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Pringle CP, Filipp SL, Morrison WE, Fainberg NA, Aczon MD, Avesar M, Burkiewicz KF, Chandnani HK, Hsu SC, Laksana E, Ledbetter DR, McCrory MC, Morrow KR, Noguchi AE, O'Brien CE, Ojha A, Ross PA, Shah S, Shah JK, Siegel LB, Tripathi S, Wetzel RC, Zhou AX, Winter MC. Ventilator Weaning and Terminal Extubation: Withdrawal of Life-Sustaining Therapy in Children. Secondary Analysis of the Death One Hour After Terminal Extubation Study. Crit Care Med 2024; 52:396-406. [PMID: 37889228 PMCID: PMC10922051 DOI: 10.1097/ccm.0000000000006101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
OBJECTIVE Terminal extubation (TE) and terminal weaning (TW) during withdrawal of life-sustaining therapies (WLSTs) have been described and defined in adults. The recent Death One Hour After Terminal Extubation study aimed to validate a model developed to predict whether a child would die within 1 hour after discontinuation of mechanical ventilation for WLST. Although TW has not been described in children, pre-extubation weaning has been known to occur before WLST, though to what extent is unknown. In this preplanned secondary analysis, we aim to describe/define TE and pre-extubation weaning (PW) in children and compare characteristics of patients who had ventilatory support decreased before WLST with those who did not. DESIGN Secondary analysis of multicenter retrospective cohort study. SETTING Ten PICUs in the United States between 2009 and 2021. PATIENTS Nine hundred thirteen patients 0-21 years old who died after WLST. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS 71.4% ( n = 652) had TE without decrease in ventilatory support in the 6 hours prior. TE without decrease in ventilatory support in the 6 hours prior = 71.4% ( n = 652) of our sample. Clinically relevant decrease in ventilatory support before WLST = 11% ( n = 100), and 17.6% ( n = 161) had likely incidental decrease in ventilatory support before WLST. Relevant ventilator parameters decreased were F io2 and/or ventilator set rates. There were no significant differences in any of the other evaluated patient characteristics between groups (weight, body mass index, unit type, primary diagnostic category, presence of coma, time to death after WLST, analgosedative requirements, postextubation respiratory support modality). CONCLUSIONS Decreasing ventilatory support before WLST with extubation in children does occur. This practice was not associated with significant differences in palliative analgosedation doses or time to death after extubation.
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Affiliation(s)
- Charlene P Pringle
- Department of Pediatrics, Critical Care Medicine, University of Florida, Gainesville, FL
| | - Stephanie L Filipp
- Department of Pediatrics, Pediatric Research Hub, University of Florida Gainesville, FL
| | - Wynne E Morrison
- Department of Pediatrics, Critical Care Medicine, University of Florida, Gainesville, FL
- Department of Pediatrics, Pediatric Research Hub, University of Florida Gainesville, FL
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania Philadelphia, PA
- Justin Michael Ingerman Center for Palliative Care, Children's Hospital of Philadelphia Philadelphia, PA
- Division of Pediatric Critical Care, Children's Hospital of Philadelphia Philadelphia, PA
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles Los Angeles, CA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
- Division of Pediatric Critical Care Medicine, Loma Linda University Children's Hospital, Loma Linda, CA
- Pediatric Intensive Care, OSF HealthCare, Children's Hospital of Illinois, Peoria, IL Peoria, IL
- Division of Critical Care Medicine, Department of Pediatrics, Dallas, TX
- The University of Texas Southwestern Medical Center at Dallas, Children's Health Medical Center Dallas Dallas, TX
- KPMG Lighthouse, Dallas, TX
- Departments of Anesthesiology and Pediatrics, Wake Forest University School of Medicine, Winston Salem, NC
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
- Program Coordinator for Organ, Eye, and Tissue Donation Johns Hopkins Hospital, Baltimore, MD
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
- Michigan State University College of Human Medicine, East Lansing, MI
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
- Division of Pediatric Critical Care, Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA
- Division of Pediatric Critical Care Medicine, Cohen Children's Medical Center, New Hyde Park, NY
| | - Nina A Fainberg
- Division of Pediatric Critical Care, Children's Hospital of Philadelphia Philadelphia, PA
| | - Melissa D Aczon
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles Los Angeles, CA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
| | - Michael Avesar
- Division of Pediatric Critical Care Medicine, Loma Linda University Children's Hospital, Loma Linda, CA
| | - Kimberly F Burkiewicz
- Pediatric Intensive Care, OSF HealthCare, Children's Hospital of Illinois, Peoria, IL Peoria, IL
| | - Harsha K Chandnani
- Division of Pediatric Critical Care Medicine, Loma Linda University Children's Hospital, Loma Linda, CA
| | - Stephanie C Hsu
- Division of Critical Care Medicine, Department of Pediatrics, Dallas, TX
- The University of Texas Southwestern Medical Center at Dallas, Children's Health Medical Center Dallas Dallas, TX
| | - Eugene Laksana
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles Los Angeles, CA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
| | | | - Michael C McCrory
- Departments of Anesthesiology and Pediatrics, Wake Forest University School of Medicine, Winston Salem, NC
| | - Katie R Morrow
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Anna E Noguchi
- Program Coordinator for Organ, Eye, and Tissue Donation Johns Hopkins Hospital, Baltimore, MD
| | - Caitlin E O'Brien
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Apoorva Ojha
- Michigan State University College of Human Medicine, East Lansing, MI
| | - Patrick A Ross
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles Los Angeles, CA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Sareen Shah
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
- Division of Pediatric Critical Care, Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jui K Shah
- Division of Pediatric Critical Care Medicine, Loma Linda University Children's Hospital, Loma Linda, CA
| | - Linda B Siegel
- Division of Pediatric Critical Care Medicine, Cohen Children's Medical Center, New Hyde Park, NY
| | - Sandeep Tripathi
- Pediatric Intensive Care, OSF HealthCare, Children's Hospital of Illinois, Peoria, IL Peoria, IL
| | - Randall C Wetzel
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles Los Angeles, CA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Alice X Zhou
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles Los Angeles, CA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
| | - Meredith C Winter
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles Los Angeles, CA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
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Kumar A, Sinha S, Mani RK. A Survey for Assessment of Practical Aspects of End-of-life Practices across Indian Intensive Care Units. Indian J Crit Care Med 2023; 27:531-536. [PMID: 37636851 PMCID: PMC10452772 DOI: 10.5005/jp-journals-10071-24500] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 07/13/2023] [Indexed: 08/29/2023] Open
Abstract
Background The end-of-life (EOL) decisions continue to be debated for their moral and legal standing. The acceptance of these decisions varies, based upon the perceptions and personal choices of the intensivists. Materials and methods An online questionnaire-based survey was designed and circulated among the practicing intensivists via Indian Society of Critical Care Medicine (ISCCM) e-mail. Results Out of 200 responses, 165 (82.5%) affirmed that EOL decisions are routinely undertaken in their intensive care units. The most prevalent reasons expressed for avoidance of EOL decisions are moral and ethical dilemmas and fear of litigation. There is notable variability in the practice of withholding (47.7%) vs withdrawal (3.5%) of therapies. A good proportion of intensivists follow do-not-intubate (91%) and do-not-resuscitate (86%) orders, whereas only 18% affirmed to be practicing terminal extubation. About 93% of the respondents acknowledged the use of monitoring toward the EOL, and 49% reported the use of preformatted documents. A meager 2% admitted to facing a medicolegal issue after taking an EOL decision. Conclusion The survey establishes a general acceptance among the Indian intensivists regarding providing compassionate care to terminally ill patients, especially toward the EOL. The pattern of responses, however, indicates significant dilemmas and hesitancy with regard to the decision-making process. How to cite this article Kumar A, Sinha S, Mani RK. A Survey for Assessment of Practical Aspects of End-of-life Practices across Indian Intensive Care Units. Indian J Crit Care Med 2023;27(8):531-536.
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Affiliation(s)
- Arun Kumar
- Department of Intensive Care, Medical Intensive Care Unit, Fortis Healthcare Ltd., Mohali, Punjab, India
| | - Sharmili Sinha
- Department of Critical Care Medicine, Apollo Hospitals, Bhubaneswar, Odisha, India
| | - Raj Kumar Mani
- Department of Critical Care and Pulmonology, Yashoda Super Specialty Hospital, Ghaziabad, Uttar Pradesh, India
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Lincoln T, Shields AM, Buddadhumaruk P, Chang CCH, Pike F, Chen H, Brown E, Kozar V, Pidro C, Kahn JM, Darby JM, Martin S, Angus DC, Arnold RM, White DB. Protocol for a randomised trial of an interprofessional team-delivered intervention to support surrogate decision-makers in ICUs. BMJ Open 2020; 10:e033521. [PMID: 32229520 PMCID: PMC7170558 DOI: 10.1136/bmjopen-2019-033521] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Although shortcomings in clinician-family communication and decision making for incapacitated, critically ill patients are common, there are few rigorously tested interventions to improve outcomes. In this manuscript, we present our methodology for the Pairing Re-engineered Intensive Care Unit Teams with Nurse-Driven Emotional support and Relationship Building (PARTNER 2) trial, and discuss design challenges and their resolution. METHODS AND ANALYSIS This is a pragmatic, stepped-wedge, cluster randomised controlled trial comparing the PARTNER 2 intervention to usual care among 690 incapacitated, critically ill patients and their surrogates in five ICUs in Pennsylvania. Eligible subjects will include critically ill patients at high risk of death and/or severe long-term functional impairment, their main surrogate decision-maker and their clinicians. The PARTNER intervention is delivered by the interprofessional ICU team and overseen by 4-6 nurses from each ICU. It involves: (1) advanced communication skills training for nurses to deliver support to surrogates throughout the ICU stay; (2) deploying a structured family support pathway; (3) enacting strategies to foster collaboration between ICU and palliative care services and (4) providing intensive implementation support to each ICU to incorporate the family support pathway into clinicians' workflow. The primary outcome is surrogates' ratings of the quality of communication during the ICU stay as assessed by telephone at 6-month follow-up. Prespecified secondary outcomes include surrogates' scores on the Hospital Anxiety and Depression Scale, the Impact of Event Scale, the modified Patient Perception of Patient Centredness scale, the Decision Regret Scale, nurses' scores on the Maslach Burnout Inventory, and length of stay during and costs of the index hospitalisation.We also discuss key methodological challenges, including determining the optimal level of randomisation, using existing staff to deploy the intervention and maximising long-term follow-up of participants. ETHICS AND DISSEMINATION We obtained ethics approval through the University of Pittsburgh, Human Research Protection Office. The findings will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT02445937.
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Affiliation(s)
- Taylor Lincoln
- Department of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Anne-Marie Shields
- Department of Critical Care Medicine, The CRISMA Center, Program on Ethics and Decision Making, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Praewpannarai Buddadhumaruk
- Department of Critical Care Medicine, The CRISMA Center, Program on Ethics and Decision Making, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Chung-Chou H Chang
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
- Department of Critical Care Medicine, The CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Francis Pike
- Department of Neuroscience, Ely Lilly and Company, Indianapolis, Indiana, USA
| | - Hsiangyu Chen
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Elke Brown
- Department of Critical Care Medicine, The CRISMA Center, Program on Ethics and Decision Making, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Veronica Kozar
- Department of Critical Care Medicine, The CRISMA Center, Program on Ethics and Decision Making, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Caroline Pidro
- Department of Critical Care Medicine, The CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jeremy M Kahn
- Department of Critical Care Medicine, The CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Joseph M Darby
- Department of Critical Care Medicine, The CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- ICU Service Center, UPMC Health System, Pittsburgh, Pennsylvania, USA
| | - Susan Martin
- Donald Wolff Center for Quality Improvement and Innovation, UPMC Health System, Pittsburgh, Pennsylvania, USA
| | - Derek C Angus
- Department of Critical Care Medicine, The CRISMA Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- ICU Service Center, UPMC Health System, Pittsburgh, Pennsylvania, USA
| | - Robert M Arnold
- Department of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Palliative Support Institute, UPMC Health System, Pittsburgh, Pennsylvania, USA
| | - Douglas B White
- Department of Critical Care Medicine, The CRISMA Center, Program on Ethics and Decision Making, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- ICU Service Center, UPMC Health System, Pittsburgh, Pennsylvania, USA
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Rocker G, Dunbar S. Withholding or Withdrawal of Life Support: The Canadian Critical Care Society Position Paper. J Palliat Care 2019. [DOI: 10.1177/082585970001601s10] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Graeme Rocker
- Canadian Critical Care Society Provincial Representative for Nova Scotia
| | - Scott Dunbar
- Postgraduate Diploma in Medical Law and Medical Ethics, (KCL), and Fellow in Bioethics, Cleveland Clinic Foundation, Ohio, and Medical Ethicist, Halifax, Nova Scotia, Canada
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Wang CH, Huang PW, Hung CY, Lee SH, Kao CY, Wang HM, Hung YS, Su PJ, Kuo YC, Hsieh CH, Chou WC. Clinical Factors Associated With Adherence to the Premedication Protocol for Withdrawal of Mechanical Ventilation in Terminally Ill Patients: A 4-Year Experience at a Single Medical Center in Asia. Am J Hosp Palliat Care 2018; 35:772-779. [DOI: 10.1177/1049909117732282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Chao-Hui Wang
- Department of Nursing, Chang Gung Medical Foundation at Linkou, Guishan, Taoyuan, Taiwan
| | - Pei-Wei Huang
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Guishan, Taoyuan, Taiwan
| | - Chia-Yen Hung
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Guishan, Taoyuan, Taiwan
- Department of Hema-Oncology, Division of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Shu-Hui Lee
- Department of Nursing, Chang Gung Medical Foundation at Linkou, Guishan, Taoyuan, Taiwan
| | - Chen-Yi Kao
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Guishan, Taoyuan, Taiwan
| | - Hung-Ming Wang
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Guishan, Taoyuan, Taiwan
| | - Yu-Shin Hung
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Guishan, Taoyuan, Taiwan
| | - Po-Jung Su
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Guishan, Taoyuan, Taiwan
| | - Yung-Chia Kuo
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Guishan, Taoyuan, Taiwan
| | - Chia-Hsun Hsieh
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Guishan, Taoyuan, Taiwan
| | - Wen-Chi Chou
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Guishan, Taoyuan, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Guishan, Taoyuan, Taiwan
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Terminal weaning or immediate extubation for withdrawing mechanical ventilation in critically ill patients (the ARREVE observational study). Intensive Care Med 2017; 43:1793-1807. [PMID: 28936597 DOI: 10.1007/s00134-017-4891-0] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 07/18/2017] [Indexed: 12/20/2022]
Abstract
PURPOSE The relative merits of immediate extubation versus terminal weaning for mechanical ventilation withdrawal are controversial, particularly regarding the experience of patients and relatives. METHODS This prospective observational multicentre study (ARREVE) was done in 43 French ICUs to compare terminal weaning and immediate extubation, as chosen by the ICU team. Terminal weaning was a gradual decrease in the amount of ventilatory assistance and immediate extubation was extubation without any previous decrease in ventilatory assistance. The primary outcome was posttraumatic stress symptoms (Impact of Event Scale Revised, IES-R) in relatives 3 months after the death. Secondary outcomes were complicated grief, anxiety, and depression symptoms in relatives; comfort of patients during the dying process; and job strain in staff. RESULTS We enrolled 212 (85.5%) relatives of 248 patients with terminal weaning and 190 relatives (90.5%) of 210 patients with immediate extubation. Immediate extubation was associated with airway obstruction and a higher mean Behavioural Pain Scale score compared to terminal weaning. In relatives, IES-R scores after 3 months were not significantly different between groups (31.9 ± 18.1 versus 30.5 ± 16.2, respectively; adjusted difference, -1.9; 95% confidence interval, -5.9 to 2.1; p = 0.36); neither were there any differences in complicated grief, anxiety, or depression scores. Assistant nurses had lower job strain scores in the immediate extubation group. CONCLUSIONS Compared to terminal weaning, immediate extubation was not associated with differences in psychological welfare of relatives when each method constituted standard practice in the ICU where it was applied. Patients had more airway obstruction and gasps with immediate extubation. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01818895.
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Clinical Practice Guidelines for Sustained Neuromuscular Blockade in the Adult Critically Ill Patient. Crit Care Med 2017; 44:2079-2103. [PMID: 27755068 DOI: 10.1097/ccm.0000000000002027] [Citation(s) in RCA: 161] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To update the 2002 version of "Clinical practice guidelines for sustained neuromuscular blockade in the adult critically ill patient." DESIGN A Task Force comprising 17 members of the Society of Critical Medicine with particular expertise in the use of neuromuscular-blocking agents; a Grading of Recommendations Assessment, Development, and Evaluation expert; and a medical writer met via teleconference and three face-to-face meetings and communicated via e-mail to examine the evidence and develop these practice guidelines. Annually, all members completed conflict of interest statements; no conflicts were identified. This activity was funded by the Society for Critical Care Medicine, and no industry support was provided. METHODS Using the Grading of Recommendations Assessment, Development, and Evaluation system, the Grading of Recommendations Assessment, Development, and Evaluation expert on the Task Force created profiles for the evidence related to six of the 21 questions and assigned quality-of-evidence scores to these and the additional 15 questions for which insufficient evidence was available to create a profile. Task Force members reviewed this material and all available evidence and provided recommendations, suggestions, or good practice statements for these 21 questions. RESULTS The Task Force developed a single strong recommendation: we recommend scheduled eye care that includes lubricating drops or gel and eyelid closure for patients receiving continuous infusions of neuromuscular-blocking agents. The Task Force developed 10 weak recommendations. 1) We suggest that a neuromuscular-blocking agent be administered by continuous intravenous infusion early in the course of acute respiratory distress syndrome for patients with a PaO2/FIO2 less than 150. 2) We suggest against the routine administration of an neuromuscular-blocking agents to mechanically ventilated patients with status asthmaticus. 3) We suggest a trial of a neuromuscular-blocking agents in life-threatening situations associated with profound hypoxemia, respiratory acidosis, or hemodynamic compromise. 4) We suggest that neuromuscular-blocking agents may be used to manage overt shivering in therapeutic hypothermia. 5) We suggest that peripheral nerve stimulation with train-of-four monitoring may be a useful tool for monitoring the depth of neuromuscular blockade but only if it is incorporated into a more inclusive assessment of the patient that includes clinical assessment. 6) We suggest against the use of peripheral nerve stimulation with train of four alone for monitoring the depth of neuromuscular blockade in patients receiving continuous infusion of neuromuscular-blocking agents. 7) We suggest that patients receiving a continuous infusion of neuromuscular-blocking agent receive a structured physiotherapy regimen. 8) We suggest that clinicians target a blood glucose level of less than 180 mg/dL in patients receiving neuromuscular-blocking agents. 9) We suggest that clinicians not use actual body weight and instead use a consistent weight (ideal body weight or adjusted body weight) when calculating neuromuscular-blocking agents doses for obese patients. 10) We suggest that neuromuscular-blocking agents be discontinued at the end of life or when life support is withdrawn. In situations in which evidence was lacking or insufficient and the study results were equivocal or optimal clinical practice varies, the Task Force made no recommendations for nine of the topics. 1) We make no recommendation as to whether neuromuscular blockade is beneficial or harmful when used in patients with acute brain injury and raised intracranial pressure. 2) We make no recommendation on the routine use of neuromuscular-blocking agents for patients undergoing therapeutic hypothermia following cardiac arrest. 3) We make no recommendation on the use of peripheral nerve stimulation to monitor degree of block in patients undergoing therapeutic hypothermia. 4) We make no recommendation on the use of neuromuscular blockade to improve the accuracy of intravascular-volume assessment in mechanically ventilated patients. 5) We make no recommendation concerning the use of electroencephalogram-derived parameters as a measure of sedation during continuous administration of neuromuscular-blocking agents. 6) We make no recommendation regarding nutritional requirements specific to patients receiving infusions of neuromuscular-blocking agents. 7) We make no recommendation concerning the use of one measure of consistent weight over another when calculating neuromuscular-blocking agent doses in obese patients. 8) We make no recommendation on the use of neuromuscular-blocking agents in pregnant patients. 9) We make no recommendation on which muscle group should be monitored in patients with myasthenia gravis receiving neuromuscular-blocking agents. Finally, in situations in which evidence was lacking or insufficient but expert consensus was unanimous, the Task Force developed six good practice statements. 1) If peripheral nerve stimulation is used, optimal clinical practice suggests that it should be done in conjunction with assessment of other clinical findings (e.g., triggering of the ventilator and degree of shivering) to assess the degree of neuromuscular blockade in patients undergoing therapeutic hypothermia. 2) Optimal clinical practice suggests that a protocol should include guidance on neuromuscular-blocking agent administration in patients undergoing therapeutic hypothermia. 3) Optimal clinical practice suggests that analgesic and sedative drugs should be used prior to and during neuromuscular blockade, with the goal of achieving deep sedation. 4) Optimal clinical practice suggests that clinicians at the bedside implement measure to attenuate the risk of unintended extubation in patients receiving neuromuscular-blocking agents. 5) Optimal clinical practice suggests that a reduced dose of an neuromuscular-blocking agent be used for patients with myasthenia gravis and that the dose should be based on peripheral nerve stimulation with train-of-four monitoring. 6) Optimal clinical practice suggests that neuromuscular-blocking agents be discontinued prior to the clinical determination of brain death.
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Ziegler SJ. Euthanasia and the Administration of Neuromuscular Blockers without Ventilation: Should Physicians Fear Prosecution? OMEGA-JOURNAL OF DEATH AND DYING 2016. [DOI: 10.2190/7603-0605-1488-7577] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
A common dilemma among physicians who treat the dying is whether pharmacological paralysis should be reversed prior to removal of mechanical ventilation. But what if a physician were to administer a neuromuscular blocker without ever ventilating the patient in the first place? While there is evidence that euthanasia does occur in the United States, few physicians have been prosecuted. Could these infrequent prosecutions reflect a conscious desire by prosecutors not to pursue such matters? In an effort to explore this question, chief prosecutors in four U.S. states were presented with a vignette based on an actual event involving the administration of Succinylcholine to a dying patient. Response rates in this study were very acceptable (76.36% overall), and results indicated that not only was the likelihood of criminal prosecution low, almost half of the prosecutors believed that a physicianadministered lethal injection may be morally justified in some circumstances even though illegal.
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Cottereau A, Robert R, le Gouge A, Adda M, Audibert J, Barbier F, Bardou P, Bourcier S, Boyer A, Brenas F, Canet E, Da Silva D, Das V, Desachy A, Devaquet J, Embriaco N, Eon B, Feissel M, Friedman D, Ganster F, Garrouste-Orgeas M, Grillet G, Guisset O, Guitton C, Hamidfar-Roy R, Hyacinthe AC, Jochmans S, Lion F, Jourdain M, Lautrette A, Lerolle N, Lesieur O, Mateu P, Megarbane B, Mercier E, Messika J, Morin-Longuet P, Philippon-Jouve B, Quenot JP, Renault A, Repesse X, Rigaud JP, Robin S, Roquilly A, Seguin A, Thevenin D, Tirot P, Contentin L, Kentish-Barnes N, Reignier J. ICU physicians' and nurses' perceptions of terminal extubation and terminal weaning: a self-questionnaire study. Intensive Care Med 2016; 42:1248-57. [PMID: 27155604 DOI: 10.1007/s00134-016-4373-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 04/26/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE Terminal extubation (TE) and terminal weaning (TW) are the methods available for withdrawing mechanical ventilation. Perceptions of TE and TW by intensive care unit (ICU) staff may influence bedside practices and the feasibility of studies comparing these methods. METHODS From January to June 2013, 5 nurses and 5 physicians in each of 46 (out of 70, 65.7 %) French ICUs completed an anonymous self-questionnaire. Clusters of staff members defined by perceptions of TE and TW were identified by exploratory analysis. Denominators for computing percentages were total numbers of responses to each item; cases with missing data were excluded for the relevant item. RESULTS Of the 451 (98 %) participants (225 nurses and 226 physicians), 37 (8.4 %) had never or almost never performed TW and 138 (31.3 %) had never or almost never performed TE. A moral difference between TW and TE was perceived by 205 (45.8 %) participants. The exploratory analysis identified three clusters defined by personal beliefs about TW and TE: 21.2 % of participants preferred TW, 18.1 % preferred TE, and 60.7 % had no preference. A preference for TW seemed chiefly related to unfavorable perceptions or insufficient knowledge of TE. Staff members who preferred TE and those with no preference perceived TE as providing a more natural dying process with less ambiguity. CONCLUSION Nearly two-fifths of ICU nurses and physicians in participating ICUs preferred TW or TE. This finding suggests both a need for shared decision-making and training before performing TE or TW and a high risk of poor compliance with randomly allocated TW or TE.
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Affiliation(s)
- Alice Cottereau
- Medical-Surgical Intensive Care Unit, District Hospital Center, Montreuil, France
| | - René Robert
- Medical Intensive Care Unit, University Hospital, Poitiers, France.,INSERM CIC 1402, Equipe 5 ALIVE, University Hospital, Poitiers, France
| | - Amélie le Gouge
- Biometrical Department, INSERM CIC 1415, University Hospital, Tours, France
| | - Mélanie Adda
- Medical Intensive Care Unit, University Hospital, Hopital Nord, Marseille, France
| | - Juliette Audibert
- Medical-Surgical Intensive Care Unit, District Hospital Center, Chartres, France
| | - François Barbier
- Orléans Medical Intensive Care Unit, District Hospital Center, Orléans, France
| | - Patrick Bardou
- Medical-Surgical Intensive Care Unit, District Hospital Center, Montauban, France
| | - Simon Bourcier
- Medical Intensive Care Unit, Cochin University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France
| | - Alexandre Boyer
- Medical Intensive Care Unit, Pellegrin University Hospital, Bordeaux, France
| | - François Brenas
- Medical-Surgical Intensive Care Unit, District Hospital Center, Le Puy-En-Velay, France
| | - Emmanuel Canet
- Medical Intensive Care Unit, Saint-Louis University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France
| | - Daniel Da Silva
- Medical-Surgical Intensive Care Unit, Delafontaine Hospital Center, Saint-Denis, France
| | - Vincent Das
- Medical-Surgical Intensive Care Unit, District Hospital Center, Montreuil, France
| | - Arnaud Desachy
- Medical-Surgical Intensive Care Unit, District Hospital Center, Angoulême, France
| | - Jérôme Devaquet
- Medical-Surgical Intensive Care Unit, Foch Hospital Center, Suresnes, France
| | - Nathalie Embriaco
- Medical-Surgical Intensive Care Unit, District Hospital Center, Toulon, France
| | - Beatrice Eon
- Medical Intensive Care Unit, University Hospital, Hopital La Timone, Marseille, France
| | - Marc Feissel
- Medical-Surgical Intensive Care Unit, District Hospital Center, Belfort, France
| | - Diane Friedman
- Medical Intensive Care Unit, Raymond Poincaré University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Garches, France
| | - Frédérique Ganster
- Medical-Surgical Intensive Care Unit, District Hospital Center, Mulhouse, France
| | | | - Guillaume Grillet
- Medical-Surgical Intensive Care Unit, District Hospital Center, Lorient, France
| | - Olivier Guisset
- Medical Intensive Care Unit, Saint-André University Hospital, Bordeaux, France
| | | | | | | | - Sebastien Jochmans
- Medical-Surgical Intensive Care Unit, Marc Jaquet Hospital Center, Melun, France
| | - Fabien Lion
- Medical-Surgical Intensive Care Unit, Institut Gustave Roussy, Villejuif, France
| | - Mercé Jourdain
- Medical Intensive Care Unit, University Hospital, Lille, France
| | - Alexandre Lautrette
- Medical Intensive Care Unit, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | - Nicolas Lerolle
- Medical Intensive Care Unit, Angers University Hospital, Angers, France
| | - Olivier Lesieur
- Medical-Surgical Intensive Care Unit, District Hospital Center, La Rochelle, France
| | - Philippe Mateu
- Medical-Surgical Intensive Care Unit, District Hospital Center, Charleville-Mézières, France
| | - Bruno Megarbane
- Medical Intensive Care Unit, Saint-Louis University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France
| | | | - Jonathan Messika
- Medical-Surgical Intensive Care Unit, Louis Mourier University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Colombes, France
| | - Paul Morin-Longuet
- Medical-Surgical Intensive Care Unit, District Hospital Center, Saint-Nazaire, France
| | | | | | - Anne Renault
- Medical Intensive Care Unit, La Cavale Blanche University Hospital, Brest, France
| | - Xavier Repesse
- Medical-Surgical Intensive Care Unit, Ambroise Paré University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Boulogne, France
| | | | - Ségolène Robin
- Surgical Intensive Care Unit, Hôpital Européen Georges Pompidou, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris, France
| | - Antoine Roquilly
- Surgical Intensive Care Unit, Hotel Dieu University Hospital, Nantes, France
| | - Amélie Seguin
- Medical Intensive Care Unit, Côte de Nacre University Hospital, Caen, France
| | - Didier Thevenin
- Medical-Surgical Intensive Care Unit, District Hospital Center, Lens, France
| | - Patrice Tirot
- Medical-Surgical Intensive Care Unit, District Hospital Center, Le Mans, France
| | - Laetitia Contentin
- Biometrical Department, INSERM CIC 1415, University Hospital, Tours, France
| | - Nancy Kentish-Barnes
- Saint-Louis University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Paris Diderot Sorbonne University, Paris, France
| | - Jean Reignier
- Medical Intensive Care Unit, Saint-André University Hospital, Bordeaux, France. .,Service de Réanimation Médicale, Centre Hospitalier Universitaire Hotel-Dieu, 30 Bd. Jean Monnet, 44093, Nantes Cedex 1, France.
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12
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Delaney JW, Downar J. How is life support withdrawn in intensive care units: A narrative review. J Crit Care 2016; 35:12-8. [PMID: 27481730 DOI: 10.1016/j.jcrc.2016.04.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 03/17/2016] [Accepted: 04/03/2016] [Indexed: 01/20/2023]
Abstract
PURPOSE Decisions to withdraw life-sustaining therapy (WDLS) are relatively common in intensive care units across Canada. As part of preliminary work to develop guidelines for WDLS, we performed a narrative review of the literature to identify published studies of WDLS. MATERIALS AND METHODS A search of MEDLINE and EMBASE databases was performed. The results were reviewed and only articles relevant to WDLS were included. Any references within these articles deemed to be relevant were subsequently included. RESULTS The initial search identified 3687 articles. A total of 100 articles of interest were identified from the initial search and a review of their references. The articles were primarily composed of observational data and expert opinion. The information from the literature was organized into 6 themes: preparation for WDLS, monitoring parameters, pharmacologic symptom management, withdrawing life-sustaining therapies, withdrawal of mechanical ventilation, and bereavement. CONCLUSIONS This review describes current practices and opinions about WDLS, and also demonstrates the significant practice variation that currently exists. We believe that the development of guidelines to help increase transparency and standardize the process will be an important step to ensuring high quality care during WDLS.
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Affiliation(s)
| | - James Downar
- Division of Palliative Care, University of Toronto, Toronto, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
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13
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Schimmer C, Hamouda K, Oezkur M, Sommer SP, Leistner M, Leyh R. [End-of-life decisions and practices in critically ill patients in the cardiac intensive care unit. A nationwide survey]. Med Klin Intensivmed Notfmed 2015; 111:92-7. [PMID: 26065385 DOI: 10.1007/s00063-015-0045-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Revised: 04/04/2014] [Accepted: 04/03/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Ethical and medical criteria in the decision-making process of withholding or withdrawal of life support therapy in critically ill patients present a great challenge in intensive care medicine. OBJECTIVES The purpose of this work was to assess medical and ethical criteria that influence the decision-making process for changing the aim of therapy in critically ill cardiac surgery patients. MATERIALS AND METHODS A questionnaire was distributed to all German cardiac surgery centers (n = 79). All clinical directors, intensive care unit (ICU) consultants and ICU head nurses were asked to complete questionnaires (n = 237). RESULTS In all, 86 of 237 (36.3 %) questionnaires were returned. Medical reasons which influence the decision-making process for changing the aim of therapy were cranial computed tomography (cCT) with poor prognosis (91.9 %), multi-organ failure (70.9 %), and failure of assist device therapy (69.8 %). Concerning ethical reasons, poor expected quality of life (48.8 %) and the presumed patient's wishes (40.7 %) were reported. There was a significant difference regarding the perception of the three different professional groups concerning medical and ethical criteria as well as the involvement in the decision-making process. CONCLUSION In critically ill cardiac surgery patients, medical reasons which influence the decision-making process for changing the aim of therapy included cCT with poor prognosis, multi-organ failure, and failure of assist device therapy. Further studies are mandatory in order to be able to provide adequate answers to this difficult topic.
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Affiliation(s)
- C Schimmer
- Zentrum Operative Medizin, Klinik und Poliklinik für Thorax-, Herz- und Thorakale Gefäßchirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
| | - K Hamouda
- Zentrum Operative Medizin, Klinik und Poliklinik für Thorax-, Herz- und Thorakale Gefäßchirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - M Oezkur
- Zentrum Operative Medizin, Klinik und Poliklinik für Thorax-, Herz- und Thorakale Gefäßchirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - S-P Sommer
- Zentrum Operative Medizin, Klinik und Poliklinik für Thorax-, Herz- und Thorakale Gefäßchirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - M Leistner
- Zentrum Operative Medizin, Klinik und Poliklinik für Thorax-, Herz- und Thorakale Gefäßchirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - R Leyh
- Zentrum Operative Medizin, Klinik und Poliklinik für Thorax-, Herz- und Thorakale Gefäßchirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
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14
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Paruk F, Kissoon N, Hartog CS, Feldman C, Hodgson ER, Lipman J, Guidet B, Du B, Argent A, Sprung CL. The Durban World Congress Ethics Round Table Conference Report: III. Withdrawing Mechanical ventilation--the approach should be individualized. J Crit Care 2014; 29:902-7. [PMID: 24992878 DOI: 10.1016/j.jcrc.2014.05.022] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 04/07/2014] [Accepted: 05/18/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE The purpose of this study is to determine the approaches used in withdrawing mechanical ventilator support. MATERIALS AND METHODS Speakers from the invited faculty of the World Federation of Societies of Intensive and Critical Care Medicine Congress in 2013 with an interest in ethics were asked to provide a detailed description of individual approaches to the process of withdrawal of mechanical ventilation. RESULTS Twenty-one participants originating from 13 countries, responded to the questionnaire. Four respondents indicated that they do not practice withdrawal of mechanical ventilation, and another 4 indicated that their approach is highly variable depending on the clinical scenario. Immediate withdrawal of ventilation was practiced by a large number of the respondents (7/16; 44%). A terminal wean was practiced by just more than a third of the respondents (6/16; 38%). Extubation was practiced in more than 70% of instances among most of the respondents (9/17; 53%). Two of the respondents (2/17; 12%) indicated that they would extubate all patients, whereas 14 respondents indicated that they would not extubate all their patients. The emphasis was on tailoring the approach used to suit individual case scenarios. CONCLUSIONS Withdrawing of ventilator support is not universal. However, even when withdrawing mechanical ventilation is acceptable, the approach to achieve this end point is highly variable and individualized.
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Affiliation(s)
- Fathima Paruk
- Department of Anaesthesiology and Division of Critical Care, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Niranjan Kissoon
- Department of Pediatrics and Emergency Medicine, Children's Hospital and Sunny Hill Health Centre for Children, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christiane S Hartog
- Department of Anesthesiology and Intensive Care Medicine and Center for Sepsis Control and Care (CSH), Jena University Hospital, Jena, Germany
| | - Charles Feldman
- Division of Pulmonology, Department of Internal Medicine, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Eric R Hodgson
- Department of Anaesthesia and Critical Care, Inkosi Albert Luthuli Central Hospital, University of KwaZulu-Natal eThekwini-Durban, KwaZulu-Natal, South Africa
| | - Jeffrey Lipman
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital and The University of Queensland, Queensland, Australia
| | - Bertrand Guidet
- Service de Réanimation Médicale, Assistance Publique-Hôpitaux de Paris, Hôpital St-Antoine, Paris, France
| | - Bin Du
- Medical Intensive Care Unit, Peking Union Medical College Hospital, Beijing, China
| | - Andrew Argent
- School of Child and Adolescent Health, University of Cape Town and Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Charles L Sprung
- Department of Anesthesiology and Critical Care Medicine (CLS), Hadassah Hebrew University Medical Center, Jerusalem, Israel
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15
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Abstract
Withdrawal of life support is an option for patients with prolonged mechanical ventilation when all attempts at weaning have failed and it is deemed futile to continue the therapy, when quality of life is unacceptable, or when it is perceived that the patient is suffering. The purpose of this article is to present the nursing aspects of managing an adult patient undergoing the withdrawal of mechanical ventilation as an end-of-life procedure. Withdrawal of mechanical ventilation is a complex and difficult process that requires meticulous planning and management. Conferences with the patient and the patient's family are critical to addressing emotional support and ensuring that everyone understands the process and is provided an opportunity to gather information. Clear communication with patients and their families can ensure that the process goes smoothly. Having an organized approach can ensure that patients experience a peaceful death and staff experience closure regarding the event.
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Affiliation(s)
- Kathleen M Stacy
- Intermediate Care Unit, Palomar Medical Center, 555 Valley Parkway, Escondido, CA 92025, USA.
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Papadimos TJ, Maldonado Y, Tripathi RS, Kothari DS, Rosenberg AL. An overview of end-of-life issues in the intensive care unit. Int J Crit Illn Inj Sci 2012; 1:138-46. [PMID: 22229139 PMCID: PMC3249847 DOI: 10.4103/2229-5151.84801] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The population of the earth is aging, and as medical techniques, pharmaceuticals, and devices push the boundaries of human physiological capabilities, more humans will go on to live longer. However, this prolonged existence may involve incapacities, particularly at the end-of-life, and especially in the intensive care unit. This arena involves not only patients and families, but also care givers. It involves topics from economics to existentialism, and surgery to spiritualism. It requires education, communication, acceptance of diversity, and an ultimate acquiescence to the inevitable. Here, we present a comprehensive overview of issues in the care of patients at the end-of-life stage that may cause physicians and other healthcare providers, medical, ethical, social, and philosophical concerns in the intensive care unit.
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Affiliation(s)
- Thomas J Papadimos
- Department of Anesthesiology, Division of Critical Care Medicine, The Ohio State University Medical Center, Columbus OH 43210, USA
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17
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Baggs JG, Schmitt MH, Prendergast TJ, Norton SA, Sellers CR, Quinn JR, Press N. Who is attending? End-of-life decision making in the intensive care unit. J Palliat Med 2012; 15:56-62. [PMID: 22233466 PMCID: PMC3304246 DOI: 10.1089/jpm.2011.0307] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2011] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Traditional expectations of the single attending physician who manages a patient's care do not apply in today's intensive care units (ICUs). Although many physicians and other professionals have adapted to the complexity of multiple attendings, ICU patients and families often expect the traditional, single physician model, particularly at the time of end-of-life decision making (EOLDM). Our purpose was to examine the role of ICU attending physicians in different types of ICUs and the consequences of that role for clinicians, patients, and families in the context of EOLDM. METHODS Prospective ethnographic study in a university hospital, tertiary care center. We conducted 7 months of observations including 157 interviews in each of four adult critical care units. RESULTS The term "attending physician" was understood by most patients and families to signify an individual accountable person. In practice, "the attending physician" was an ICU role, filled by multiple physicians on a rotating basis or by multiple physicians simultaneously. Clinicians noted that management of EOLDM varied in relation to these multiple and shifting attending responsibilities. The attending physician role in this practice context and in the EOLDM process created confusion for families and for some clinicians about who was making patient care decisions and with whom they should confer. CONCLUSIONS Any intervention to improve the process of EOLDM in ICUs needs to reflect system changes that address clinician and patient/family confusion about EOLDM roles of the various attending physicians encountered in the ICU.
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Affiliation(s)
- Judith Gedney Baggs
- School of Nursing, Oregon Health & Science University, Portland, Oregon 97239, USA.
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19
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Schimmer C, Gorski A, Özkur M, Sommer SP, Hamouda K, Hain J, Aleksic I, Leyh R. Policies of withholding and withdrawal of life-sustaining treatment in critically ill patients on cardiac intensive care units in Germany: a national survey. Interact Cardiovasc Thorac Surg 2011; 14:294-9. [PMID: 22194277 DOI: 10.1093/icvts/ivr119] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To determine the decision-making process of withholding and/or withdrawal (WH/WD) of life-sustaining treatment in cardiac intensive care units (ICUs) in Germany. METHODS A questionnaire regarding 16 medical and 6 ethical questions of WH/WD of life-sustaining treatment was distributed to the clinical director, senior ICU physician and head nurses of all German heart surgery centres (n = 237 questionnaires). Furthermore, we present a literature survey using the key words 'End-of-life care AND withholding/withdrawal of life support therapy AND intensive care unit'. RESULTS We received replies from 86 of 237 (36.3%) contacted persons. Concerning medical reasons, cranial computed tomography (CCT) with poor prognosis (91.9%), multi-organ failure (70.9%) and failure of assist device therapy (69.8%) were the three most frequently cited medical reasons for WH/WD life-sustaining treatment. Overall, 32.6% of persons answered that ethical aspects influence their decision-making processes. Poor expected quality of life (48.8%), the patient's willingness to limit medical care (40.7%) and the families' choice (27.9%) were the top three reported ethical reasons. There was a significant difference regarding the perception of the three involved professional groups concerning the decision-making parameters: multi-organ failure (P = 0.018), failure of assist device therapy (P = 0.001), cardiac index (P = 0.009), poor expected quality of life (P = 0.009), the patient's willingness to limit medical care (P = 0.002), intraoperative course (P = 0.054), opinion of family members (P = 0.032) and whether decision-making process are done collaboratively (clinical director, 45.7%; ICU physician, 52%; and head of nursing staff, 26.9%). Palliation medication in patients after WH/WD of life-support consisted of morphine (92%) and benzodiazepines (88%). CONCLUSIONS This survey is a step towards creating standards of end-of-life care in cardiac ICUs, which may contribute to build consensus and avoid conflicts among caregivers, patients and families at each step of the decision-making process.
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Affiliation(s)
- Christoph Schimmer
- Department of Cardiothoracic and Thoracic Vascular Surgery, University Hospital Würzburg, Würzburg, Germany.
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20
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Mazer MA, Alligood CM, Wu Q. The infusion of opioids during terminal withdrawal of mechanical ventilation in the medical intensive care unit. J Pain Symptom Manage 2011; 42:44-51. [PMID: 21232910 DOI: 10.1016/j.jpainsymman.2010.10.256] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2010] [Revised: 10/08/2010] [Accepted: 10/17/2010] [Indexed: 11/28/2022]
Abstract
CONTEXT Most deaths in intensive care units occur after limitation or withdrawal of life-sustaining therapies. Often these patients require opioids to assuage suffering; yet, little has been documented concerning their use in the medical intensive care unit. OBJECTIVES To determine the dose and factors influencing the use of opioids in patients undergoing terminal withdrawal of mechanical ventilation in this setting. METHODS Data were prospectively collected from 74 consecutive patients expected to die soon after extubation. The doses of morphine, effect on time to death, and relation of dose to diagnostic categories were analyzed. RESULTS The mean (±standard deviation) dose of morphine given to patients during the last hour of mechanical ventilation was 5.3mg/hour. Patients dying after extubation received 10.6 mg/hour just before death. Immediately before extubation, the dose correlated directly with chronic medical opioid use and sepsis with respiratory failure and inversely with coma after cardiopulmonary resuscitation or a primary neurological event. After terminal extubation, the final morphine dose correlated directly with the presence of sepsis with respiratory failure and chronic pulmonary disease. The mean time to death after terminal extubation was 152.7 ± 229.5 minutes without correlation with premorbid diagnoses. After extubation, each 1mg/hour increment of morphine infused during the last hour of life was associated with a delay of death by 7.9 minutes (P = 0.011). CONCLUSION Premorbid conditions may influence the dose of morphine given to patients undergoing terminal withdrawal of mechanical ventilation. Higher doses of morphine are associated with a longer time to death.
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Affiliation(s)
- Mark A Mazer
- Division of Pulmonary, Critical Care and Sleep Medicine, East Carolina University, Greenville, North Carolina 27834, USA.
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21
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Billings, Senior Associate Editor JA. Terminal Extubation of the Alert Patient. J Palliat Med 2011; 14:800-1. [DOI: 10.1089/jpm.2011.9676] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Festic E, Wilson ME, Gajic O, Divertie GD, Rabatin JT. Perspectives of physicians and nurses regarding end-of-life care in the intensive care unit. J Intensive Care Med 2011; 27:45-54. [PMID: 21257636 DOI: 10.1177/0885066610393465] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
CONTEXT The delivery of end-of-life care (EOLC) in the intensive care unit (ICU) varies widely among medical care providers. The differing opinions of nurses and physicians regarding EOLC may help identify areas of improvement. OBJECTIVE To explore the differences of physicians and nurses on EOLC in the ICU and how these differences vary according to self-reported proficiency level and primary work unit. DESIGN Cross-sectional survey of 69 ICU physicians and 629 ICU nurses. SETTING Single tertiary care academic medical institution. RESULTS A total of 50 physicians (72%) and 331 nurses (53%) participated in the survey. Significant differences between physicians and nurses were noted in the following areas: ability to safely raise concerns, do not resuscitate (DNR) decision making, discussion of health care directives, timely hospice referral, spiritual assessment documentation, utilization of social services, and the availability of EOLC education. In every domain of EOLC, physicians reported a more positive perception than nurses. Additional differences were noted among physicians based on experience, as well as among nurses based on their primary work unit and self-reported proficiency level. CONCLUSIONS Even with an increased focus on improving EOLC, significant differences continue to exist between the perspectives of nurses and physicians, as well as physicians among themselves and nurses among themselves. These differences may represent significant barriers toward providing comprehensive, consistent, and coordinated EOLC in the ICU.
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Affiliation(s)
- Emir Festic
- Critical Care Medicine, Mayo Clinic, Jacksonville, FL 32224, USA.
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23
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Withholding and Withdrawing Life-Sustaining Therapies. Palliat Care 2011. [DOI: 10.1016/b978-1-4377-1619-1.00022-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Dumont R, Asehnoune K, Pouplin L, Volteau C, Simonneau F, Lejus C. Limitation ou arrêt de thérapeutiques actives en situations d’urgence. Le point de vue des anesthésistes réanimateurs. ACTA ACUST UNITED AC 2010; 29:425-30. [DOI: 10.1016/j.annfar.2010.01.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2009] [Accepted: 01/13/2010] [Indexed: 10/19/2022]
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Aita K, Kai I. Physicians' psychosocial barriers to different modes of withdrawal of life support in critical care: A qualitative study in Japan. Soc Sci Med 2009; 70:616-22. [PMID: 19932548 DOI: 10.1016/j.socscimed.2009.10.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2009] [Indexed: 11/28/2022]
Abstract
Despite a number of guidelines issued in Anglo-American countries over the past few decades for forgoing treatment stating that there is no ethically relevant difference between withholding and withdrawing life-sustaining treatments (LST), it is recognized that many healthcare professionals in Japan as well as some of their western counterparts do not agree with this statement. This research was conducted to investigate the barriers that prevent physicians from withdrawing specific LST in critical care settings, focusing mainly on the modes of withdrawal of LST, in what the authors believe was the first study of its kind anywhere in the world. In 2006-2007, in-depth, face-to-face, semistructured interviews were conducted with 35 physicians working at emergency and critical care facilities across Japan. We elicited their experiences, attitudes, and perceptions regarding withdrawal of mechanical ventilation and other LST. The process of data analysis followed the grounded theory approach. We found that the psychosocial resistance of physicians to withdrawal of artificial devices varied according to the modes of withdrawal, showing a strong resistance to withdrawal of mechanical ventilation that requires physicians to halt the treatment when continuation of its mechanical operation is possible. However, there was little resistance to the withdrawal of percutaneous cardiopulmonary support and artificial liver support when their continuation was mechanically or physiologically impossible. The physicians shared a desire for a "soft landing" of the patient, that is, a slow and gradual death without drastic and immediate changes, which serves the psychosocial needs of the people surrounding the patient. For that purpose, vasopressors were often withheld and withdrawn. The findings suggest what the Japanese physicians avoid is not what they call a life-shortening act but an act that would not lead to a soft landing, or a slow death that looks 'natural' in the eyes of those surrounding the patient. The purpose of constructing such a final scene is believed to fulfill the psychosocial needs of the patient's family and the physicians, who emphasize on how death feels to those surrounding the patient. Unless withdrawing LST would lead to a soft landing, Japanese clinicians, who recognize that the results of withdrawing LST affect not only the patient but those around the patient, are likely to feel that there is an ethically relevant difference between withholding and withdrawing LST.
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Affiliation(s)
- Kaoruko Aita
- The University of Tokyo, Graduate School of Humanities and Sociology, Global COE Programme Death and Life Studies, 7-3-1 Hongo, Bunkyo-ku, Tokyo113-0033, Japan.
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26
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Gamboa Antiñolo F. [Limiting therapeutic effort: is withholding or withdrawal of life-sustaining treatment the same?]. Med Clin (Barc) 2009; 135:410-6. [PMID: 19464705 DOI: 10.1016/j.medcli.2009.02.046] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Accepted: 02/27/2009] [Indexed: 11/28/2022]
Affiliation(s)
- Fernando Gamboa Antiñolo
- Unidad de Continuidad Asistencial, Servicio Medicina Interna, Hospital Universitario de Valme, Sevilla, Spain.
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27
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[Elective termination of respiratory therapy in amyotrophic lateral sclerosis]. DER NERVENARZT 2008; 79:684-90. [PMID: 18330539 DOI: 10.1007/s00115-008-2439-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Due to the growing use of artificial respiration in amyotrophic lateral sclerosis (ALS), physicians are increasingly confronted with patients seeking discontinuation of therapy. Yet there are few systematic investigations of the withdrawal of ventilation therapy. PATIENTS AND METHODS In a retrospective investigation of nine German ALS patients, clinical data were recorded from the discontinuation of noninvasive ventilation (n=4) and mechanical ventilation (n=5). RESULTS In cases of residual spontaneous breathing, intensified symptom control of dyspnea and anxiety was possible with intravenous morphine sulfate at a low dose rate (10 mg/h) but high cumulative dose (185-380 mg). The terminal phase after removing the mask was protracted (22:10 h to 28:00 h). In cases of minimal or absent spontaneous breathing the disconnection was realized in deep sedation, which required a moderate total dose of morphine sulfate (120 mg) but a high dosage rate (up to 300 mg/h). The terminal phase in deep sedation was short (15-80 min). CONCLUSION The elective termination of ventilation requires differentiated pharmacologic palliative care. More controlled studies are required in order to establish evidence-based guidelines for the termination of ventilation.
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Abstract
AIM This paper discusses end-of-life care (EoLC) in critical care through exploration of what is known from the international literature and what is currently presented within UK policy. BACKGROUND AND CONTEXT EoLC is an important international critical care issue, and currently provides a key focus for health care policy in the UK. While society holds that critical care is delivered in a highly technical area with a strong focus on cure and recovery, mortality rates in this speciality remain at approximately 20%. When patient recovery is not an outcome, discussions with patient, family and extended care teams turn towards futility of treatment and end-of-life management. However, there are specific barriers to overcome in EoLC for the critically ill. CONCLUSION A key issue for EoLC in critical care is a lack of robust systems to prospectively identify individuals who are most at risk of dying. A further challenge is divergent perspectives within and across clinical teams on treatment withdrawal and limitation practices. To streamline patient management and underpin a hospice approach to care, EoLC policies are currently being used within the UK. While this provides a national framework to address some key critical care clinical issues in the UK, there is a need for further refinement of the tool to reflect the reality of EoLC for the critically ill. It is important that international best practice exemplars are examined and clinicians actively engage and contribute to ensure that any local EoLC frameworks are fit for purpose.
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Affiliation(s)
- Maureen Coombs
- Critical Care, Southampton University Hospitals Trust, Southampton, UK.
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Watterson J, Peaire A, Hinman J. Elevated Morphine Concentrations Determined During Infant Death Investigations: Artifacts of Withdrawal of Care. J Forensic Sci 2008; 53:1001-4. [DOI: 10.1111/j.1556-4029.2008.00776.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Kompanje EJO, van der Hoven B, Bakker J. Anticipation of distress after discontinuation of mechanical ventilation in the ICU at the end of life. Intensive Care Med 2008; 34:1593-9. [PMID: 18516588 PMCID: PMC2517089 DOI: 10.1007/s00134-008-1172-y] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2007] [Accepted: 02/20/2008] [Indexed: 11/28/2022]
Abstract
BACKGROUND A considerable number of patients admitted to the intensive care unit (ICU) die following withdrawal of mechanical ventilation. After discontinuation of ventilation without proper preparation, excessive respiratory secretion is common, resulting in a 'death rattle'. Post-extubation stridor can give rise to the relatives' perception that the patient is choking and suffering. Existing protocols lack adequate anticipatory preparation to respond to all distressing symptoms. METHODS We analyzed existing treatment strategies in distressing symptoms after discontinuation of mechanical ventilation. CONCLUSION The actual period of discontinuation of mechanical ventilation can be very short, but thoughtful anticipation of distressing symptoms takes time. There is an ethical responsibility to anticipate and treat (iatrogenic) symptoms such as pain, dyspnea-associated respiratory distress, anxiety, delirium, post-extubation stridor, and excessive broncho-pulmonary secretions. This makes withdrawal of mechanical ventilation in ICU patients a thoughtful process, taking palliative actions instead of fast terminal actions. We developed a flowchart covering all possible distressing symptoms that can occur after withdrawal of mechanical ventilation and extubation. We recommend a two-phase process. Six hours before extubation, enteral feeding should be stopped and parenteral fluids reduced, overhydrated patients should be dehydrated with furosemide, administration of sedatives (for distress) and opioids (for pain and/or dyspnea) should be continued or started and methylprednisolone should be given in anticipation of stridor after extubation. Thirty minutes before extubation, Butylscopolamine should be given and methylprednisolone repeated. After this the patient should be extubated to secure a dying process as natural as possible with the lowest burden due to distress.
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Affiliation(s)
- E J O Kompanje
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
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Lanken PN, Terry PB, Delisser HM, Fahy BF, Hansen-Flaschen J, Heffner JE, Levy M, Mularski RA, Osborne ML, Prendergast TJ, Rocker G, Sibbald WJ, Wilfond B, Yankaskas JR. An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses. Am J Respir Crit Care Med 2008; 177:912-27. [PMID: 18390964 DOI: 10.1164/rccm.200605-587st] [Citation(s) in RCA: 491] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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Lorenz KA, Rosenfeld K, Wenger N. Quality Indicators for Palliative and End-of-Life Care in Vulnerable Elders. J Am Geriatr Soc 2007; 55 Suppl 2:S318-26. [PMID: 17910553 DOI: 10.1111/j.1532-5415.2007.01338.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Karl A Lorenz
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA 90064, USA.
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Cook D, Rocker G, Marshall J, Griffith L, McDonald E, Guyatt G. Levels of Care in the Intensive Care Unit: A Research Program. Am J Crit Care 2006. [DOI: 10.4037/ajcc2006.15.3.269] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
A multidisciplinary research program on levels of care was conducted in 15 adult intensive care units in North America, Europe, and Australia. The program addressed advance directives for cardiopulmonary resuscitation, provision of advanced life support, and clinicians’ discomfort with evolving treatment plans. The results indicated that the factors that determined the establishment of directives for advance life support differed from the factors that informed a decision to limit or withdraw support after admission to an intensive care unit. In addition, clinicians’ prognoses were imprecise and often an underestimation of the probability of short-term survival. Finally, some degree of discomfort was common in care providers in the intensive care unit, most often because they thought interventions were excessive and not compatible with an acceptable future quality of life. The provision of advanced life support mandates explicit decision making about how life-support measures should be used.
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Giannini A, Consonni D. Physicians’ perceptions and attitudes regarding inappropriate admissions and resource allocation in the intensive care setting †. Br J Anaesth 2006; 96:57-62. [PMID: 16311284 DOI: 10.1093/bja/aei276] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Physicians' perceptions regarding intensive care unit (ICU) resource allocation and the problem of inappropriate admissions are unknown. METHODS We carried out an anonymous, self-administered questionnaire survey to assess the perceptions and attitudes of ICU physicians at all 20 ICUs in Milan, Italy, regarding inappropriate admissions and resource allocation. RESULTS Eighty-seven percent (225/259) of physicians responded. Inappropriate admissions were acknowledged by 86% of respondents. The reasons given were clinical doubt (33%); limited decision time (32%); assessment error (25%); pressure from superiors (13%), referring clinician (11%) or family (5%); threat of legal action (5%); and an economically advantageous 'Diagnosis Related Group' (1%). Respondents reported being pressurized to make more 'productive' use of ICU beds by Unit heads (frequently 16%), hospital management (frequently 10%) and colleagues (frequently 4%). Five percent reported refusing appropriate admissions following 'indications' not to admit financially disadvantageous cases. Admissions after elective surgery prioritized patients from profitable surgical departments: frequently for 6% of respondents and occasionally for 15%. Sixty-seven percent said they frequently received requests for appropriate admissions when no beds were available. This was considered sufficient reason to withdraw treatment from patients with lower survival probability (sometimes 21%) or for whom nothing more could be done (sometimes 51%, frequently 11%). CONCLUSIONS Inappropriate ICU admissions were perceived as a common event but were mainly attributed to difficulties in assessing suitability. Physicians were aware that their decisions were often influenced by factors other than medical necessity. Economic influences were perceived as limited but not negligible. Decisions to forgo treatment could be influenced by the need to admit other patients.
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Affiliation(s)
- A Giannini
- Paediatric Intensive Care Unit, Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Via della Commenda 9, 20122 Milano, Italy.
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Casarett D, Kapo J, Caplan A. Appropriate use of artificial nutrition and hydration--fundamental principles and recommendations. N Engl J Med 2005; 353:2607-12. [PMID: 16354899 DOI: 10.1056/nejmsb052907] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- David Casarett
- Center for Health Equity Research and Promotion, Veterans Affairs Medical Center, Philadelphia, USA
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Abstract
INTRODUCTION Decisions to withhold or withdraw active life support treatment in situations with no hope of improvement remain difficult for critical-care specialists and families; they are not always well understood by the public. This report describes terminal extubation, a particular method of withdrawing ventilator support. METHODS This retrospective analysis examines the records of patients who died in our intensive care unit after a decision to withdraw active life support by stopping artificial ventilation. Extubation was proposed for patients with irreversible neurological damage and was always performed only after a standardized collective decision-making process. This process included three stages. In the initial phase, withdrawal of ventilator support was discussed at a department staff meeting. The meeting's conclusions were transcribed into the medical file, and the possibility of extubation was raised with the family during a planned interview. At least a 24-hour period of reflection was necessary before a new interview, and any opposition, hesitation or lack of understanding by the family at this first interview resulted in suspending the decision. The technical procedures for terminal extubation were also standardized. RESULTS In 5 cases (4 men and one woman, with a mean age of 65 +/- 4 years), terminal extubation was decided in cooperation with the family, following an average of 3 interviews, 16 days after admission. All patients died within 3 days. DISCUSSION So-called "terminal" extubation, very common in the United States, but much less so in France, reinforces the transparency of end-of-life decisions in intensive care units and immediately makes tangible the end of the aggressive treatment for which critical-care specialists have been reproached. Since this first series of patients, extubation has been practiced in our department, principally in situations of irreversible neurological damage.
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Ho KM, English S, Bell J. The involvement of intensive care nurses in end-of-life decisions: a nationwide survey. Intensive Care Med 2005; 31:668-73. [PMID: 15803296 DOI: 10.1007/s00134-005-2613-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2004] [Accepted: 03/03/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To investigate the prevalence and predictors of intensive care nurses' active involvement in end-of-life (EOL) decisions. DESIGN AND SETTING A survey of intensive care nurses from 36 intensive care units (ICUs) in New Zealand. MEASUREMENTS AND RESULTS A total of 611 ICU nurses from 35 ICUs responded to this survey. The response rate was estimated to be between 43% and 81%. Seventy-eight percent of respondents reported active involvement in EOL decisions, especially the senior nurses (level IV vs. I nurses, OR 7.9; nurse educators vs. level I nurses, OR 4.3). Asian (OR 0.2) and Pacific Islander nurses (OR 0.2) were less often involved than European nurses. Sixty-eight percent of respondents preferred more involvement in EOL decisions, and this preference was associated with the perception that EOL decisions are often made too late (OR 2.2). Sixty-five percent believed their active involvement in EOL decisions would improve nursing job satisfaction. CONCLUSIONS Most ICU nurses in New Zealand reported that they are often involved in EOL decisions, especially senior and European nurses.
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Affiliation(s)
- Kwok M Ho
- Intensive Care Unit, Royal Perth Hospital, 6000 Perth, WA, Australia.
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41
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Abstract
The patient with severe brain damage represents a considerable ethical challenge for the medical team due to uncertainties in diagnosis and prognosis, the younger age of many of these patients, and the frequent acute nature of the disease, which allows little time for discussion of end-of-life issues with the patient. Surrogates are often relied on to fill in the gaps and provide their, not always reliable, interpretation of how they feel the patient would want to have been treated. The debate regarding the withdrawing/withholding of life-sustaining treatment is discussed but may not apply to many patients with severe brain damage who do not usually require invasive life support. However, withdrawal of artificial feeding and hydration is very relevant to such patients and is highly controversial. These issues are highly emotive and subjective, and individuals' views will depend on many factors including cultural background and religion. There are relatively few published data regarding ethical issues in the severely brain damaged patient and open discussion of the multiple facets of this difficult area must be encouraged.
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Free University of Brussels, B-1070 Brussels, Belgium.
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Hall RI, Rocker GM, Murray D. Simple changes can improve conduct of end-of-life care in the intensive care unit. Can J Anaesth 2004; 51:631-6. [PMID: 15197128 DOI: 10.1007/bf03018408] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To describe changes to the conduct of withdrawal of life support (WOLS) in two teaching hospital tertiary care medical surgical intensive care units (ICUs) in a single centre over two distinct time periods. METHODS We used a retrospective chart review with a before and after comparison. We assessed aspects of end-of-life care for ICU patients dying after a WOLS before and after we introduced instruments to clarify do not resuscitate (DNR) orders and to standardize the WOLS process, sought family input into the conduct of end-of-life care, and modified physicians' orders regarding use of analgesia and sedation. RESULTS One hundred thirty-eight patients died following life support withdrawal in the ICUs between July 1996 and June 1997 (PRE) and 168 patients died after a WOLS between May 1998 and April 1999 (POST). Time from ICU admission to WOLS (mean +/- SD) was shorter in the POST period (191 +/- 260 hr PRE vs 135 +/- 205 hr POST, P = 0.05). Fewer patients in the POST group received cardiopulmonary resuscitation in the 12-hr interval prior to death (PRE = 7; POST = 0: P < 0.05). Fewer comfort medications were used (PRE: 1.7 +/- 1.0 vs POST: 1.4 +/- 1.0; P < 0.05). Median cumulative dose of diazepam (PRE: 20.0 vs POST: 10.0 mg; P < 0.05) decreased. Documented involvement of physicians in WOLS discussions was unchanged but increased for pastoral care (PRE: 10/138 vs POST: 120/168 cases; P < 0.05). The majority of nurses (80%) felt that the DNR and WOLS checklists led to improved process around WOLS. CONCLUSION Simple changes to the process of WOLS can improve conduct of end-of-life care in the ICU.
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Affiliation(s)
- Richard I Hall
- Department of Anesthesia, Dalhousie University, and the Intensive Care Services, Canada
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Rocker GM, Heyland DK, Cook DJ, Dodek PM, Kutsogiannis DJ, O'Callaghan CJ. Most critically ill patients are perceived to die in comfort during withdrawal of life support: a Canadian multicentre study. Can J Anaesth 2004; 51:623-30. [PMID: 15197127 DOI: 10.1007/bf03018407] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE Most deaths in intensive care units (ICUs) follow a withdrawal of life support (LS). Evaluation of this process including the related perspectives of grieving family members is integral to improvement of palliation in the ICU. METHODS A prospective, multicentre, cohort study in six Canadian university-affiliated ICUs included 206 ICU patients (length of stay >or=48 hr) who received mechanical ventilation (MV) before LS withdrawal. We recorded modes, sequence and time course of LS withdrawal and drug usage (4 hr before; 4-8 hr and 8-12 hr before death). We asked a specified family member to assess patient comfort and key aspects of end-of life care. RESULTS MV was withdrawn from 155/206 (75.2%) patients; 97/155 (62.6%) died after extubation and 58/155 (37.4%) died with an airway in place. The most frequently used drugs and the cumulative doses [median (range)] in the four hours before death were: morphine 119/206, 24 mg, (2-450 mg); midazolam 45/206, 24 mg, (2-380 mg); and lorazepam 35/206, 4 mg, (1-80 mg). These doses did not differ among the three time periods before death. Of 196 responses from family members most indicated that patients were perceived to be either totally (73, 37.2%), very (48, 24.5%), or mostly comfortable (58, 29.6%). Times to death, morphine use and family members' perceptions of comfort were similar for each type of change to MV. CONCLUSIONS Most patients were perceived by family members to die in comfort during a withdrawal of LS. Perceptions of patient comfort and drug use in the hours before death were not associated with the mode or sequence of withdrawal of LS, or the time to death.
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Affiliation(s)
- Graeme M Rocker
- Department of Medicine, Queen Elizabeth II Health Sciences Center, Halifax, Nova Scotia, Canada.
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White DB, Luce JM. Palliative care in the intensive care unit: barriers, advances, and unmet needs. Crit Care Clin 2004; 20:329-43, vii. [PMID: 15183206 DOI: 10.1016/j.ccc.2004.03.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The concept that critical illness and terminal illness are necessarily distinct entities has given way to the understanding that they often exist on the same spectrum. Consequently, there is growing consensus that palliative treatment must coexist with attempts at restorative treatment in the intensive care unit (ICU). Palliative care in the ICU has evolved from a relatively one-dimensional construct of terminal sedation in dying patients to a multidisciplinary field addressing symptom control, physician-patient-family communication,spiritual needs, and the needs of health care providers. As ongoing research efforts yield new insights, our ability to practice evidence-based palliative care in the ICU will grow, and new avenues for improvement will become evident.
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Affiliation(s)
- Douglas B White
- Division of Pulmonary and Critical Care Medicine and Program in Medical Ethics, University of California, 521 Parnassus Avenue, Suite C-126, San Francisco, CA 94143-0903, USA.
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Kirchhoff KT, Anumandla PR, Foth KT, Lues SN, Gilbertson-White SH. Documentation on Withdrawal of Life Support in Adult Patients in the Intensive Care Unit. Am J Crit Care 2004. [DOI: 10.4037/ajcc2004.13.4.328] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
• Background Patients’ charts have been a source of data for retrospective studies of the quality of end-of-life care. In the intensive care unit, most patients die after withdrawal of life support. Chart reviews of this process could be used not only to assess the quality of documentation but also to provide information for quality improvement and research.• Objective To assess the documentation of end-of-life care of patients and their families by care providers in the intensive care unit.• Method Charts of 50 adult patients who died in the intensive care unit at a large midwestern hospital after initiation of withdrawal of life support (primarily mechanical ventilation) were reviewed. A form developed for the study was used for data collection.• Results The initiation of the decision making for withdrawal was documented in all 50 charts. Sixteen charts (32%) had no information on advance directives. Eight charts (16%) had no documentation on resuscitation status. About two thirds of the charts documented nurses’ participation during the withdrawal process; only one tenth documented physicians’ participation. A total of 13 charts (26%) had no information on the time of initiation of the withdrawal process, and 11 (22%) had no documentation of medications administered for withdrawal. Thirty-seven charts (74%) had information on whether the patient was or was not extubated during withdrawal.• Conclusion Comprehensive documentation of end-of-life care is lacking.
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Narcotic and benzodiazepine use after withdrawal of life support: association with time to death? Chest 2004; 126:286-93. [PMID: 15249473 DOI: 10.1016/s0012-3692(15)32925-1] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To determine whether the dose of narcotics and benzodiazepines is associated with length of time from mechanical ventilation withdrawal to death in the setting of withdrawal of life-sustaining treatment in the ICU. DESIGN Retrospective chart review. SETTING University-affiliated, level I trauma center. PATIENTS Consecutive critically ill patients who had mechanical ventilation withdrawn and subsequently died in the ICU during two study time periods. RESULTS There were 75 eligible patients with a mean age of 59 years. The primary ICU admission diagnoses included intracranial hemorrhage (37%), trauma (27%), acute respiratory failure (27%), and acute renal failure (20%). Patients died during a median of 35 min (range, 1 to 890 min) after ventilator withdrawal. On average, 16.2 mg/h opiates in morphine equivalents and 7.5 mg/h benzodiazepine in lorazepam equivalents were administered during the time period starting 1 h before ventilator withdrawal and ending at death. There was no statistically significant relationship between the average hourly narcotic and benzodiazepine use during the 1-h period prior to ventilator withdrawal until death, and the time from ventilator withdrawal to death. The restriction of medication assessment in the last 2 h of life showed an inverse association between the use of benzodiazepines and time to death. For every 1 mg/h increase in benzodiazepine use, time to death was increased by 13 min (p = 0.015). There was no relationship between narcotic dose and time to death during the last 2 h of life (p = 0.11). CONCLUSIONS We found no evidence that the use of narcotics or benzodiazepines to treat discomfort after the withdrawal of life support hastens death in critically ill patients at our center. Clinicians should strive to control patient symptoms in this setting and should document the rationale for escalating drug doses.
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Abstract
Critically ill patients nearing the end of life frequently present with needs for aggressive sedation and analgesia. Optimizing patient comfort while permitting effective communication are challenging goals in this patient population. This article discusses delirium and sedation as it applies to dying patients, and provides recommendations for effective management strategies to optimize the experience of such patients at the end of life.
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Affiliation(s)
- John P Kress
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, 5841 South Maryland Avenue, MC 6026, Chicago, IL 60637, USA.
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48
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Abstract
The developments in medicine in general and the technology of life support in particular have provided the means of maintaining organ function for prolonged periods of time. However, there are many situations where life-sustaining treatment in an intensive care unit (ICU) may lead to a death with lingering and suffering of the patient, as well as burdening their family. Although often equated, withholding and/or withdrawing life-prolonging treatments that allow the patient to die needs to be differentiated from the physician-assisted suicides and euthanasia that involve the active ending of life. There is a difference between an unintended but accepted consequence of forgoing therapy and an intended result of death from suicide or euthanasia. The present-day physicians view most patient deaths as an inevitable process secondary to disorders unresponsive to treatment and/or multiple organ dysfunction syndromes. The large majority of patients dying in ICUs today succumb not after cardiopulmonary resuscitation, but rather, after the forgoing of life-sustaining treatment. Such approach has frequently caused families, institutions, and conservators of patients to resort to judicial fiat for resolution.
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Affiliation(s)
- B R Sharma
- Department of Forensic Medicine and Toxicology, Government Medical College and Hospital, Chandigarh, 160030, India.
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Zawistowski CA, DeVita MA. A descriptive study of children dying in the pediatric intensive care unit after withdrawal of life-sustaining treatment. Pediatr Crit Care Med 2004; 5:216-23. [PMID: 15115557 DOI: 10.1097/01.pcc.0000123547.28099.44] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine physiologic and therapeutic changes following withdrawal of life-sustaining treatment in children. DESIGN Retrospective chart review. SETTING University-affiliated tertiary care pediatric hospital. PATIENTS All patients who had life-sustaining treatment withdrawn over a 5-yr period. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 125 charts were examined to obtain 50 in which the terminal event preceding death was withdrawal of life-sustaining treatment. Data are expressed as median (1st, 3rd quartiles). Median hospital stay before death was 20 days (1st and 3rd quartiles, 8 and 30). Median time from decision to withdraw life-sustaining treatment to actual withdrawal was 30 mins (1st and 3rd quartiles, 10 and 180). All interventions were simultaneously discontinued in 80% of patients with mechanical ventilation followed by vasopressors being most common. No patients had stepwise reduction in ventilator rate before discontinuing the mechanical ventilation. Devices were rarely removed from patients including endotracheal tubes. Time from withdrawal of life-sustaining treatment to death was 15 mins (5, 30); only seven patients took >60 mins to die. Multivariable analysis (Kruskal-Wallis test) of various factors revealed simultaneous withdrawal of life-sustaining treatment, female gender, and not having received renal therapy as hastening death. CONCLUSIONS Forgoing life-sustaining treatment in a small cohort of children at a single institution follows a pattern: Most cases occur after prolonged intensive care unit stays, withdrawal of treatment occurs almost immediately after the decision to withdraw, most treatments are withdrawn simultaneously rather than sequentially, and most patients die within minutes of life-sustaining treatment cessation. This is the first pediatric study to report the time to death after withdrawal of life-sustaining treatment and factors associated with shorter time to death in children.
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Affiliation(s)
- Christine A Zawistowski
- University of Pittsburgh Department of Critical Care Medicine, Critical Care Medicine, Pittsburgh, PA, USA
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Abstract
PURPOSE OF REVIEW New data on the efficacy of low tidal volume ventilation for acute lung injury, noninvasive ventilation for chronic obstructive pulmonary disease exacerbation, weaning from mechanical ventilation, and prevention of ventilator-associated pneumonia provide, for perhaps the first time in respiratory care, compelling evidence for clinicians to change practice. However, experience from every other field in medicine suggests that there will be significant barriers to changing clinical practice at the bedside. Studies on implementation of effective practice in medicine shows that a multifaceted, team-oriented approach incorporating reminders, efficient use of non-physician personnel, protocols, and education is required to change clinical practice. Limited data on current practice of mechanical ventilation suggest that it deviates from recommended practice. Unfortunately, there are no studies exploring community-based implementation of mechanical ventilation guidelines and only a few studies to inform clinicians as to why ventilator practice may be difficult to change. As the evidence base grows for effective critical care practice, so does the responsibility to translate practices that improve outcome from research journals to patients' bedsides. Strategies for doing this are presented in the review.
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Affiliation(s)
- Gordon D Rubenfeld
- Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, Washington, USA.
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