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Comer AR, Fettig L, Bartlett S, Sinha S, D'Cruz L, Odgers A, Waite C, Slaven JE, White R, Schmidt A, Petras L, Torke AM. Code status orders in hospitalized patients with COVID-19. Resusc Plus 2023; 15:100452. [PMID: 37662642 PMCID: PMC10470381 DOI: 10.1016/j.resplu.2023.100452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 07/18/2023] [Accepted: 08/01/2023] [Indexed: 09/05/2023] Open
Abstract
Background The COVID-19 pandemic created complex challenges regarding the timing and appropriateness of do-not-attempt cardiopulmonary resuscitation (DNACPR) and/or Do Not Intubate (DNI) code status orders. This paper sought to determine differences in utilization of DNACPR and/or DNI orders during different time periods of the COVID-19 pandemic, including prevalence, predictors, timing, and outcomes associated with having a documented DNACPR and/or DNI order in hospitalized patients with COVID-19. Methods A cohort study of hospitalized patients with COVID-19 at two hospitals located in the Midwest. DNACPR code status orders including, DNI orders, demographics, labs, COVID-19 treatments, clinical interventions during hospitalization, and outcome measures including mortality, discharge disposition, and hospice utilization were collected. Patients were divided into two time periods (early and late) by timing of hospitalization during the first wave of the pandemic (March-October 2020). Results Among 1375 hospitalized patients with COVID-19, 19% (n = 258) of all patients had a documented DNACPR and/or DNI order. In multivariable analysis, age (older) p =< 0.01, OR 1.12 and hospitalization early in the pandemic p = 0.01, OR 2.08, were associated with having a DNACPR order. Median day from DNACPR order to death varied between cohorts p => 0.01 (early cohort 5 days versus late cohort 2 days). In-hospital mortality did not differ between cohorts among patients with DNACPR orders, p = 0.80. Conclusions There was a higher prevalence of DNACPR and/or DNI orders and these orders were written earlier in the hospital course for patients hospitalized early in the pandemic versus later despite similarities in clinical characteristics and medical interventions. Changes in clinical care between cohorts may be due to fear of resource shortages and changes in knowledge about COVID-19.
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Affiliation(s)
- Amber R. Comer
- Indiana University School of Health and Human Science, United States
- Indiana University School of Medicine, United States
- American Medical Association, United States
| | - Lyle Fettig
- Indiana University School of Medicine, United States
| | | | - Shilpee Sinha
- Indiana University School of Medicine, United States
| | - Lynn D'Cruz
- Indiana University School of Health and Human Science, United States
| | - Aubrey Odgers
- Indiana University School of Health and Human Science, United States
| | - Carly Waite
- Indiana University School of Health and Human Science, United States
| | | | - Ryan White
- Indiana University School of Medicine, United States
| | | | - Laura Petras
- Indiana University School of Medicine, United States
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Vahedian-Azimi A, Rahimibashar F, Ashtari S, Guest PC, Sahebkar A. Comparison of the clinical features in open and closed format intensive care units: A systematic review and meta-analysis. Anaesth Crit Care Pain Med 2021; 40:100950. [PMID: 34555538 DOI: 10.1016/j.accpm.2021.100950] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 03/29/2021] [Accepted: 06/06/2021] [Indexed: 01/09/2023]
Abstract
IMPORTANCE The difference in clinical outcomes between closed and open designs of intensive care units (ICUs) is still an open question. OBJECTIVE We conducted a systematic review and meta-analysis to compare total mortality, hospital and ICU length of stay (LOS) and mortality as primary outcomes, and severity of illness based on physiological variables, organ failure assessment, age, duration of mechanical ventilation and ventilator-associated pneumonia frequency as secondary outcomes in closed and open ICUs. EVIDENCE REVIEW Medline, PubMed, Scopus, Web of Science, Cochrane database, Iran-doc and Elm-net according to the MeSH terms were searched from 1988 to October 2019. The standardised mean difference (SMD), relative risk (RR) with 95% confidence interval (CI) were applied to display summary statistics of primary and secondary outcomes. FINDINGS A total of 90 studies with 444,042 participants were analysed. ICU mortality (RR: 1.16, CI: 1.07-1.27, p < 0.001), hospital mortality (RR: 1.12, CI: 1.03-1.22, p = 0.010) and ICU LOS (SMD: 0.43, CI: 0.01-0.85, p = 0.040) were significantly higher in open ICUs. Total mortality (RR: 0.91, CI: 0.77-1.08, p = 0.28) and hospital LOS (SMD: 1.14, CI: 1.31-3.59, p = 0.36) showed no significant difference between the two types of ICU. The secondary outcome measures were also comparable between the two ICU formats (p > 0.05). CONCLUSIONS AND RELEVANCE The results demonstrated superiority of closed versus open ICUs in hospital and ICU mortality rates and ICU LOS, with no difference in total mortality, hospital LOS or severity of illness parameters. The superiority of the closed ICU format may be a result of the intensivist-led patient care and should therefore be implemented by clinicians to decrease ICU mortality rates and LOS for critically ill patients.
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Affiliation(s)
- Amir Vahedian-Azimi
- Trauma Research Centre, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Farshid Rahimibashar
- Anaesthesia and Critical Care Department, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Sara Ashtari
- Gastroenterology and Liver Diseases Research Centre, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Paul C Guest
- Department of Biochemistry and Tissue Biology, Institute of Biology, University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran; School of Medicine, The University of Western Australia, Perth, Australia; School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran.
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Prognosticating Outcomes and Nudging Decisions with Electronic Records in the Intensive Care Unit Trial Protocol. Ann Am Thorac Soc 2021; 18:336-346. [PMID: 32936675 DOI: 10.1513/annalsats.202002-088sd] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Expert recommendations to discuss prognosis and offer palliative options for critically ill patients at high risk of death are variably heeded by intensive care unit (ICU) clinicians. How to best promote such communication to avoid potentially unwanted aggressive care is unknown. The PONDER-ICU (Prognosticating Outcomes and Nudging Decisions with Electronic Records in the ICU) study is a 33-month pragmatic, stepped-wedge cluster randomized trial testing the effectiveness of two electronic health record (EHR) interventions designed to increase ICU clinicians' engagement of critically ill patients at high risk of death and their caregivers in discussions about all treatment options, including care focused on comfort. We hypothesize that the quality of care and patient-centered outcomes can be improved by requiring ICU clinicians to document a functional prognostic estimate (intervention A) and/or to provide justification if they have not offered patients the option of comfort-focused care (intervention B). The trial enrolls all adult patients admitted to 17 ICUs in 10 hospitals in North Carolina with a preexisting life-limiting illness and acute respiratory failure requiring continuous mechanical ventilation for at least 48 hours. Eligibility is determined using a validated algorithm in the EHR. The sequence in which hospitals transition from usual care (control), to intervention A or B and then to combined interventions A + B, is randomly assigned. The primary outcome is hospital length of stay. Secondary outcomes include other clinical outcomes, palliative care process measures, and nurse-assessed quality of dying and death.Clinical trial registered with clinicaltrials.gov (NCT03139838).
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Lo ML, Huang CC, Hu TH, Chou WC, Chuang LP, Chiang MC, Wen FH, Tang ST. Quality Assessments of End-of-Life Care by Medical Record Review for Patients Dying in Intensive Care Units in Taiwan. J Pain Symptom Manage 2020; 60:1092-1099.e1. [PMID: 32650138 DOI: 10.1016/j.jpainsymman.2020.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/28/2020] [Accepted: 07/01/2020] [Indexed: 12/14/2022]
Abstract
CONTEXT/OBJECTIVE Essential indicators of high-quality end-of-life care in intensive care units (ICUs) have been established but examined inconsistently and predominantly with small samples, mostly from Western countries. Our study goal was to comprehensively measure end-of-life-care quality delivered in ICUs using chart-derived process-based quality measures for a large cohort of critically ill Taiwanese patients. METHODS For this observational study, patients with APACHE II score ≥20 or goal of palliative care and with ICU stay exceeding three days (N = 326) were consecutively recruited and followed until death. RESULTS Documentation of process-based indicators for Taiwanese patients dying in ICUs was variable (8.9%-96.3%), but high for physician communication of the patient's poor prognosis to his/her family members (93.0%), providing specialty palliative-care consultations (73.3%), a do-not-resuscitate order in place at death (96.3%), death without cardiopulmonary resuscitation (93.5%), and family presence at patient death (76.1%). Documentation was infrequent for social-worker involvement (8.9%) and interdisciplinary family meetings to discuss goals of care (22.4%). Patients predominantly (79.8%) continued life-sustaining treatments (LSTs) until death and died with full life support, with 88.3% and 58.9% of patients dying with mechanical ventilation support and vasopressors, respectively. CONCLUSIONS Taiwanese patients dying in ICUs heavily used LSTs until death despite high prevalences of documented prognostic communication, providing specialty palliative-care consultations, having a do-not-resuscitate order in place, and death without cardiopulmonary resuscitation. Family meetings should be actively promoted to facilitate appropriate end-of-life-care decisions to avoid unnecessary suffering from potentially inappropriate LSTs during the last days of life.
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Affiliation(s)
- Mei-Ling Lo
- Department of Nursing, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, R.O.C; School of Nursing, Medical College, Chang Gung University, Tao-Yuan, Taiwan, R.O.C
| | - Chung-Chi Huang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, R.O.C; Department of Respiratory Therapy, Chang Gung University, Tao-Yuan, Taiwan, R.O.C
| | - Tsung-Hui Hu
- Division of Hepato-Gastroenterology, Department of Internal Medicine, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, R.O.C
| | - Wen-Chi Chou
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, R.O.C; College of Medicine, Chang Gung University, Tao-Yuan, Taiwan, R.O.C
| | - Li-Pang Chuang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, R.O.C
| | - Ming Chu Chiang
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, R.O.C
| | - Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan, R.O.C
| | - Siew Tzuh Tang
- School of Nursing, Medical College, Chang Gung University, Tao-Yuan, Taiwan, R.O.C; Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan, R.O.C; Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan, R.O.C.
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Huard P, Kalavrouziotis D, Lipes J, Simon M, Tardif MA, Blackburn S, Langevin S, Sia YT, Mohammadi S. Does the full-time presence of an intensivist lead to better outcomes in the cardiac surgical intensive care unit? J Thorac Cardiovasc Surg 2020; 159:1363-1375.e7. [DOI: 10.1016/j.jtcvs.2019.03.124] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 03/06/2019] [Accepted: 03/07/2019] [Indexed: 10/26/2022]
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Pastores SM, Kvetan V, Coopersmith CM, Farmer JC, Sessler C, Christman JW, D'Agostino R, Diaz-Gomez J, Gregg SR, Khan RA, Kapu AN, Masur H, Mehta G, Moore J, Oropello JM, Price K. Workforce, Workload, and Burnout Among Intensivists and Advanced Practice Providers: A Narrative Review. Crit Care Med 2019; 47:550-557. [PMID: 30688716 DOI: 10.1097/ccm.0000000000003637] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To assess-by literature review and expert consensus-workforce, workload, and burnout considerations among intensivists and advanced practice providers. DESIGN Data were synthesized from monthly expert consensus and literature review. SETTING Workforce and Workload section workgroup of the Academic Leaders in Critical Care Medicine Task Force. MEASUREMENTS AND MAIN RESULTS Multidisciplinary care teams led by intensivists are an essential component of critical care delivery. Advanced practice providers (nurse practitioners and physician assistants) are progressively being integrated into ICU practice models. The ever-increasing number of patients with complex, life-threatening diseases, concentration of ICU beds in few centralized hospitals, expansion of specialty ICU services, and desire for 24/7 availability have contributed to growing intensivist staffing concerns. Such staffing challenges may negatively impact practitioner wellness, team perception of care quality, time available for teaching, and length of stay when the patient to intensivist ratio is greater than or equal to 15. Enhanced team communication and reduction of practice variation are important factors for improved patient outcomes. A diverse workforce adds value and enrichment to the overall work environment. Formal succession planning for ICU leaders is crucial to the success of critical care organizations. Implementation of a continuous 24/7 ICU coverage care model in high-acuity, high-volume centers should be based on patient-centered outcomes. High levels of burnout syndrome are common among intensivists. Prospective analyses of interventions to decrease burnout within the ICU setting are limited. However, organizational interventions are felt to be more effective than those directed at individuals. CONCLUSIONS Critical care workforce and staffing models are myriad and based on several factors including local culture and resources, ICU organization, and strategies to reduce burden on the ICU provider workforce. Prospective studies to assess and avoid the burnout syndrome among intensivists and advanced practice providers are needed.
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Affiliation(s)
- Stephen M Pastores
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | | | - Craig M Coopersmith
- Department of Surgery, Emory Critical Care Center, Emory University, Atlanta, GA
| | | | - Curtis Sessler
- Division of Pulmonary Diseases and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA
| | - John W Christman
- Division of Pulmonary, Allergy, Critical Care and Sleep, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Rhonda D'Agostino
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jose Diaz-Gomez
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | - Sara R Gregg
- Department of Surgery, Emory Critical Care Center, Emory University, Atlanta, GA
| | - Roozehra A Khan
- Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - April N Kapu
- Vanderbilt University School of Nursing, Vanderbilt University Medical Center, Nashville, TN
| | - Henry Masur
- Department of Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, MD
| | - Gargi Mehta
- Jay B. Langner Critical Care System, Montefiore Medical Center, Albert Einstein College of Medicine of Yeshiva University, Bronx, NY
| | - Jason Moore
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - John M Oropello
- Division of Critical Care Medicine, Department of Surgery, Mount Sinai Medical Center, New York, NY
| | - Kristen Price
- Department of Critical Care Medicine, MD Anderson Cancer Center, Houston, TX
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Min-Jie J, Zhun-Yong G, Yan H, Yu-Jing L, Hong-Yu H, Yi-Mei L, Guo-Wei T, Jian-Feng L, Du-Ming Z, Zhe L. The 24-Hour Intensivists Staffing Model Improves the Outcome for Nighttime Admitted Patients: A Matched Historical Control Study. J Intensive Care Med 2019; 35:1439-1446. [PMID: 30744471 DOI: 10.1177/0885066619828338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION We previously showed that a "10-hour daytime on-site" and "nighttime (NT) on-call" staffing strategy was associated with higher mortality for intensive care unit (ICU) patients admitted during NT than it was for patients admitted during office hours (OH). In here, we evaluated the clinical effects of a 24-hour intensivist staffing model. METHODS We formed an intervention group of 3034 consecutive ICU patients hospitalized from January 2013 to December 2015, and a control group of 2891 patients from our previous study (2009-2011). We applied propensity score matching (PSM) for whole and subgroup analyses adjusting for confounding factors. We compared clinical outcomes of patients under the 2 staffing models using multivariate logistic regression and survival analyses. RESULTS After PSM, we balanced the clinical data between the complete cohorts and the subgroups. Comparison of ICU survivals between the intervention and control cohorts yielded no significant differences. However, the intervention was significantly associated with a higher ICU survival in the NT (5:30 pm-07:30 am) admission patients (P = .049) than in those admitted during OH (07:30 am to 5:30 pm; P = .456). Additionally, the intervention shortened the LOSHOS (P = .001) and/or LOSICU (P < .001), reduced the hospital (P = .672) and/or ICU (P = .004) expenses, and resulted in earlier mechanical ventilation extubation (P = .442) as compared to the same variables in the control group, especially for NT admissions. CONCLUSIONS The 24-hour intensivists staffing could significantly improve ICU outcomes, especially for NT-admission patients in high-acuity, high-volume ICUs with frequent NT admissions.
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Affiliation(s)
- Ju Min-Jie
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Gu Zhun-Yong
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Han Yan
- Department of General Medical Practice, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Liu Yu-Jing
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - He Hong-Yu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Liu Yi-Mei
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Tu Guo-Wei
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Luo Jian-Feng
- Department of Biostatistics, School of Public Health, Fudan University, Shanghai, People's Republic of China
| | - Zhu Du-Ming
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Luo Zhe
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
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9
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Blazquez V, Rodríguez A, Sandiumenge A, Oliver E, Cancio B, Ibañez M, Miró G, Navas E, Badía M, Bosque MD, Jurado MT, López M, Llauradó M, Masnou N, Pont T, Bodí M. Factors related to limitation of life support within 48h of intensive care unit admission: A multicenter study. Med Intensiva 2018; 43:352-361. [PMID: 29747939 DOI: 10.1016/j.medin.2018.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/09/2018] [Accepted: 03/22/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine factors related to limitations on life support within 48h of intensive care unit (ICU) admission. STUDY DESIGN Prospective multicenter study. SETTING Eleven ICUs. PATIENTS All patients who died and/or had limitations on life support after ICU admission during a four-month period. VARIABLES Patient characteristics, hospital characteristics, characteristics of limitations on life support. Time-to-first-limitation was classified as early (<48h of admission) or late (≥48h). We performed univariate, multivariate analyses and CHAID (chi-square automatic interaction detection) analysis of variables associated with limitation of life support within 48h of ICU admission. RESULTS 3335 patients were admitted; 326 (9.8%) had limitations on life support. A total of 344 patients died; 247 (71.8%) had limitations on life support (range among centers, 58.6%-84.2%). The median (p25-p75) time from admission to initial limitation was 2 (0-7) days. CHAID analysis found that the modified Rankin score was the variable most closely related with early limitations. Among patients with Rankin >2, early limitations were implemented in 71.7% (OR=2.5; 95% CI: 1.5-4.4) and lung disease was the variable most strongly associated with early limitations (OR=12.29; 95% CI: 1.63-255.91). Among patients with Rankin ≤2, 48.8% had early limitations; patients admitted after emergency surgery had the highest rate of early limitations (66.7%; OR=2.4; 95% CI: 1.1-5.5). CONCLUSION Limitations on life support are common, but the practice varies. Quality of life has the greatest impact on decisions to limit life support within 48h of admission.
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Affiliation(s)
- V Blazquez
- Intensive Care Unit, University Hospital Joan XXIII, Institut d'Investigació Sanitària Pere Virgili, Tarragona, Spain
| | - A Rodríguez
- Intensive Care Unit, University Hospital Joan XXIII, Institut d'Investigació Sanitària Pere Virgili, University Rovira i Virgili, CIBERES, Tarragona, Spain
| | - A Sandiumenge
- Transplant Coordination, University Hospital Vall d'Hebron, Barcelona, Spain
| | - E Oliver
- Transplant Coordination, University Hospital Bellvitge, Barcelona, Spain
| | - B Cancio
- Intensive Care Unit, University Hospital Moises Broggi, Barcelona, Spain
| | - M Ibañez
- Intensive Care Unit, University Hospital Verge de la Cinta de Tortosa, Tortosa, Spain
| | - G Miró
- Intensive Care Unit, Consorci Sanitari del Maresme, Mataró, Spain
| | - E Navas
- Intensive Care Unit, University Hospital Mutua de Terrassa, Terrassa, Spain
| | - M Badía
- Intensive Care Unit, University Hospital Arnau de Vilanova, Lleida, Spain
| | - M D Bosque
- Intensive Care Unit, University Hospital General de Catalunya, Barcelona, Spain
| | - M T Jurado
- Intensive Care Unit, Hospital de Terrassa, Terrassa, Spain
| | - M López
- Intensive Care Unit, University Hospital de Vic, Vic, Spain
| | - M Llauradó
- International University of Catalunya, Barcelona, Spain
| | - N Masnou
- Transplant Coordination, University Hospital Dr. Trueta, Girona, Spain
| | - T Pont
- Transplant Coordination, University Hospital Vall d'Hebron, Barcelona, Spain
| | - M Bodí
- Intensive Care Unit, University Hospital Joan XXIII, Institut d'Investigació Sanitària Pere Virgili, University Rovira i Virgili, CIBERES, Tarragona, Spain.
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Examining racial disparities in the time to withdrawal of life-sustaining treatment in trauma. J Trauma Acute Care Surg 2018; 84:590-597. [DOI: 10.1097/ta.0000000000001775] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Chronic Critical Illness in Infants and Children: A Speculative Synthesis on Adapting ICU Care to Meet the Needs of Long-Stay Patients. Pediatr Crit Care Med 2016; 17:743-52. [PMID: 27295581 DOI: 10.1097/pcc.0000000000000792] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES In this review, we examine features of ICU systems and ICU clinician training that can undermine continuity of communication and longitudinal guidance for decision making for chronically critically ill infants and children. Drawing upon a conceptual model of the dynamic interactions between patients, families, clinicians, and ICU systems, we propose strategies to promote longitudinal decision making and improve communication for infants and children with prolonged ICU stays. DATA SOURCES We searched MEDLINE and PubMed from inception to September 2015 for English-language articles relevant to chronic critical illness, particularly of pediatric patients. We also reviewed bibliographies of relevant studies to broaden our search. STUDY SELECTION Two authors (physicians with experience in pediatric neonatology, critical care, and palliative care) made the final selections. DATA EXTRACTION We critically reviewed the existing data and models of care to identify strategies for improving ICU care of chronically critically ill children. DATA SYNTHESIS Utilizing the available data and personal experience, we addressed concerns related to family perspectives, ICU processes, and issues with ICU training that shape longitudinal decision making. CONCLUSIONS As the number of chronically critically ill infants and children increases, specific communication and decision-making models targeted at this population could improve the feedback between acute, daily ICU decisions and the patient's overall goals of care. Adaptations to ICU systems of care and ICU clinician training will be essential components of this progress.
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Perkins GD, Griffiths F, Slowther AM, George R, Fritz Z, Satherley P, Williams B, Waugh N, Cooke MW, Chambers S, Mockford C, Freeman K, Grove A, Field R, Owen S, Clarke B, Court R, Hawkes C. Do-not-attempt-cardiopulmonary-resuscitation decisions: an evidence synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04110] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundCardiac arrest is the final common step in the dying process. In the right context, resuscitation can reverse the dying process, yet success rates are low. However, cardiopulmonary resuscitation (CPR) is a highly invasive medical treatment, which, if applied in the wrong setting, can deprive the patient of dignified death. Do-not-attempt-cardiopulmonary-resuscitation (DNACPR) decisions provide a mechanism to withhold CPR. Recent scientific and lay press reports suggest that the implementation of DNACPR decisions in NHS practice is problematic.Aims and objectivesThis project sought to identify reasons why conflict and complaints arise, identify inconsistencies in NHS trusts’ implementation of national guidelines, understand health professionals’ experience in relation to DNACPR, its process and ethical challenges, and explore the literature for evidence to improve DNACPR policy and practice.MethodsA systematic review synthesised evidence of processes, barriers and facilitators related to DNACPR decision-making and implementation. Reports from NHS trusts, the National Reporting and Learning System, the Parliamentary and Health Service Ombudsman, the Office of the Chief Coroner, trust resuscitation policies and telephone calls to a patient information line were reviewed. Multiple focus groups explored service-provider perspectives on DNACPR decisions. A stakeholder group discussed the research findings and identified priorities for future research.ResultsThe literature review found evidence that structured discussions at admission to hospital or following deterioration improved patient involvement and decision-making. Linking DNACPR to overall treatment plans improved clarity about goals of care, aided communication and reduced harms. Standardised documentation improved the frequency and quality of recording decisions. Approximately 1500 DNACPR incidents are reported annually. One-third of these report harms, including some instances of death. Problems with communication and variation in trusts’ implementation of national guidelines were common. Members of the public were concerned that their wishes with regard to resuscitation would not be respected. Clinicians felt that DNACPR decisions should be considered within the overall care of individual patients. Some clinicians avoid raising discussions about CPR for fear of conflict or complaint. A key theme across all focus groups, and reinforced by the literature review, was the negative impact on overall patient care of having a DNACPR decision and the conflation of ‘do not resuscitate’ with ‘do not provide active treatment’.LimitationsThe variable quality of some data sources allows potential overstatement or understatement of findings. However, data source triangulation identified common issues.ConclusionThere is evidence of variation and suboptimal practice in relation to DNACPR decisions across health-care settings. There were deficiencies in considering, discussing and implementing the decision, as well as unintended consequences of DNACPR decisions being made on other aspects of patient care.Future workRecommendations supported by the stakeholder group are standardising NHS policies and forms, ensuring cross-boundary recognition of DNACPR decisions, integrating decisions with overall treatment plans and developing tools and training strategies to support clinician and patient decision-making, including improving communication.Study registrationThis study is registered as PROSPERO CRD42012002669.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Gavin D Perkins
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
- Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Frances Griffiths
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Anne-Marie Slowther
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Robert George
- Cicely Saunders Institute, King’s College London, London, UK
- Palliative Care, Guy’s and St Thomas’ Hospitals NHS Foundation Trust, London, UK
| | - Zoe Fritz
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Barry Williams
- Patient and Relative Committee, The Intensive Care Foundation, London, UK
| | - Norman Waugh
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Matthew W Cooke
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
- Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Sue Chambers
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Carole Mockford
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Karoline Freeman
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Amy Grove
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Richard Field
- Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Sarah Owen
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Ben Clarke
- Medical School, University of Glasgow, Glasgow, UK
| | - Rachel Court
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - Claire Hawkes
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
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13
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Gu X, Chen M, Liu M, Zhang Z, Cheng W. End-of-life decision-making of terminally ill cancer patients in a tertiary cancer center in Shanghai, China. Support Care Cancer 2015; 24:2209-2215. [PMID: 26567116 DOI: 10.1007/s00520-015-3017-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 11/08/2015] [Indexed: 11/30/2022]
Abstract
PURPOSE Different countries have various decision-making practices, which are formalized according to laws, rules, traditions, religious beliefs, and ethical views of different cultural backgrounds. We investigated the characteristics and factors associated with the decision-making details in terminally ill cancer patients in a tertiary cancer center in Shanghai, China. METHOD A single center, retrospective study was performed among advanced cancer patients who died between March 2007 and December 2013 in ward at Palliative Care Unit, Fudan University Shanghai Cancer Center. RESULTS Of 436 patients' end-of-life (EOL) discussions, 424 (97.2 %) occurred between family caregivers and physicians. The main decision-maker was in the following order: spouse (45.6 %), offsprings (44.3 %), parents (3.2 %), son-/daughter-in-law (1.8 %), and relatives (1.4 %). Two hundred twenty-one (47.3 %) patients received at least one of six life-sustaining treatments. One hundred eighty-four (40.4 %) patients continued artificial nutrition and hydration (ANH) until death. Cardiopulmonary resuscitation (CPR) was performed in 26 patients (6.0 %). Two hundred fourteen (49.1 %) patients received vasopressors before death. Only two patients received mechanical ventilation and only one patient received tracheostomy. The median time interval since the decision made till death was 20.17 h (95 % CI = 18.94-21.40, range 4.3 to 70.2 h). Patients who were older than 65 years old were less likely to undergo an intensive procedure (AOR = 0.559, 95 % CI = 0.367-0.852, p = 0.007). Patients living in urban settings (AOR = 2.177, 95 % CI = 1.398-3.390, p = 0.001) were more likely to undergo an intensive procedure in the EOL period. CONCLUSIONS This study reflected some Chinese characteristics for decision-making at the end of life among advanced cancer patients. More prospective studies focused on specific EOL issues are required to improve the quality of EOL care.
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Affiliation(s)
- Xiaoli Gu
- Department of Integrated Therapy, Fudan University Shanghai Cancer Center, #270, DongAn Road, Shanghai, People's Republic of China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Menglei Chen
- Department of Integrated Therapy, Fudan University Shanghai Cancer Center, #270, DongAn Road, Shanghai, People's Republic of China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Minghui Liu
- Department of Integrated Therapy, Fudan University Shanghai Cancer Center, #270, DongAn Road, Shanghai, People's Republic of China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Zhe Zhang
- Department of Integrated Therapy, Fudan University Shanghai Cancer Center, #270, DongAn Road, Shanghai, People's Republic of China.,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China
| | - Wenwu Cheng
- Department of Integrated Therapy, Fudan University Shanghai Cancer Center, #270, DongAn Road, Shanghai, People's Republic of China. .,Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, 200032, China.
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14
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Field RA, Fritz Z, Baker A, Grove A, Perkins GD. Systematic review of interventions to improve appropriate use and outcomes associated with do-not-attempt-cardiopulmonary-resuscitation decisions. Resuscitation 2014; 85:1418-31. [DOI: 10.1016/j.resuscitation.2014.08.024] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 08/03/2014] [Accepted: 08/16/2014] [Indexed: 11/15/2022]
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15
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A Unique Look at Ohio’s Do-Not-Resuscitate Law. Crit Care Med 2014; 42:2299-300. [DOI: 10.1097/ccm.0000000000000466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Wilson ME, Rhudy LM, Ballinger BA, Tescher AN, Pickering BW, Gajic O. Factors that contribute to physician variability in decisions to limit life support in the ICU: a qualitative study. Intensive Care Med 2013; 39:1009-18. [DOI: 10.1007/s00134-013-2896-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Accepted: 02/26/2013] [Indexed: 11/30/2022]
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