs) among patients with dementia who die in hospital. AIM Examine the relationship between dementia, DNR timing, and end-of-life care intensity. DESIGN Observational cohort study. SETTING/PARTICIPANTS Inpatient electronic health record extraction for 2,566 persons age 65 and older who died in 2 New York City hospitals in the United States from 2015 to 2017. RESULTS Multivariable logistic regression analyses modeled associations between dementia diagnosis, DNR timing, and 6 end-of-life care outcomes. 31% of subjects had a dementia diagnosis; 23% had a DNR on day of hospital admission. Patients with dementia were 18%-40% less likely to have received 4 of 6 types of intensive care (mechanical ventilation AOR: 0.82, 95%CI: 0.67 -1.00; intensive care unit admission AOR: 0.60, 95%CI: 0.49-0.83). Having a DNR on file was inversely associated with staying in the intensive care unit (AOR: 0.57, 95%CI: 0.47-0.70) and avoiding other intensive care measures. DNR placement later during the hospitalization and not having a DNR were associated with more intensive care compared to having a DNR upon admission. CONCLUSIONS Having dementia and a do-not resuscitate order upon hospital admission are associated with less intensive end-of-life care. Additional research is needed to understand why persons with dementia receive less intensive care. In clinical practice, encouraging advance care planning prior to and at hospital admission may be particularly important for patients wishing to avoid intensive end-of-life care, including patients with dementia.
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