1
|
Iyer S, Sonawane RN, Shah J, Salins N. Semiotics of ICU Physicians' Views on End-of-life Care and Quality of Dying in a Critical Care Setting: A Qualitative Study. Indian J Crit Care Med 2024; 28:424-435. [PMID: 38738199 PMCID: PMC11080105 DOI: 10.5005/jp-journals-10071-24696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 03/22/2024] [Indexed: 05/14/2024] Open
Abstract
Background and aim While intensive care unit (ICU) mortality rates in India are higher when compared to countries with more resources, fewer patients with clinically futile conditions are subjected to limitation of life-sustaining treatments or given access to palliative care. Although a few surveys and audits have been conducted exploring this phenomenon, the qualitative perspectives of ICU physicians regarding end-of-life care (EOLC) and the quality of dying are yet to be explored. Methods There are 22 eligible consultant-level ICU physicians working in multidisciplinary ICUs were purposively recruited and interviewed. The study data was analyzed using reflexive thematic analysis (RTA) with a critical realist perspective, and the study findings were interpreted using the lens of the semiotic theory that facilitated the development of themes. Results About four themes were generated. Intensive care unit physicians perceived the quality of dying as respecting patients' and families' choices, fulfilling their needs, providing continued care beyond death, and ensuring family satisfaction. To achieve this, the EOLC process must encompass timely decision-making, communication, treatment guidelines, visitation rights, and trust-building. The contextual challenges were legal concerns, decision-making complexities, cost-related issues, and managing expectations. To improve care, ICU physicians suggested amplifying patient and family voices, building therapeutic relationships, mitigating conflicts, enhancing palliative care services, and training ICU providers in EOLC. Conclusion Effective management of critically ill patients with life-limiting illnesses in ICUs requires a holistic approach that considers the complex interplay between the EOLC process, its desired outcome, the quality of dying, care context, and the process of meaning-making by ICU physicians. How to cite this article Iyer S, Sonawane RN, Shah J, Salins N. Semiotics of ICU Physicians' Views on End-of-life Care and Quality of Dying in a Critical Care Setting: A Qualitative Study. Indian J Crit Care Med 2024;28(5):424-435.
Collapse
Affiliation(s)
- Shivakumar Iyer
- Department of Critical Care Medicine, Bharati Vidyapeeth Deemed University Medical College, Pune, Maharashtra, India
| | - Rutula N Sonawane
- Department of Critical Care Medicine, Bharati Vidyapeeth Deemed University Medical College, Pune, Maharashtra, India
| | - Jignesh Shah
- Department of Critical Care Medicine, Bharati Vidyapeeth Deemed University Medical College, Pune, Maharashtra, India
| | - Naveen Salins
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
| |
Collapse
|
2
|
Mani RK, Bhatnagar S, Butola S, Gursahani R, Mehta D, Simha S, Divatia JV, Kumar A, Iyer SK, Deodhar J, Bhat RS, Salins N, Thota RS, Mathur R, Iyer RK, Gupta S, Kulkarni P, Murugan S, Nasa P, Myatra SN. Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit. Indian J Crit Care Med 2024; 28:200-250. [PMID: 38477011 PMCID: PMC10926026 DOI: 10.5005/jp-journals-10071-24661] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 02/28/2024] [Indexed: 03/14/2024] Open
Abstract
End-of-life care (EOLC) exemplifies the joint mission of intensive and palliative care (PC) in their human-centeredness. The explosion of technological advances in medicine must be balanced with the culture of holistic care. Inevitably, it brings together the science and the art of medicine in their full expression. High-quality EOLC in the ICU is grounded in evidence, ethical principles, and professionalism within the framework of the Law. Expert professional statements over the last two decades in India were developed while the law was evolving. Recent landmark Supreme Court judgments have necessitated a review of the clinical pathway for EOLC outlined in the previous statements. Much empirical and interventional evidence has accumulated since the position statement in 2014. This iteration of the joint Indian Society of Critical Care Medicine-Indian Association of Palliative Care (ISCCM-IAPC) Position Statement for EOLC combines contemporary evidence, ethics, and law for decision support by the bedside in Indian ICUs. How to cite this article Mani RK, Bhatnagar S, Butola S, Gursahani R, Mehta D, Simha S, et al. Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit. Indian J Crit Care Med 2024;28(3):200-250.
Collapse
Affiliation(s)
- Raj K Mani
- Department of Critical Care and Pulmonology, Yashoda Super Specialty Hospital, Ghaziabad, Kaushambi, Uttar Pradesh, India
| | - Sushma Bhatnagar
- Department of Onco-Anaesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Savita Butola
- Department of Palliative Care, Border Security Force Sector Hospital, Panisagar, Tripura, India
| | - Roop Gursahani
- Department of Neurology, P. D. Hinduja National Hospital & Medical Research Centre, Mumbai, Maharashtra, India
| | - Dhvani Mehta
- Division of Health, Vidhi Centre for Legal Policy, New Delhi, India
| | - Srinagesh Simha
- Department of Palliative Care, Karunashraya, Bengaluru, Karnataka, India
| | - Jigeeshu V Divatia
- Department of Anaesthesia, Critical Care, and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Arun Kumar
- Department of Intensive Care, Medical Intensive Care Unit, Fortis Healthcare Ltd, Mohali, Punjab, India
| | - Shiva K Iyer
- Department of Critical Care, Bharati Vidyapeeth (Deemed to be University) Medical College, Pune, Maharashtra, India
| | - Jayita Deodhar
- Department Palliative Care, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Rajani S Bhat
- Department of Interventional Pulmonology and Palliative Medicine, SPARSH Hospitals, Bengaluru, Karnataka, India
| | - Naveen Salins
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Raghu S Thota
- Department Palliative Care, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Roli Mathur
- Department of Bioethics, Indian Council of Medical Research, Bengaluru, Karnataka, India
| | - Rajam K Iyer
- Department of Palliative Care, Bhatia Hospital; P. D. Hinduja National Hospital & Medical Research Centre, Mumbai, Maharashtra, India
| | - Sudeep Gupta
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | | | - Sangeetha Murugan
- Department of Education and Research, Karunashraya, Bengaluru, Karnataka, India
| | - Prashant Nasa
- Department of Critical Care Medicine, NMC Specialty Hospital, Dubai, United Arab Emirates
| | - Sheila N Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| |
Collapse
|
3
|
Georgakis S, Dragioti E, Gouva M, Papathanakos G, Koulouras V. The Complex Dynamics of Decision-Making at the End of Life in the Intensive Care Unit: A Systematic Review of Stakeholders' Views and Influential Factors. Cureus 2024; 16:e52912. [PMID: 38406151 PMCID: PMC10893775 DOI: 10.7759/cureus.52912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2024] [Indexed: 02/27/2024] Open
Abstract
A lack of consensus resulting in severe conflicts is often observed between the stakeholders regarding their respective roles in end-of-life (EOL) decision-making in the ICU. Since the burden of these decisions lies upon the individuals, their opinions must be known by medical, judicial, legislative, and governmental authorities. Part of the solution to the issues that arise would be to examine and understand the views of the people in different societies. Hence, in this systematic review, we assessed the attitudes of the physicians, nurses, families, and the general public toward who should be involved in decision-making and influencing factors. Toward this, we searched three electronic databases, i.e., PubMed, CINAHL (Cumulative Index to Nursing & Allied Health), and Embase. A matrix was developed, discussed, accepted, and used for data extraction by two independent investigators. Study quality was evaluated using the Newcastle-Ottawa Scale. Data were extracted by one researcher and double-checked by a second one, and any discrepancies were discussed with a third researcher. The data were analyzed descriptively and synthesized according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Thirty-three studies met our inclusion criteria. Most involved healthcare professionals and reported geographic variations in different timeframes. While paternalistic features have been observed, physicians overall showed an inclination toward collaborative decision-making. Correspondingly, the nursing staff, families, and the public are aligned toward patient and relatives' participation, with nurses expressing their own involvement as well. Six categories of influencing factors were identified, with high-impact factors, including demographics, fear of litigation, and regulation-related ones. Findings delineate three key points. Firstly, overall stakeholders' perspectives toward EOL decision-making in the ICU seem to be leaning toward a more collaborative decision-making direction. Secondly, to reduce conflicts and reach a consensus, multifaceted efforts are needed by both healthcare professionals and governmental/regulatory authorities. Finally, due to the multifactorial complexity of the subject, directly related to demographic and regulatory factors, these efforts should be more extensively sought at a regional level.
Collapse
Affiliation(s)
- Spiros Georgakis
- Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, GRC
| | - Elena Dragioti
- Research Laboratory Psychology of Patients, Families & Health Professionals, University of Ioannina, Ioannina, GRC
| | - Mary Gouva
- Research Laboratory Psychology of Patients, Families & Health Professionals, University of Ioannina, Ioannina, GRC
| | | | | |
Collapse
|
4
|
Mani RK, Simha S, Gursahani R. Simplified Legal Procedure for End-of-life Decisions in India: A New Dawn in the Care of the Dying? Indian J Crit Care Med 2023; 27:374-376. [PMID: 37214121 PMCID: PMC10196646 DOI: 10.5005/jp-journals-10071-24464] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 04/20/2023] [Indexed: 05/24/2023] Open
Abstract
Recent amendments to the onerous legal procedure laid down in the Landmark Supreme Court Judgment Common Cause vs The Union of India have aroused widespread interest. The new procedural guidelines of January 2023 appear workable and should ease ethical decision-making toward the end-of-life in India. This commentary provides the backdrop to the evolution of legal provisions for advance directives, withdrawal, and withholding decisions in terminal care. How to cite this article Mani RK, Simha S, Gursahani R. Simplified Legal Procedure for End-of-life Decisions in India: A New Dawn in the Care of the Dying? Indian J Crit Care Med 2023;27(5):374-376.
Collapse
Affiliation(s)
- Raj Kumar Mani
- Department of Critical Care and Pulmonology, Yashoda Super Specialty Hospital, Ghaziabad, Uttar Pradesh, India
| | - Srinagesh Simha
- Department of Critical Care and Pulmonology, Karunashraya– Bangalore Hospice Trust, Bengaluru, Karnataka, India
| | - Roopkumar Gursahani
- Department of Neurology, P.D. Hinduja National Hospital, Mumbai, Maharashtra, India
| |
Collapse
|
5
|
Advance Care Planning in Asia: A Systematic Narrative Review of Healthcare Professionals’ Knowledge, Attitude, and Experience. J Am Med Dir Assoc 2021; 22:349.e1-349.e28. [DOI: 10.1016/j.jamda.2020.12.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 12/09/2020] [Accepted: 12/09/2020] [Indexed: 11/18/2022]
|
6
|
Burman S, Garg R, Bhatnagar S, Mishra S, Kumar V, Bharati SJ, Gupta N. Awareness and Attitudes of Primary Caregivers toward End-of-Life Care in Advanced Cancer Patients: A Cross-Sectional Study. Indian J Palliat Care 2021; 27:126-132. [PMID: 34035630 PMCID: PMC8121228 DOI: 10.4103/ijpc.ijpc_226_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 10/09/2020] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Awareness of end-of-life care (EOLC) has been at grass root level in our country. The caregivers are clueless about the concept of comfort care and that terminally ill cancer patients need care at home rather than the paraphernalia of the hospital ward. The basic aim of the study was to assess the awareness of the EOLC in the caregivers of the advanced cancer patients. METHODS After Ethics Committee approval, this prospective cross-sectional observational study was conducted among primary caregivers of patients receiving palliative care for advanced cancer. The primary caregiver was identified and written informed consent was obtained. The questionnaire for assessing awareness and attitudes of primary caregivers toward EOLC in advanced cancer patients was prepared and validated. The standardized study questionnaire was completed by the primary caregiver assisted by the researcher. The categorical data were analyzed using Fisher's exact test and Chi-square tests. The intergroup correlation was done using the Chi-square and nonparametric tests. RESULTS The results showed that only mere 26% of caregivers were aware of the term palliative care. The female population was more knowledgeable about EOLC, with 68% of them willing to initiate the same. The rural population was more willing to adopt palliative care (47%) and was more receptive about discontinuing aggressive definitive therapy. CONCLUSION We conclude that the awareness about EOLC remains poor in caregiver if patients with advanced cancer in spite of good awareness of the disease. The consequences of the outcome of disease, EOLC understanding, futility for definitive care, acceptability, and understanding of palliative care lacked in most of the caregivers.
Collapse
Affiliation(s)
- Sourav Burman
- Department of Onco-Anaesthesia and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Garg
- Department of Onco-Anaesthesia and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, India
- Address for correspondence: Dr. Rakesh Garg, Room No 139, First Floor, Department of Onco-Anaesthesia and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029, India. E-mail:
| | - Sushma Bhatnagar
- Department of Onco-Anaesthesia and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Seema Mishra
- Department of Onco-Anaesthesia and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Vinod Kumar
- Department of Onco-Anaesthesia and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Sachidanand Jee Bharati
- Department of Onco-Anaesthesia and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, India
| | - Nishkarsh Gupta
- Department of Onco-Anaesthesia and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
7
|
Divatia JV, Chawla R, Kapadia F, Myatra SN, Rajagopalan R, Amin P, Khilnani P, Prayag S, Todi SK, Uttam R. Guidelines for end-of-life and palliative care in Indian intensive care to units: ISCCM consensus Ethical Position Statement. Indian J Crit Care Med 2020. [DOI: 10.5005/ijccm-17-s1-26] [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
|
8
|
Abstract
Divatia JV. End-of-life Care in the Intensive Care Unit: Better Late Than Never? Indian J Crit Care Med 2020;24(6):375-377.
Collapse
Affiliation(s)
- Jigeeshu V Divatia
- Department of Anesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| |
Collapse
|
9
|
Kulkarni AP, Zirpe KG, Dixit SB, Chaudhry D, Mehta Y, Mishra RC, Samavedam S, Munjal M. Development of critical care medicine in India. J Crit Care 2020; 56:188-196. [PMID: 31945585 DOI: 10.1016/j.jcrc.2019.11.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 11/19/2019] [Accepted: 11/25/2019] [Indexed: 12/29/2022]
Affiliation(s)
- Atul Prabhakar Kulkarni
- Division of Critical Care Medicine, Department of Anaesthesiology, Critical Care & Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Dr. Ernest Borges Road, Parel (E), Mumbai 400012, India.
| | | | | | - Dhruva Chaudhry
- Department of Pulmonary & Critical Care, Pt. B.D.S. University of Health Sciences, Rohtak, Haryana, India
| | - Yatin Mehta
- Medanta Institute of Critical Care and Anesthesiology, Medanta The Medicity, Sector-38, Gurgaon 122001, Haryana, India
| | | | | | - Manish Munjal
- Anaesthetist and Intensivist, Jigyasa Foundation, Jaipur, India
| | | |
Collapse
|
10
|
|
11
|
Salins N, Gursahani R, Mathur R, Iyer S, Macaden S, Simha N, Mani RK, Rajagopal MR. Definition of Terms Used in Limitation of Treatment and Providing Palliative Care at the End of Life: The Indian Council of Medical Research Commission Report. Indian J Crit Care Med 2018; 22:249-262. [PMID: 29743764 PMCID: PMC5930529 DOI: 10.4103/ijccm.ijccm_165_18] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Indian hospitals, in general, lack policies on the limitation of inappropriate life-sustaining interventions at the end of life. To facilitate discussion, preparation of guidelines and framing of laws, terminologies relating to the treatment limitation, and providing palliative care at the end-of-life care (EOLC) need to be defined and brought up to date. METHODOLOGY This consensus document on terminologies and definitions of terminologies was prepared under the aegis of the Indian Council of Medical Research. The consensus statement was created using Nominal Group and Delphi Method. RESULTS Twenty-five definitions related to the limitations of treatment and providing palliative care at the end of life were created by reviewing existing international documents and suitably modifying it to the Indian sociocultural context by achieving national consensus. Twenty-five terminologies defined within the scope of this document are (1) terminal illness, (2) actively dying, (3) life-sustaining treatment, (4) potentially inappropriate treatment, (5) cardiopulmonary resuscitation (CPR), (6) do not attempt CPR, (7) withholding life-sustaining treatment, (8) withdrawing life-sustaining treatment, (9) euthanasia (10) active shortening of the dying process, (11) physician-assisted suicide, (12) palliative care, (13) EOLC, (14) palliative sedation, (15) double effect, (16) death, (17) best interests, (18) health-care decision-making capacity, (19) shared decision-making, (20) advance directives, (21) surrogates, (22) autonomy, (23) beneficence, (24) nonmaleficence, and (25) justice.
Collapse
Affiliation(s)
- Naveen Salins
- Department of Palliative Medicine, Tata Memorial Centre, Mumbai, India
| | - Roop Gursahani
- Department of Neurology, P.D. Hinduja National Hospital, Mumbai, India
| | - Roli Mathur
- ICMR Bioethics Unit, National Centre for Disease Informatics and Research (Indian Council of Medical Research), Bengaluru, Karnataka, India
| | - Shivakumar Iyer
- Department of Critical Care Medicine, Bharati Vidyapeeth Medical College, Pune, Maharashtra, India
| | - Stanley Macaden
- Palliative Care Program of the Christian Medical Association of India, India
- Coordinator of the Palliative Care Program of Christian Medical Association of India and Honorary Palliative Medicine Consultant at Bangalore Baptist Hospital, Bengaluru, Karnataka, India
| | - Nagesh Simha
- Medical Director, Karunashraya Hospice, Bengaluru, Karnataka, India
| | - Raj Kumar Mani
- CEO and Chairman, Department of Critical Care, Pulmonology and Sleep Medicine, Nayati Medicity, Mathura, Uttar Pradesh, India
| | - M. R. Rajagopal
- Chairman of Pallium India and Director of Trivandrum Institute of Palliative Sciences, Pallium, India
- Trivandrum Institute of Palliative Sciences, Thiruvananthapuram, Kerala, India
| |
Collapse
|
12
|
Mani RK, Simha SN, Gursahani R. The Advance Directives and Foregoing of Life Support: Where do we Stand Now? Indian J Crit Care Med 2018; 22:135-137. [PMID: 29657368 PMCID: PMC5879853 DOI: 10.4103/ijccm.ijccm_116_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Raj Kumar Mani
- Department of Critical Care and Pulmonology, Nayati Medicity, Mathura, Uttar Pradesh, India
| | - Sri Nagesh Simha
- Department of Palliative Medicine, Karunashraya, Bengaluru, Karnataka, India
| | - Roop Gursahani
- Department of Neurology, P.D. Hinduja Hospital, Mumbai, Maharashtra, India
| |
Collapse
|
13
|
Sengupta J, Chatterjee SC. Dying in intensive care units of India: Commentaries on policies and position papers on palliative and end-of-life care. J Crit Care 2016; 39:11-17. [PMID: 28104546 DOI: 10.1016/j.jcrc.2016.12.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 10/07/2016] [Accepted: 12/18/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE This study critically examines the available policy guidelines on integration of palliative and end-of-life care in Indian intensive care units to appraise their congruence with Indian reality. MATERIALS AND METHODS Six position statements and guidelines issued by the Indian Society for Critical Care Medicine and the Indian Association of Palliative Care from 2005 till 2015 were examined. The present study reflects upon the recommendations suggested by these texts. RESULT Although the policy documents conform to the universally set norms of introducing palliative and end-of-life care in intensive care units, they hardly suit Indian reality. The study illustrates local complexities that are not addressed by the policy documents. This include difficulties faced by intensivists and physicians in arriving at a consensus decision, challenges in death prognostication, hurdles in providing compassionate care, providing "culture-specific" religious and spiritual care, barriers in effective communication, limitations of documenting end-of-life decisions, and ambiguities in defining modalities of palliative care. Moreover, the policy documents largely dismiss special needs of elderly patients. CONCLUSION The article suggests the need to reexamine policies in terms of their attainability and congruence with Indian reality.
Collapse
Affiliation(s)
- Jaydeep Sengupta
- Department of Humanities & Social Sciences, Indian Institute of Technology Kharagpur, West Bengal 721302, India.
| | - Suhita Chopra Chatterjee
- Department of Humanities & Social Sciences, Indian Institute of Technology Kharagpur, West Bengal 721302, India
| |
Collapse
|
14
|
Divatia JV, Amin PR, Ramakrishnan N, Kapadia FN, Todi S, Sahu S, Govil D, Chawla R, Kulkarni AP, Samavedam S, Jani CK, Rungta N, Samaddar DP, Mehta S, Venkataraman R, Hegde A, Bande BD, Dhanuka S, Singh V, Tewari R, Zirpe K, Sathe P. Intensive Care in India: The Indian Intensive Care Case Mix and Practice Patterns Study. Indian J Crit Care Med 2016; 20:216-25. [PMID: 27186054 PMCID: PMC4859158 DOI: 10.4103/0972-5229.180042] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Aims: To obtain information on organizational aspects, case mix and practices in Indian Intensive Care Units (ICUs). Patients and Methods: An observational, 4-day point prevalence study was performed between 2010 and 2011 in 4209 patients from 124 ICUs. ICU and patient characteristics, and interventions were recorded for 24 h of the study day, and outcomes till 30 days after the study day. Data were analyzed for 4038 adult patients from 120 ICUs. Results: On the study day, mean age, Acute Physiology and Chronic Health Evaluation (APACHE II) and sequential organ failure assessment (SOFA) scores were 54.1 ± 17.1 years, 17.4 ± 9.2 and 3.8 ± 3.6, respectively. About 46.4% patients had ≥1 organ failure. Nearly, 37% and 22.2% patients received mechanical ventilation (MV) and vasopressors or inotropes, respectively. Nearly, 12.2% patients developed an infection in the ICU. About 28.3% patients had severe sepsis or septic shock (SvSpSS) during their ICU stay. About 60.7% patients without infection received antibiotics. There were 546 deaths and 183 terminal discharges (TDs) from ICU (including left against medical advice or discharged on request), with ICU mortality 729/4038 (18.1%). In 1627 patients admitted within 24 h of the study day, the standardized mortality ratio was 0.67. The APACHE II and SOFA scores, public hospital ICUs, medical ICUs, inadequately equipped ICUs, medical admission, self-paying patient, presence of SvSpSS, acute respiratory failure or cancer, need for a fluid bolus, and MV were independent predictors of mortality. Conclusions: The high proportion of TDs and the association of public hospitals, self-paying patients, and inadequately equipped hospitals with mortality has important implications for critical care in India.
Collapse
Affiliation(s)
- Jigeeshu V Divatia
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Mumbai, India
| | - Pravin R Amin
- Department of Medicine and Critical Care, Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | | | - Farhad N Kapadia
- Department of Medicine and Critical Care, P D Hinduja National Hospital, Mumbai, India
| | - Subhash Todi
- Department of Critical Care Medicine, AMRI Hospitals Dhakuria, Kolkata, West Bengal, India
| | - Samir Sahu
- Department of Critical Care and Pulmonology, AMRI Hospitals, Bhubaneswar, Odisha, India
| | - Deepak Govil
- Institute of Anesthesia and Critical Care, Medanta The Medicity, Gurgaon, Haryana, India
| | - Rajesh Chawla
- Department of Pulmonary and Critical Care Medicine, Indraprastha Apollo Hospitals, New Delhi, India
| | - Atul P Kulkarni
- Division of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Mumbai, India
| | - Srinivas Samavedam
- Department of Critical Care Medicine, Century Super Speciality Hospital, Banjara Hills, Hyderabad, Telangana, India
| | - Charu K Jani
- Department of Critical Care Medicine, Saifee Hospital, Mumbai, India
| | - Narendra Rungta
- Department of Critical Care Medicine, Jeevan Rekha Critical Care and Trauma Hospital, Jaipur, Rajasthan, India
| | - Devi Prasad Samaddar
- Department of Anaesthesia and Critical Care, Tata Main Hospital, Jamshedpur, Jharkhand, India
| | - Sujata Mehta
- Department of Medicine and Critical Care, Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | - Ramesh Venkataraman
- Department of Critical Care Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
| | - Ashit Hegde
- Department of Medicine and Critical Care, P D Hinduja National Hospital, Mumbai, India
| | - B D Bande
- Department of Critical Care, KEM Hospital, Pune, Maharashtra, India
| | - Sanjay Dhanuka
- Department of Critical Care Medicine, Greater Kailash Hospital, Indore, Madhya Pradesh, India
| | - Virendra Singh
- Department of Pulmonology, Asthma Bhawan, Jaipur, Rajasthan, India
| | - Reshma Tewari
- Department of Critical Care Medicine, Artemis Health Institute, Gurgaon, Haryana, India
| | - Kapil Zirpe
- Department of Critical Care Medicine, Ruby Hall Clinic, Pune, Maharashtra, India
| | - Prachee Sathe
- Department of Critical Care Medicine, Ruby Hall Clinic, Pune, Maharashtra, India
| | | |
Collapse
|
15
|
Withholding and withdrawal of life-sustaining treatments in low-middle-income versus high-income Asian countries and regions. Intensive Care Med 2016; 42:1118-27. [DOI: 10.1007/s00134-016-4347-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 03/30/2016] [Indexed: 10/22/2022]
|
16
|
Mani RK. Constitutional and Legal Protection for Life Support Limitation in India. Indian J Palliat Care 2015; 21:258-61. [PMID: 26600691 PMCID: PMC4617030 DOI: 10.4103/0973-1075.164903] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Appropriate treatment limitations towards the end of life to reduce unwanted burdens require ethical clarity that is supported by appropriate legislation. The lack of knowledge of enabling legal provisions, physicians feel vulnerable to legal misinterpretation of treatment limiting decisions. In India the lack of societal awareness, inadequate exploration of the gray areas of bio-ethics and unambiguous legal position relating to terminal illness have resulted in poor quality end of life care. Much of the perceived vulnerability by the physician is attributable to insufficient knowledge and understanding of existing constitutional and legal position in India. While we await informed legal and legislative opinion, this paper highlights possible legal liabilities arising from treatment limitation decisions with available defense. It is hoped that such clarity would lead to more confident ethical decisions and improved end of life care for patients.
Collapse
Affiliation(s)
- R K Mani
- Department of Critical Care, Pulmonology and Sleep Medicine, Nayati Healthcare and Research Pvt. Ltd, DLF Corporate Park, Gurgaon, Haryana, India
| |
Collapse
|
17
|
Medical decision making for older adults: an international perspective comparing the United States and India. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2015; 12:329-34. [PMID: 26346983 PMCID: PMC4554781 DOI: 10.11909/j.issn.1671-5411.2015.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 07/03/2015] [Accepted: 07/03/2015] [Indexed: 12/02/2022]
Abstract
There has been a significant decline in cardiovascular morbidity and mortality amidst pervasive advances in care, including percutaneous revascularization, mechanical circulatory support, and transcatheter valvular therapies. While advancing therapies may add significant longevity, they also bring about new end-of-life decision-making challenges for patients and their families who also must weigh the advantages of reduced mortality to the possibility of longer lives consisting of high morbidity, frailty, pain, and poor quality of living. Advance care entails options of withholding or withdrawing therapies, and has become a familiar part of cardiovascular care for older patients in Western countries. However, as advanced cardiovascular practices extend to developing countries, the interrelated concept of advance care is rarely straight forward as it is affected by local cultural traditions and mores, and can lead to very different inferences and use. This paper discusses the concepts of advance care planning, surrogate decision-making, orders for resuscitation and futility in patients with cardiac disease with comparisons of West to East, focusing particularly on the United States versus India.
Collapse
|
18
|
Salins NS. Author′s Reply. Indian J Crit Care Med 2015. [DOI: 10.5005/ijccm-19-4-240] [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
|
19
|
Mani RK, Myatra SN, Salins NS. Author's Reply. Indian J Crit Care Med 2015; 19:240-1. [PMID: 25878436 PMCID: PMC4397635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Raj Kumar Mani
- Department of Critical Care and Pulmonology, Nayati Healthcare Pvt. Ltd., Gurgaon, Haryana, India,Correspondence: Dr. R. K. Mani, Critical Care and Pulmonology, Nayati Healthcare Pvt. Ltd., Gurgaon, Haryana, India. E-mail:
| | - Sheila Nainan Myatra
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Naveen S Salins
- Department of Palliative Medicine, Tata Memorial Centre, Parel, Mumbai, Maharashtra, India
| |
Collapse
|
20
|
Myatra SN, Salins N, Iyer S, Macaden SC, Divatia JV, Muckaden M, Kulkarni P, Simha S, Mani RK. End-of-life care policy: An integrated care plan for the dying: A Joint Position Statement of the Indian Society of Critical Care Medicine (ISCCM) and the Indian Association of Palliative Care (IAPC). Indian J Crit Care Med 2014; 18:615-35. [PMID: 25249748 PMCID: PMC4166879 DOI: 10.4103/0972-5229.140155] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
PURPOSE The purpose was to develop an end-of-life care (EOLC) policy for patients who are dying with an advanced life limiting illness and to develop practical procedural guidelines for limiting inappropriate therapeutic medical interventions and improve the quality of care of the dying within an ethical framework and through a professional and family/patient consensus process. EVIDENCE The Indian Society of Critical Care Medicine (ISCCM) published its first guidelines on EOLC in 2005 [1] which was later revised in 2012.[2] Since these publications, there has been an exponential increase in empirical information and discussion on the subject. The literature reviewed observational studies, surveys, randomized controlled studies, as well as guidelines and recommendations, for education and quality improvement published across the world. The search terms were: EOLC; do not resuscitate directives; withdrawal and withholding; intensive care; terminal care; medical futility; ethical issues; palliative care; EOLC in India; cultural variations. Indian Association of Palliative Care (IAPC) also recently published its consensus position statement on EOLC policy for the dying.[3]. METHOD An expert committee of members of the ISCCM and IAPC was formed to make a joint EOLC policy for the dying patients. Proposals from the chair were discussed, debated, and recommendations were formulated through a consensus process. The members extensively reviewed national and international established ethical principles and current procedural practices. This joint EOLC policy has incorporated the sociocultural, ethical, and legal perspectives, while taking into account the needs and situation unique to India.
Collapse
Affiliation(s)
- Sheila Nainan Myatra
- From: Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Pune, Maharashtra, India
| | - Naveen Salins
- Department of Palliative Medicine, Tata Memorial Hospital, Pune, Maharashtra, India
| | - Shivakumar Iyer
- Department of Critical Care, Bharati Vidyapeeth, University Medical College, Pune, Maharashtra, India
| | - Stanley C. Macaden
- Palliative Care Program of Christian Medical Association of India, Bangalore, Karnataka, India
| | - Jigeeshu V. Divatia
- From: Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Pune, Maharashtra, India
| | - Maryann Muckaden
- Department of Palliative Medicine, Tata Memorial Hospital, Pune, Maharashtra, India
| | | | | | - Raj Kumar Mani
- Department of Pulmonology, Critical Care and Sleep Medicine, Saket City Hospital, New Delhi, India
| |
Collapse
|
21
|
Macaden SC, Salins N, Muckaden M, Kulkarni P, Joad A, Nirabhawane V, Simha S. End of life care policy for the dying: consensus position statement of Indian association of palliative care. Indian J Palliat Care 2014; 20:171-81. [PMID: 25191002 PMCID: PMC4154162 DOI: 10.4103/0973-1075.138384] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
PURPOSE To develop an End of Life Care (EOLC) Policy for patients who are dying with an advanced life limiting illness. To improve the quality of care of the dying by limiting unnecessary therapeutic medical interventions, providing access to trained palliative care providers, ensuring availability of essential medications for pain and symptom control and improving awareness of EOLC issues through education initiatives. EVIDENCE A review of Country reports, observational studies and key surveys demonstrates that EOLC in India is delivered ineffectively, with a majority of the Indian population dying with no access to palliative care at end of life and essential medications for pain and symptom control. Limited awareness of EOLC among public and health care providers, lack of EOLC education, absent EOLC policy and ambiguous legal standpoint are some of the major barriers in effective EOLC delivery. RECOMMENDATIONS Access to receive good palliative and EOLC is a human right. All patients are entitled to a dignified death. Government of India (GOI) to take urgent steps towards a legislation supporting good EOLC, and all hospitals and health care institutions to have a working EOLC policyProviding a comprehensive care process that minimizes physical and non physical symptoms in the end of life phase and ensuring access to essential medications for pain and symptom controlPalliative care and EOLC to be part of all hospital and community/home based programsStandards of palliative and EOLC as established by appropriate authorities and Indian Association of Palliative Care (IAPC) met and standards accredited and monitored by national and international accreditation bodiesAll health care providers with direct patient contact are urged to undergo EOLC certification, and EOLC training should be incorporated into the curriculum of health care education.
Collapse
Affiliation(s)
- Stanley C Macaden
- Palliative Medicine Consultant, National Coordinator, Palliative Care Program of Christian Medical Association of India, India
| | - Naveen Salins
- Associate Editor, Consultant, Department of Palliative Medicine, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Maryann Muckaden
- Associate Editor, Consultant, Department of Palliative Medicine, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | | | - Anjum Joad
- Department of Palliative Medicine, Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan, India
| | - Vivek Nirabhawane
- Palliative Medicine Specialist, Cipla Palliative Care and Training Centre, Pune, Maharashtra, India
| | - Srinagesh Simha
- Medical Director, Karunashraya Hospice, Bangalore, Karnataka, India
| |
Collapse
|
22
|
Butola S. Inappropriate referrals at the end of life--the existing Indian scenario. Support Care Cancer 2014; 22:2219-22. [PMID: 24664357 DOI: 10.1007/s00520-014-2214-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 03/09/2014] [Indexed: 01/06/2023]
Abstract
The Economist Intelligence Unit has ranked India's end-of-life care last out of 40 countries. The lack of orientation towards palliative care, poor communication skills, a disease-focused, curative approach and the unending battle against death-all lead to unrealistic hope in patients and their families. Inappropriate referrals at the end of life are common and result in a lot of avoidable suffering for both the patients and their families. Propagation of clear guidelines to limit inappropriate therapeutic interventions and referrals in patients with limited prognosis is the need of the hour. Awareness, sensitization, education and training in palliative care are urgently required to change attitudes. This would go a long way in mitigating the misery for both the dying and their carers.
Collapse
Affiliation(s)
- Savita Butola
- Composite Hospital, Border Security Force, GT Road, Jalandhar Cantt, Punjab, India,
| |
Collapse
|
23
|
Ramalingam VS, Saeed F, Sinnakirouchenan R, Holley JL, Srinivasan S. End-of-life care beliefs among Hindu physicians in the United States. Am J Hosp Palliat Care 2013; 32:8-14. [PMID: 24052431 DOI: 10.1177/1049909113505138] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Several studies from the United States and Europe showed that physicians' religiosity is associated with their approach to end-of-life care beliefs. No such studies have focused exclusively on Hindu physicians practicing in the United States. A 34-item questionnaire was sent to 293 Hindu physicians in the United States. Most participants believed that their religious beliefs do not influence their practice of medicine and do not interfere with withdrawal of life support. The US practice of discussing end-of-life issues with the patient, rather than primarily with the family, seems to have been adopted by Hindu physicians practicing in the United States. It is likely that the ethical, cultural, and patient-centered environment of US health care has influenced the practice of end-of-life care by Hindu physicians in this country.
Collapse
Affiliation(s)
| | - Fahad Saeed
- Division of Nephrology, Dartmouth Hitchcock Medical Center, Hanover, NH, USA
| | | | - Jean L Holley
- Department of Medicine, University of Illinois, Urbana-Champaign and Carle Physician Group, Urbana, IL, USA
| | | |
Collapse
|
24
|
Goel A, Chhabra G, Weijma R, Solari M, Thornton S, Achondo B, Pruthi S, Gupta V, Kalantri SP, Ramavat AS, Kalra OP. End-of-Life Care Attitudes, Values, and Practices Among Health Care Workers. Am J Hosp Palliat Care 2013; 31:139-47. [DOI: 10.1177/1049909113479440] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Introduction: This study aims to ascertain attitudes of health care workers on end-of-life care (EOLC) issues and to highlight the disparity that exists in countries with different backgrounds. Methods: It is a cross-sectional questionnaire survey across heterogeneous health care providers in India, Chile, the United Kingdom, and the Netherlands using an indigenously prepared questionnaire considering regional variations, covering different areas of EOLC. Results: Of the 109 participants, 68 (62.4%) felt that cardiopulmonary resuscitation should be done selectively, 25 (22.9%) had come in contact with at least 1 patient who had asked them to hasten death, and 36 (33%) felt that training was insufficient to prepare them for skills in issues of EOLC. Conclusion: To avoid cumbersome through well-meant interventions, it is important that the caregiving team is aware of the patient’s own wishes with respect to EOLC issues.
Collapse
Affiliation(s)
- Ashish Goel
- University College of Medical Sciences, Delhi, India
| | | | - Robyn Weijma
- VU University Medical Centre, Amsterdam, the Netherlands
| | - Marla Solari
- Centro de Salud Familiar, Fundacion Cristo Vive, Recoleta, Santiago, Chile
| | - Sarah Thornton
- Department of Anaesthesia, Royal Bolton Hospital, Bolton , United Kingdom
| | - Bernardita Achondo
- Centro de Salud Familiar, Fundacion Cristo Vive, Recoleta, Santiago, Chile
| | - Sonal Pruthi
- University College of Medical Sciences, Delhi, India
| | - Vineet Gupta
- University of Pittsburgh Medical Center (UPMC) Mercy, Pittsburgh, PA, USA
| | - S. P. Kalantri
- Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra, India
| | - Anurag S. Ramavat
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - O. P. Kalra
- University College of Medical Sciences, Delhi, India
| |
Collapse
|
25
|
Mani RK, Amin P, Chawla R, Divatia JV, Kapadia F, Khilnani P, Myatra SN, Prayag S, Rajagopalan R, Todi SK, Uttam R. Guidelines for end-of-life and palliative care in Indian intensive care units' ISCCM consensus Ethical Position Statement. Indian J Crit Care Med 2012. [PMID: 23188961 PMCID: PMC3506078 DOI: 10.4103/0972-5229.102112] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- R K Mani
- Committee for the Development of Guidelines for limiting life-prolonging interventions and providing palliative care towards the end-of-life: Indian Society of Critical Care Medicine
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Datta R, Chaturvedi R, Rudra A, Jaideep CN. End of life issues in the intensive care units. Med J Armed Forces India 2012; 69:48-53. [PMID: 24532934 DOI: 10.1016/j.mjafi.2012.03.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2010] [Accepted: 03/23/2012] [Indexed: 11/16/2022] Open
Abstract
A structured discussion of End-of-Life (EOL) issues is a relatively new phenomenon in India. Personal beliefs, cultural and religious influences, peer, family and societal pressures affect EOL decisions. Indian law does not provide sanction to contentious issues such as do-not-resuscitate (DNR) orders, living wills, and euthanasia. Finally, published data on EOL decisions in Indian ICUs is lacking. What is needed is a prospective determination of which patients will benefit from aggressive management and life-support. A consensus regarding the concept of Medical Futility is necessary to give impetus to further discussion on more advanced policies including ideas such as Managed Care to restrict unnecessary health care costs, euthanasia, the principle of withhold and/or withdraw, ethical and moral guidelines that would govern decisions regarding futile treatment, informed consent to EOL decisions and do-not-resuscitate orders. This review examines the above concepts as practiced worldwide and looks at some landmark judgments that have shaped current Indian policy, as well as raising talking points for possible legislative intervention in the field.
Collapse
Affiliation(s)
- Rashmi Datta
- Senior Advisor, Anaesthesiology, Army Hospital (R&R), New Delhi, India
| | - R Chaturvedi
- Dean & Deputy Commandant, CH (AF), Bangalore 560 007, India
| | - A Rudra
- Commanding Officer, 408 Field Hospital, C/o 56 APO, India
| | - C N Jaideep
- Associate Professor, Anaesthesiology, AFMC, Pune 40, India
| |
Collapse
|
27
|
Adolph MD, Frier KA, Stawicki SP, Gerlach AT, Papadimos TJ. Palliative critical care in the intensive care unit: A 2011 perspective. Int J Crit Illn Inj Sci 2012; 1:147-53. [PMID: 22229140 PMCID: PMC3249848 DOI: 10.4103/2229-5151.84803] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Pain relief and palliative care play an increasingly important role in the overall approach to critically ill and injured patients. Despite significant progress in clinical patient care, our understanding of death and the dying process remains limited. For various reasons, people tend to delay facing questions associated with end-of-life, and the fear of the unknown often creates an environment of avoidance and an atmosphere of taboo. The topic of end-of-life care is multifaceted. It incorporates medical, ethical, spiritual, and religious aspects, among many others. Our ability to sustain the lives of the critically ill may be complicated by continuing life support in medically futile scenarios. This article, as well as the remainder of the IJCIIS Symposium on End-of-Life in Trauma/Intensive Care Unit, will explore the most important issues in the field of modern end-of-life care and palliative medicine, with a focus on critically ill and injured patients.
Collapse
Affiliation(s)
- Michael D Adolph
- Center for Palliative Care, The James Cancer Hospital and Solove Research Institute, The Ohio State University Medical Center, Columbus, OH USA
| | | | | | | | | |
Collapse
|
28
|
Aldawood AS, Alsultan M, Arabi YM, Baharoon SA, Al-Qahtani S, Al-Qahtani M, Haddad SH, Al-Dorzi HM, Al-Jahdali H, Jahdali HA, Alatassi A, Rishu AH. End-of-life practices in a tertiary intensive care unit in Saudi Arabia. Anaesth Intensive Care 2012; 40:137-41. [PMID: 22313074 DOI: 10.1177/0310057x1204000116] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Our aim was to evaluate end-of-life practices in a tertiary intensive care unit in Saudi Arabia. A prospective observational study was conducted in the medical-surgical intensive care unit of a teaching hospital in Riyadh, Saudi Arabia. Over the course of the one-year study period, 176 patients died and 77% of these deaths were preceded by end-of-life decisions. Of these, 66% made do-not-resuscitate decisions, 30% decided to withhold life support and 4% withdrew life support. These decisions were made after a median time of four days (Q1 to Q3: 1 to 9) and at least one day before death (Q1 to Q3: 1 to 4). The patients' families or surrogates were informed for 88% of the decisions and all decisions were documented in the patients' medical records. Despite religious and cultural values, more than three-quarters of the patients whose deaths were preceded by end-of-life decisions gave do-not-resuscitate decisions before death. These decisions should be made early in the patients' stay in the intensive care unit.
Collapse
Affiliation(s)
- Abdulaziz S Aldawood
- Department of Intensive Care Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Salins NS, Pai SG, Vidyasagar M, Sobhana M. Ethics and medico legal aspects of "not for resuscitation". Indian J Palliat Care 2011; 16:66-9. [PMID: 21811350 PMCID: PMC3144433 DOI: 10.4103/0973-1075.68404] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Not for resuscitation in India still remains an abstract concept with no clear guidelines or legal frame work. Cardiopulmonary resuscitation is a complex medical intervention which is often used inappropriately in hospitalized patients and usually guided by medical decision making rather than patient-directed choices. Patient autonomy still remains a weak concept and relatives are expected to make this big decision in a short time and at a time of great emotional distress. This article outlines concepts around ethics and medico legal aspects of not for resuscitation, especially in Indian setting.
Collapse
Affiliation(s)
- Naveen Sulakshan Salins
- Palliative Medicine Consultant, Palliative Medicine Unit, Departments of Radiotherapy and Oncology, Shiridi SaiBaba Cancer Hospital and Research Centre, KMC Manipal, Manipal University 576104, India
| | | | | | | |
Collapse
|
30
|
Mani RK, Mandal AK, Bal S, Javeri Y, Kumar R, Nama DK, Pandey P, Rawat T, Singh N, Tewari H, Uttam R. End-of-life decisions in an Indian intensive care unit. Intensive Care Med 2009; 35:1713-9. [PMID: 19568731 DOI: 10.1007/s00134-009-1561-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2008] [Accepted: 06/06/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND There is a paucity of data on end-of-life decisions (EOLD) for patients in Indian intensive care units (ICUs). OBJECTIVE To document the end-of-life and full-support (FS) decisions among patients dying in an ICU, to compare the respective patient characteristics and to describe the process of decision-making. DESIGN Retrospective, observational. PATIENTS Consecutive patients admitted to a 12-bed closed medical-surgical ICU. EXCLUSIONS Patients with EOLD discharged home or transferred to another hospital. MEASUREMENTS AND RESULTS Demographic profile, APACHE IV at 24 h, ICU outcome, type of limitation, disease category, pre-admission functional status, reasons for EOLD, interventions and therapies within 3 days of death, time to EOLD, time to death after EOLD and ICU length of stay. Out of 88 deaths among 830 admissions, 49% were preceded by EOLD. Of these 58% had withholding of treatment, 35% had do-not-resuscitate orders (DNR) and 7% had a withdrawal decision. Mean age and APACHE IV scores were similar between EOLD and FS groups. Functional dependence before hospitalization favored EOLD. Patients receiving EOLD as opposed to FS had longer stays. Fifty-three percent of limitations were decided during the first week of ICU stay well before the time of death. Escalation of therapy within 3 days of death was less frequent in the EOLD group. CONCLUSIONS Despite societal and legal barriers, half the patients dying in the ICU received a decision to limit therapy mostly as withholding or DNR orders. These decisions evolved early in the course of stay and resulted in significant reduction of therapeutic burdens.
Collapse
Affiliation(s)
- Raj Kumar Mani
- Pulmonology-Thoracic Surgery and MICU, Fortis Flt. Lt. Rajan Dhall Hospital, B-1, Aruna Asif Ali Marg, Vasant Kunj, New Delhi, 110070, India.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|