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Wyckoff MH, Wyllie J, Aziz K, de Almeida MF, Fabres J, Fawke J, Guinsburg R, Hosono S, Isayama T, Kapadia VS, Kim HS, Liley HG, McKinlay CJD, Mildenhall L, Perlman JM, Rabi Y, Roehr CC, Schmölzer GM, Szyld E, Trevisanuto D, Velaphi S, Weiner GM. Neonatal Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2020; 142:S185-S221. [PMID: 33084392 DOI: 10.1161/cir.0000000000000895] [Citation(s) in RCA: 154] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for neonatal life support includes evidence from 7 systematic reviews, 3 scoping reviews, and 12 evidence updates. The Neonatal Life Support Task Force generally determined by consensus the type of evidence evaluation to perform; the topics for the evidence updates followed consultation with International Liaison Committee on Resuscitation member resuscitation councils. The 2020 CoSTRs for neonatal life support are published either as new statements or, if appropriate, reiterations of existing statements when the task force found they remained valid. Evidence review topics of particular interest include the use of suction in the presence of both clear and meconium-stained amniotic fluid, sustained inflations for initiation of positive-pressure ventilation, initial oxygen concentrations for initiation of resuscitation in both preterm and term infants, use of epinephrine (adrenaline) when ventilation and compressions fail to stabilize the newborn infant, appropriate routes of drug delivery during resuscitation, and consideration of when it is appropriate to redirect resuscitation efforts after significant efforts have failed. All sections of the Neonatal Resuscitation Algorithm are addressed, from preparation through to postresuscitation care. This document now forms the basis for ongoing evidence evaluation and reevaluation, which will be triggered as further evidence is published. Over 140 million babies are born annually worldwide (https://ourworldindata.org/grapher/births-and-deaths-projected-to-2100). If up to 5% receive positive-pressure ventilation, this evidence evaluation is relevant to more than 7 million newborn infants every year. However, in terms of early care of the newborn infant, some of the topics addressed are relevant to every single baby born.
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Maconochie IK, Aickin R, Hazinski MF, Atkins DL, Bingham R, Couto TB, Guerguerian AM, Nadkarni VM, Ng KC, Nuthall GA, Ong GYK, Reis AG, Schexnayder SM, Scholefield BR, Tijssen JA, Nolan JP, Morley PT, Van de Voorde P, Zaritsky AL, de Caen AR. Pediatric Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2020; 142:S140-S184. [PMID: 33084393 DOI: 10.1161/cir.0000000000000894] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
This 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations (CoSTR) for pediatric life support is based on the most extensive evidence evaluation ever performed by the Pediatric Life Support Task Force. Three types of evidence evaluation were used in this review: systematic reviews, scoping reviews, and evidence updates. Per agreement with the evidence evaluation recommendations of the International Liaison Committee on Resuscitation, only systematic reviews could result in a new or revised treatment recommendation. Systematic reviews performed for this 2020 CoSTR for pediatric life support included the topics of sequencing of airway-breaths-compressions versus compressions-airway-breaths in the delivery of pediatric basic life support, the initial timing and dose intervals for epinephrine administration during resuscitation, and the targets for oxygen and carbon dioxide levels in pediatric patients after return of spontaneous circulation. The most controversial topics included the initial timing and dose intervals of epinephrine administration (new treatment recommendations were made) and the administration of fluid for infants and children with septic shock (this latter topic was evaluated by evidence update). All evidence reviews identified the paucity of pediatric data and the need for more research involving resuscitation of infants and children.
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Nolan JP, Maconochie I, Soar J, Olasveengen TM, Greif R, Wyckoff MH, Singletary EM, Aickin R, Berg KM, Mancini ME, Bhanji F, Wyllie J, Zideman D, Neumar RW, Perkins GD, Castrén M, Morley PT, Montgomery WH, Nadkarni VM, Billi JE, Merchant RM, de Caen A, Escalante-Kanashiro R, Kloeck D, Wang TL, Hazinski MF. Executive Summary: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2020; 142:S2-S27. [PMID: 33084397 DOI: 10.1161/cir.0000000000000890] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Daddato AE, Griff M, Shanbhag P, Hickman SE, Lum HD. Appropriate Use of Physician Orders for Life-Sustaining Treatment in the Outpatient Setting. J Palliat Med 2020; 23:449-450. [PMID: 32216694 DOI: 10.1089/jpm.2019.0635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Andrea E Daddato
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Megan Griff
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Prajakta Shanbhag
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Susan E Hickman
- Indiana University Center for Aging Research, Regenstrief Institute, Inc., and Indiana University School of Nursing, Indianapolis, Indiana
| | - Hillary D Lum
- Division of Geriatric Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
- Veterans Affairs Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, Colorado
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Tark A, Agarwal M, Dick AW, Stone PW. Variations in Physician Orders for Life-Sustaining Treatment Program across the Nation: Environmental Scan. J Palliat Med 2019; 22:1032-1038. [PMID: 30789297 PMCID: PMC6735313 DOI: 10.1089/jpm.2018.0626] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2018] [Indexed: 11/13/2022] Open
Abstract
Background: Physician Orders for Life-Sustaining Treatment (POLST) is an advance care planning tool that is designed to document end-of-life (EoL) care wishes of those living with limited life expectancies. Although positive impacts of POLST program has been studied, variations in state-specific POLST programs across the nation remain unknown. Objective: Identify state variations in POLST forms and determine if variations are associated with program maturity status. Design: Environmental scan. Measurements: Using the national POLST website, state-specific POLST program characteristics were examined. With available sample POLST forms, EoL care options were abstracted. Results: Of all 51 states (50 United States states and Washington, D.C examined), the majority (n = 48, 98%) were actively participating in POLST; 3 states (5.9%) had Mature status, 19 states and District of Columbia (39.2%) were Endorsed, 24 states were in the developing phase (47.1%), and 4 states (7.8%) were nonconforming. Forty-five states (88.2%) had forms available for review. Antibiotic and intravenous fluid options were identified in 32 (71.1%), and 33 (73.3%) POLST forms, respectively. Hospital transfer and use of oxygen were mentioned in all forms. Use of respiratory devices (i.e., continuous positive airway pressure and bi-level positive airway pressure) were mentioned on 27 (60%) forms, whereas ventilator or intubation use were mentioned in 36 POLST forms (80%). No associations were found between POLST maturity status and provision of treatment options. Conclusions: Variations in integration of infection and symptom management options were identified. Further research is needed to determine if there are regional factors associated with provision of treatment options on POLST forms and if there are differences in actual rates of infection or symptoms reported.
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Affiliation(s)
- Aluem Tark
- Center for Health Policy and Center for Improving Palliative Care for Vulnerable Adults with Multiple Chronic Conditions, Columbia University School of Nursing, New York, New York
| | - Mansi Agarwal
- Center for Health Policy and Center for Improving Palliative Care for Vulnerable Adults with Multiple Chronic Conditions, Columbia University School of Nursing, New York, New York
| | | | - Patricia W. Stone
- Center for Health Policy and Center for Improving Palliative Care for Vulnerable Adults with Multiple Chronic Conditions, Columbia University School of Nursing, New York, New York
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Abstract
Withdrawing and withholding life-support therapy in patients who are unlikely to survive despite treatment are common practices in intensive care units (ICUs). The literature suggests there is a large variation in practice between different ICUs in different parts of the world. We conducted a postal survey among all public ICUs in New Zealand to investigate the pattern of practice in withholding and withdrawal of therapy. Nineteen ICUs responded to this survey and they represented 74% of all the public ICU beds and 83% of the annual ICU admissions. The percentage of ICU admissions with therapy withdrawn or withheld was less than 10% in most ICUs. Only a small percentage (21%) of ICUs had a formal policy in withholding and withdrawal of therapy. The timing of making the decision to withhold or withdraw therapy was very variable. The patient and/or the family, the primary medical team consultant, two or more ICU consultants, and ICU nurses were usually involved in the decision making process. ICU nurses were more commonly involved in the decision making process in smaller ICUs (5 beds vs 10 beds, P=0.03). The patient's pre-ICU quality of life, medical comorbidities, predicted mortality, predicted post-ICU quality of life, and the family's wishes were important factors in deciding whether ICU therapy would be withheld or withdrawn. Hospice ward or the patient's home was the preferred place for palliative care in 32% of the responses.
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Affiliation(s)
- K M Ho
- Department of Anaesthesia and Intensive Care, North Shore Hospital, Auckland 1309, New Zealand
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Abstract
Prehospital use of ventilators by emergency medical services (EMS) during 911 calls is increasing. This study described the impact of prehospital mechanical ventilation on prehospital time intervals and on mortality.This retrospective matched-cohort study used 4 consecutive public releases of the US National Emergency Medical Services Information System dataset (2011-2014). EMS activations with recorded ventilator use were randomly matched with activations without ventilator use (1 to 1) on age (range ± 2 years), gender, provider's primary impression, urbanicity, and level of service.A total of 5740 EMS activations were included (2870 patients per group). Patients in the ventilator group had a mean age of 69.1 (±17.3) years with 49.4% males, similar to the non-ventilator group. Activations were mostly in urban settings (83.8%) with an advanced life support level of care (94.5%). Respiratory distress (77.8%) and cardiac arrest (6.8%) were the most common provider's primary impressions. Continuous positive airway pressure was the most common mode of ventilation used (79.2%).Mortality was higher at hospital discharge (29.0% vs 21.1%, P = .01) but not at emergency department (ED) discharge (8.4% vs 7.4%, P = .19) with prehospital ventilator use. Both total on-scene time and total prehospital time intervals increased with reported ventilator use (4.10 minutes (95% confidence interval [CI]: 2.71-5.49) and 3.59 minutes (95% CI: 3.04-4.14), respectively).Ventilator use by EMS agencies in 911 calls in the US is associated with higher prehospital time intervals without observed impact on survival to ED discharge. More EMS outcome research is needed to provide evidence-based prehospital care guidelines and targeted resource utilization.
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Affiliation(s)
- Mazen J. El Sayed
- Department of Emergency Medicine
- Emergency Medical Services and Prehospital Care Program
| | - Hani Tamim
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | | | - N. Clay Mann
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
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Abstract
Patients with prolonged or rapidly recurring convulsions lasting more than 5 min should be considered to be in status epilepticus (SE) and receive immediate resuscitation. Although there are few randomized clinical trials, available evidence and experience suggest that early and aggressive treatment of SE improves patient outcomes, for which reason this was chosen as an Emergency Neurological Life Support protocol. The current approach to the emergency treatment of SE emphasizes rapid initiation of adequate doses of first line therapy, as well as accelerated second line anticonvulsant drugs and induced coma when these fail, coupled with admission to a unit capable of neurological critical care and electroencephalography monitoring. This protocol will focus on the initial treatment of SE but also review subsequent steps in the protocol once the patient is hospitalized.
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Affiliation(s)
- Jan Claassen
- Division of Critical Care Neurology, Columbia University College of Physicians and Surgeons, New York, NY, USA.
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
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Abstract
Cardiac arrest is the most common cause of death in North America. An organized bundle of neurocritical care interventions can improve chances of survival and neurological recovery in patients who are successfully resuscitated from cardiac arrest. Therefore, resuscitation following cardiac arrest was chosen as an Emergency Neurological Life Support protocol. Key aspects of successful early post-arrest management include: prevention of secondary brain injury; identification of treatable causes of arrest in need of emergent intervention; and, delayed neurological prognostication. Secondary brain injury can be attenuated through targeted temperature management (TTM), avoidance of hypoxia and hypotension, avoidance of hyperoxia, hyperventilation or hypoventilation, and treatment of seizures. Most patients remaining comatose after resuscitation from cardiac arrest should undergo TTM. Treatable precipitants of arrest that require emergent intervention include, but are not limited to, acute coronary syndrome, intracranial hemorrhage, pulmonary embolism and major trauma. Accurate neurological prognostication is generally not appropriate for several days after cardiac arrest, so early aggressive care should never be limited based on perceived poor neurological prognosis.
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Affiliation(s)
- Jonathan Elmer
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Iroquois Building, Suite 400A, 3600 Forbes Avenue, Pittsburgh, PA, 15213, USA.
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Kees H Polderman
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Abstract
The appropriate use of medications during Emergency Neurological Life Support (ENLS) is essential to optimize patient care. Important considerations when choosing the appropriate agent include the patient's organ function and medication allergies, potential adverse drug effects, drug interactions and critical illness and aging pathophysiologic changes. Critical medications used during ENLS include hyperosmolar therapy, anticonvulsants, antithrombotics, anticoagulant reversal and hemostatic agents, anti-shivering agents, neuromuscular blockers, antihypertensive agents, sedatives, vasopressors and inotropes, and antimicrobials. This article focuses on the important pharmacokinetic and pharmacodynamics characteristics, advantages and disadvantages and clinical pearls of these therapies, providing practitioners with essential drug information to optimize pharmacotherapy in acutely ill neurocritical care patients.
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Affiliation(s)
- Gretchen M Brophy
- Departments of Pharmacotherapy and Outcomes Science and Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA.
| | - Theresa Human
- Department of Clinical Pharmacy, Barnes-Jewish Hospital, Washington University in St. Louis, St. Louis, MO, USA
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Krammel M, Schnaubelt S, Weidenauer D, Winnisch M, Steininger M, Eichelter J, Hamp T, van Tulder R, Sulzgruber P. Gender and age-specific aspects of awareness and knowledge in basic life support. PLoS One 2018; 13:e0198918. [PMID: 29894491 PMCID: PMC5997304 DOI: 10.1371/journal.pone.0198918] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 05/29/2018] [Indexed: 11/26/2022] Open
Abstract
Background The ‘chain of survival’—including early call for help, early cardiopulmonary resuscitation (CPR) and early defibrillation—represents the most beneficial approach for favourable patient outcome after out-of-hospital cardiac arrest (OHCA). Despite increasing numbers of publicly accessible automated external defibrillators (AED) and interventions to increase public awareness for basic life support (BLS), the number of their use in real-life emergency situations remains low. Methods In this prospective population-based cross-sectional study, a total of 501 registered inhabitants of Vienna (Austria) were randomly approached via telephone calls between 08/2014 and 09/2014 and invited to answer a standardized questionnaire in order to identify public knowledge and awareness of BLS and AED-use. Results We found that more than 52 percent of participants would presume OHCA correctly and would properly initiate BLS attempts. Of alarming importance, only 33 percent reported that they would be willing to perform CPR and 50 percent would use an AED device. There was a significantly lower willingness to initiate BLS attempts (male: 40% vs. female: 25%; OR: 2.03 [95%CI: 1.39–2.98]; p<0.001) and to use an AED device (male: 58% vs. female: 44%; OR: 1.76 [95%CI: 1.26–2.53]; p = 0.002) in questioned female individuals compared to their male counterparts. Interestingly, we observed a strongly decreasing level of knowledge and willingness for BLS attempts (-14%; OR: 0.72 [95%CI: 0.57–0.92]; p = 0.027) and AED-use (-19%; OR: 0.68 [95%CI: 0.54–0.85]; p = 0.001) with increasing age. Conclusion We found an overall poor knowledge and awareness concerning BLS and the use of AEDs among the Viennese population. Both female and elderly participants reported the lowest willingness to perform BLS and use an AED in case of OHCA. Specially tailored programs to increase awareness and willingness among both the female and elderly community need to be considered for future educational interventions.
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Affiliation(s)
- Mario Krammel
- Department of Anesthesiology, Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
- Emergency Medical Service Vienna, Vienna, Austria
- Austrian Cardiac Arrest Awareness Association – PULS, Vienna, Austria
| | - Sebastian Schnaubelt
- Austrian Cardiac Arrest Awareness Association – PULS, Vienna, Austria
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - David Weidenauer
- Austrian Cardiac Arrest Awareness Association – PULS, Vienna, Austria
- Department of Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Markus Winnisch
- Austrian Cardiac Arrest Awareness Association – PULS, Vienna, Austria
- Department of Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Matthias Steininger
- Austrian Cardiac Arrest Awareness Association – PULS, Vienna, Austria
- Department of Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Jakob Eichelter
- Department of Anesthesiology, Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
- Austrian Cardiac Arrest Awareness Association – PULS, Vienna, Austria
| | - Thomas Hamp
- Emergency Medical Service Vienna, Vienna, Austria
- Austrian Cardiac Arrest Awareness Association – PULS, Vienna, Austria
| | - Raphael van Tulder
- Austrian Cardiac Arrest Awareness Association – PULS, Vienna, Austria
- Department of Internal Medicine I, Division of Cardiology, Karl Landsteiner University of Health Sciences, Krems, Austria
| | - Patrick Sulzgruber
- Austrian Cardiac Arrest Awareness Association – PULS, Vienna, Austria
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
- * E-mail:
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12
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Wade DT. Using best interests meetings for people in a prolonged disorder of consciousness to improve clinical and ethical management. J Med Ethics 2018; 44:336-342. [PMID: 28912289 DOI: 10.1136/medethics-2017-104244] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 07/14/2017] [Accepted: 07/18/2017] [Indexed: 06/07/2023]
Abstract
Current management of people with prolonged disorders of consciousness is failing patients, families and society. The causes include a general lack of concern, knowledge and expertise; a legal and professional framework which impedes timely and appropriate decision-making and/or enactment of the decision; and the exclusive focus on the patient, with no legitimate means to consider the broader consequences of healthcare decisions. This article argues that a clinical pathway based on the principles of (a) the English Mental Capacity Act 2005 and (b) using time-limited treatment trials could greatly improve patient management and reduce stress on families. There needs to be early and continuing use of formal best interests meetings, starting between 7 and 21 days after onset of unconsciousness (from any cause, including progressive disorders). The treatment options need to evolve as the clinical state and prognosis becomes more certain. A formal discussion of treatment withdrawal should occur when the upper bound of predicted recovery falls below a level the patient would have considered acceptable, and it should always be discussed when the condition is considered permanent. Any decision to stop treatment should be contingent on a formal second opinion from an independent expert who should review the clinical situation and expected prognosis, but not the best interests decision. The article also asks how, if at all, the adverse effects on the family and the resource implications of long-term care of people left in a prolonged state of unconsciousness should be incorporated in the process.
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Collier J, Kelsberg G, Safranek S. Clinical Inquiries: How well do POLST forms assure that patients get the end-of-life care they requested? J Fam Pract 2018; 67:249-251. [PMID: 29614148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Quite well, for cardiopulmonary resuscitation (CPR). Most patients (91%-100%) who select "do not resuscitate" (DNR) on their physician's orders for life-sustaining treatment (POLST) forms are allowed a natural death without attempted CPR across a variety of settings (community, skilled nursing facilities, emergency medical services, and hospice). Few patients (6%) who select "comfort measures only" die in the hospital, whereas more (22%) who choose "limited interventions," and still more (34%) without a POLST form, die in the hospital (strength of recommendation [SOR]: B, large, consistent cross-sectional and cohort studies).
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Affiliation(s)
- Jordan Collier
- Valley Family Medicine Residency, Renton, Washington, USA
| | - Gary Kelsberg
- Valley Family Medicine Residency, Renton, Washington, USA
| | - Sarah Safranek
- University of Washington Health Sciences Library, Seattle, USA
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Paris JJ, Ahluwalia J, Cummings BM, Moreland MP, Wilkinson DJ. The Charlie Gard case: British and American approaches to court resolution of disputes over medical decisions. J Perinatol 2017; 37:1268-1271. [PMID: 29048408 PMCID: PMC5712473 DOI: 10.1038/jp.2017.138] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 06/29/2017] [Indexed: 02/03/2023]
Affiliation(s)
- J J Paris
- Department of Bioethics, Boston College, Chestnut Hill, MA, USA
- Campion Hall, Oxford University, Oxford, UK
| | | | - B M Cummings
- Department of Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | - M P Moreland
- Villanova University School of Law, Villanova, PA, USA
| | - D J Wilkinson
- John Radcliffe Hospital, Oxford, UK
- Oxford Uehiro Center for Practical Ethics, University of Oxford, Oxford, UK
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Chawla LS, Terek M, Junker C, Akst S, Yoon B, Brasha-Mitchell E, Seneff MG. Characterization of end-of-life electroencephalographic surges in critically ill patients. Death Stud 2017; 41:385-392. [PMID: 28145850 DOI: 10.1080/07481187.2017.1287138] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Neuromonitoring devices to assess level of sedation are now used commonly in many hospital settings. The authors previously reported that electroencephalicgraphic (EEG) spikes frequently occurred after the time of death in patients being neuromonitored at the time of cessation of circulation. In addition to the initial report, end-of-life electrical surges (ELES) have been subsequently documented in animal and human studies by other investigators. The frequency, character, intensity, and significance of ELES are unknown. Some have proposed that patients should not be declared dead for purposes of organ donation prior to the occurrence of an ELES. If clinical practice were altered to await the presence of an ELES, there could be detrimental consequences to donated organs and their recipients. To better characterize ELES, the authors retrospectively assessed the frequency and nature of ELES in serial patients. To better document ELES, they collected neuromonitoring, demographic, and clinical data on consecutive patients who expired while being actively monitored as part of their standard palliative care. These data were retrospectively collected when available as a convenience sample. The authors assessed 35 patients of which 7 were clinically confirmed as brain dead. None of the brain-dead patients displayed an ELES. Thirteen of the 28 remaining patients (46.4%) exhibited an ELES. The ELES observed were demonstrated to have high frequency EEG signal. The mean peak amplitude of ELES as measured by Patient State IndexTM (PSI) was 58.5 ± 25.7. In this preliminary assessment, the authors found that ELES are common in critically ill patients who succumb. The exact cause and significance of ELES remain unknown; further study is warranted.
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Affiliation(s)
- Lakhmir S Chawla
- a Department of Medicine, Division of Intensive Care Medicine , Veterans Affairs Medical Center , Washington , DC , USA
- b Department of Medicine, Division of Nephrology , Veterans Affairs Medical Center , Washington , DC , USA
- c Department of Anesthesiology and Critical Care Medicine , George Washington University Medical Center , Washington , DC , USA
| | - Megan Terek
- c Department of Anesthesiology and Critical Care Medicine , George Washington University Medical Center , Washington , DC , USA
| | - Christopher Junker
- c Department of Anesthesiology and Critical Care Medicine , George Washington University Medical Center , Washington , DC , USA
| | - Seth Akst
- c Department of Anesthesiology and Critical Care Medicine , George Washington University Medical Center , Washington , DC , USA
| | - Bona Yoon
- a Department of Medicine, Division of Intensive Care Medicine , Veterans Affairs Medical Center , Washington , DC , USA
| | - Ermira Brasha-Mitchell
- c Department of Anesthesiology and Critical Care Medicine , George Washington University Medical Center , Washington , DC , USA
| | - Michael G Seneff
- c Department of Anesthesiology and Critical Care Medicine , George Washington University Medical Center , Washington , DC , USA
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Beck S, Ruhnke B, Issleib M, Daubmann A, Harendza S, Zöllner C. Analyses of inter-rater reliability between professionals, medical students and trained school children as assessors of basic life support skills. BMC Med Educ 2016; 16:263. [PMID: 27717352 PMCID: PMC5054623 DOI: 10.1186/s12909-016-0788-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 09/30/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND Training of lay-rescuers is essential to improve survival-rates after cardiac arrest. Multiple campaigns emphasise the importance of basic life support (BLS) training for school children. Trainings require a valid assessment to give feedback to school children and to compare the outcomes of different training formats. Considering these requirements, we developed an assessment of BLS skills using MiniAnne and tested the inter-rater reliability between professionals, medical students and trained school children as assessors. METHODS Fifteen professional assessors, 10 medical students and 111-trained school children (peers) assessed 1087 school children at the end of a CPR-training event using the new assessment format. Analyses of inter-rater reliability (intraclass correlation coefficient; ICC) were performed. RESULTS Overall inter-rater reliability of the summative assessment was high (ICC = 0.84, 95 %-CI: 0.84 to 0.86, n = 889). The number of comparisons between peer-peer assessors (n = 303), peer-professional assessors (n = 339), and peer-student assessors (n = 191) was adequate to demonstrate high inter-rater reliability between peer- and professional-assessors (ICC: 0.76), peer- and student-assessors (ICC: 0.88) and peer- and other peer-assessors (ICC: 0.91). Systematic variation in rating of specific items was observed for three items between professional- and peer-assessors. CONCLUSION Using this assessment and integrating peers and medical students as assessors gives the opportunity to assess hands-on skills of school children with high reliability.
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Affiliation(s)
- Stefanie Beck
- Department of Anaesthesiology, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Bjarne Ruhnke
- The Medical Faculty of the University Hamburg, Martinistr. 52, 20246 Hamburg, Germany
| | - Malte Issleib
- Department of Anaesthesiology, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Anne Daubmann
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Sigrid Harendza
- Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
| | - Christian Zöllner
- Department of Anaesthesiology, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246 Hamburg, Germany
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17
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Abstract
The complex care of the organ donor during preparation for organ removal and provision of the best organs for transplantation is often the responsibility of the organ procurement coordinator. To assist in that process the following clinical problem-based guidelines have been developed. A standard order set is recommended to initiate treatment and to provide a continuing laboratory database. As clinical concerns arise from that database, past medical history, or ongoing donor care, section of these guidelines may serve as references for specific interventions. Physician consultation and collaboration with other bedside care providers are encouraged throughout.
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Affiliation(s)
- David J Powner
- Vivian L. Smith Center for Neurologic Research, University of Texas Health Science Center at Houston, Tex, USA
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18
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Richmond NJ. Mountain Climbing: Finding a path for EMS. JEMS 2016; 41:63. [PMID: 29185690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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19
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Affiliation(s)
- Karen Jean Craig-Brangan
- Karen Jean Craig-Brangan is an AHA training center manager for Temple University Health System in Philadelphia, Pa., and owner/president and CEO of EMS Educational Services in Cheltenham, Pa. Mary Patricia Day is a certified registered nurse anesthetist at Temple University Hospital in Philadelphia, Pa
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20
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Maudet L, Carron PN, Trueb L. [Cardiopulmonary resuscitation: the essential of 2015 guidelines]. Rev Med Suisse 2016; 12:313-317. [PMID: 27039445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Cardiopulmonary resuscitation (CPR) guidelines have been updated in October 2015. The 2010 guidelines are reaffirmed: immediate call for help via the local dispatch center, high quality CPR (frequency between 100 and 120/min, compression depth between 5 and 6 cm) and early defibrillation improve patient's survival chances. This article reviews the essential elements of resuscitation and recommended advanced measures.
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21
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Affiliation(s)
- Karen Jean Craig-Brangan
- Karen Jean Craig-Brangan is owner/president and CEO of EMS Educational Services, Inc., in Cheltenham, Pa., and AHA training center manager, Temple University Health System, Philadelphia, Pa. Mary Patricia Day is a certified registered nurse anesthetist at Temple University Hospital in Philadelphia, Pa
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22
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Affiliation(s)
- Kendra A Moore
- Perelman School of Medicine, University of Pennsylvania, Philadelphia2Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, University of Pennsylvania, Philadelphia
| | - Emily B Rubin
- Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, University of Pennsylvania, Philadelphia3Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia
| | - Scott D Halpern
- Fostering Improvement in End-of-Life Decision Science (FIELDS) Program, University of Pennsylvania, Philadelphia3Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia
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23
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Abstract
Mastery learning is a powerful educational strategy in which learners gain knowledge and skills that are rigorously measured against predetermined mastery standards with different learners needing variable time to reach uniform outcomes. Central to mastery learning are repetitive deliberate practice and robust feedback that promote performance improvement. Traditional health care simulation involves a simulation exercise followed by a facilitated postevent debriefing in which learners discuss what went well and what they should do differently next time, usually without additional opportunities to apply the specific new knowledge. Mastery learning approaches enable learners to "try again" until they master the skill in question. Despite the growing body of health care simulation literature documenting the efficacy of mastery learning models, to date insufficient details have been reported on how to design and implement the feedback and debriefing components of deliberate-practice-based educational interventions. Using simulation-based training for adult and pediatric advanced life support as case studies, this article focuses on how to prepare learners for feedback and debriefing by establishing a supportive yet challenging learning environment; how to implement educational interventions that maximize opportunities for deliberate practice with feedback and reflection during debriefing; describing the role of within-event debriefing or "microdebriefing" (i.e., during a pause in the simulation scenario or during ongoing case management without interruption), as a strategy to promote performance improvement; and highlighting directions for future research in feedback and debriefing for mastery learning.
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Affiliation(s)
- Walter J Eppich
- W.J. Eppich is associate professor of pediatrics and medical education, Northwestern University Feinberg School of Medicine, Chicago, Illinois. E.A. Hunt is associate professor of anesthesiology and critical care medicine and of health science informatics and pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland. J.M. Duval-Arnould is instructor of anesthesiology and critical care medicine and of health sciences informatics, Johns Hopkins University School of Medicine, Baltimore, Maryland. V.J. Siddall is simulation clinical educator and research assistant, Stritch School of Medicine, Loyola University, Maywood, Illinois. A. Cheng is associate professor of pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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24
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Chirac A, David G, Rieg N, Schott-Pethelaz AM, Bohe J, Carpentier F, Jacob X, Rhondali W, Filbet M. [Development of a tool for withholding and withdrawing life-sustaining treatment in the emergency room]. Ann Fr Anesth Reanim 2014; 33:555-62. [PMID: 25450728 DOI: 10.1016/j.annfar.2014.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 09/08/2014] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Active treatment withholding and withdrawing decisions in the emergency room (ER) must be taken collegially according to ethical and juridical statements. Specific tools can support this process and our main goal was to create and validate such a tool. METHOD We created a first version of a tool to help for treatment withholding and withdrawing decisions inspired by similar documents from literature. Every item of this tool was then assessed by a group of experts (ER physicians and nurses) using the Delphi method to reach a consensus. RESULTS Thirty-four experts from eleven ER (academic, regional centre) were included and participate to the first round and twenty-seven to the second round. From the eighty-two-item tool, sixty-five items reach a consensus during these two rounds and were kept to constitute the final version of the tool. CONCLUSION We have been able to create a tool to help for treatment withholding and withdrawing decisions adapted to the guidelines for end of life patient's management in the ER. This tool has been validated using a Delphi method by a group of experts from different centres. This multicentre validation will help for the diffusion and use of this tool in the different ER of the Rhône-Alpes region.
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Affiliation(s)
- A Chirac
- Centre de soins palliatifs Pavillon 1K, CHU de Lyon-Sud, hospices civils de Lyon, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite cedex, France; Institut de psychologie, université de Lyon 2, 69500 Bron, France
| | - G David
- Structure des urgences du CHU de Grenoble, 38700 La Tronche, France
| | - N Rieg
- Structure des urgences du CHU de Lyon-Sud, 69495 Pierre-Bénite cedex, France
| | - A-M Schott-Pethelaz
- Information médicale évaluation recherche, hospices civils de Lyon, Lyon, France
| | - J Bohe
- Service de réanimation médicale, CHU de Lyon-Sud, hospices civils de Lyon, 69495 Pierre-Bénite cedex, France
| | - F Carpentier
- Structure des urgences du CHU de Grenoble, 38700 La Tronche, France
| | - X Jacob
- Structure des urgences du CHU de Lyon-Sud, 69495 Pierre-Bénite cedex, France
| | - W Rhondali
- Centre de soins palliatifs Pavillon 1K, CHU de Lyon-Sud, hospices civils de Lyon, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite cedex, France
| | - M Filbet
- Centre de soins palliatifs Pavillon 1K, CHU de Lyon-Sud, hospices civils de Lyon, 165, chemin du Grand-Revoyet, 69495 Pierre-Bénite cedex, France.
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25
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26
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Wolf SM. What Adrienne knew: living bioethics. Hastings Cent Rep 2014; 44:17-9. [PMID: 24634042 DOI: 10.1002/hast.282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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27
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Janeczek M, Rice C, Aitchison R, Aitchison P, Wang E, Kharasch M. Pediatric resuscitation guidelines. Dis Mon 2013; 59:182-95. [PMID: 23642272 DOI: 10.1016/j.disamonth.2013.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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29
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Abstract
Sepsis is a serious worldwide health care condition that is associated with high mortality rates, despite improvements in the ability to manage infection. New guidelines for the management of sepsis were recently released that advocate for implementation of care based on evidence-based practice for both adult and pediatric patients. Critical care nurses are directly involved in the assessment of patients at risk for developing sepsis and in the treatment of patients with sepsis and can, therefore, affect outcomes for critically ill patients. Nurses' knowledge of the recommendations in the new guidelines can help to ensure that patients with sepsis receive therapies that are based on the latest scientific evidence. This article presents an overview of new evidence-based recommendations for the treatment of adult patients with sepsis, highlighting the role of critical care nurses.
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30
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Abstract
Nearly all global mortality in children younger than 5 years (99%) occurs in developing countries. The leading causes of mortality in children younger than 5 years worldwide, pneumonia and diarrhoeal illness, account for 1·396 and 0·801 million annual deaths, respectively. Although important advances in prevention are being made, advanced life support management in children in developing countries is often incomplete because of limited resources. Existing advanced life support management guidelines for children in limited-resource settings are mainly empirical, rather than evidence-based, written for the hospital setting, not standardised with a systematic approach to patient assessment and categorisation of illness, and taught in current paediatric advanced life support training courses from the perspective of full-resource settings. In this Review, we focus on extension of higher quality emergency and critical care services to children in developing countries. When integrated into existing primary care programmes, simple inexpensive advanced life support management can improve child survival worldwide.
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Affiliation(s)
- Mark E Ralston
- Department of Pediatrics, Naval Hospital, Oak Harbor, WA 98278, USA
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31
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Helft PR. To reduce futile care, build trust. Oncology (Williston Park) 2012; 26:993. [PMID: 23176015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Paul R Helft
- The Charles Warren Fairbanks Center for Medical Ethics at Indiana University Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
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32
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Scheunemann LP, Arnold RM, White DB. The facilitated values history: helping surrogates make authentic decisions for incapacitated patients with advanced illness. Am J Respir Crit Care Med 2012; 186:480-6. [PMID: 22822020 PMCID: PMC3480534 DOI: 10.1164/rccm.201204-0710cp] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Accepted: 07/07/2012] [Indexed: 11/16/2022] Open
Abstract
Many patients who develop incapacitating illness have not expressed clear treatment preferences. Therefore, surrogate decision makers are asked to make judgments about what treatment pathway is most consistent with the patient's values. Surrogates often struggle with such decisions. The difficulty arises because answering the seemingly straightforward question, "What do you think the patient would choose?" is emotionally, cognitively, and morally complex. There is little guidance for clinicians to assist families in constructing an authentic picture of the patient's values and applying them to medical decisions, in part because current models of medical decision making treat the surrogate as the expert on the patient's values and the physician as the expert on technical medical considerations. However, many surrogates need assistance in identifying and working through the sometimes conflicting values relevant to medical decisions near the end of life. We present a framework for clinicians to help surrogates overcome the emotional, cognitive, and moral barriers to high-quality surrogate decision making for incapacitated patients.
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Affiliation(s)
- Leslie P Scheunemann
- Division of Geriatric Medicine and Center for Aging and Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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33
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Abstract
AbstractIt has been stated that the Franco-German Emergency Medical Services System (FGS) has considerable drawbacks compared to the Anglo-American Emergency Medical Services System (AAS):1. The key differences between the AAS and the FGS are that in the AAS, the patients is brought to the doctor, while in the FGS, the doctor is brought to the patient.2. In the FGS, patients with urgent conditions usually are evaluated and treated by general practitioners in their offices or at the patient`s home; initially, very few approach an emergency department.3. Emergency patients with life-threatening trauma or disease are treated by emergency physicians at the scene and during transport. Paramedics often are first to arrive at the scene, and until the emergency physician arrives at the scene, are allowed to defibrillate, to intubate endotracheal-ly, and to administer life-saving drugs (epinephrine endotracheally, glucose intravenously, etc.).4. Prehospital emergency physicians treat patients at the scene and during transport.5. Emergency patients are guaranteed to be reached by an appropriate emergency vehicle and a respective crew within 10 minutes in 80% of the responses and within 15 minutes in 95% of cases.6. The FGS deploys qualified emergency physicians assisted by qualified paramedics as prehospital intensive care providers; extended immediate care is standard. Total Prehospital Times (TPT) and scene times only are minimally longer than in the AAS.7. Emergency Medicine is recognized as a supra-specialty to the base specialties. Specific training programs exist for emergency physicians, medical directors of emergency medical services systems (EMSS), and chief emergency physicians (CEP).8. Resuscitation attempts are carried out not only by anesthesiologists, but also by internists, surgeons, pediatricians, etc. Emergency medicine encompasses cardiopulmonary resuscitation (CPR) and shock cases, and patients with an acute myocardial infarction, stroke, poly-trauma, status asthmaticus, etc. Emergency patients are admitted directly to emergency departments of the hospitals, which, depending upon the size of the hospital.9. The incidence of life-threatening trauma victims has decreased to <10% in the FGS. Of a total of 830,000 deaths/year, fatal trauma cases ranked the lowest at 4%.10. Survival figures on cardiac arrest (asystole, ventricular fibrillation/ventricular tachycardia (VF/VT), pulseless electrical activity (PEA), etc.) reported in the German EMSS correspond to those in Europe and the United States.11. Paramedic training is characterized by a two-year program followed by a theoretical and a practical examination.12. Paramedics and emergency physicians-in-training are supervised at the scene and during transport. Quality assurance (Q/A) constitutes an integral and legally compulsory part of the EMSS.13. In the majority of cases, the emergency patients are evaluated and treated by the respective specialties without delays caused by patient transfer to other hospitals.14. The FGS does not require a greater number of ambulances and/or personnel than does the AAS.15. The German healthcare system creates less expenses/ capita than the does the U.S. system at a similar level of quality of care.16. Emergency procedures are carried out by anesthesiologists, emergency physicians, surgeons, internists, and other specialists.
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Affiliation(s)
- Wolfgang F Dick
- Clinic of Anesthesiology-University Hospital, Mainz, Germany.
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34
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Chong NK. Newborn and paediatric resuscitation 2011 guidelines. Singapore Med J 2011; 52:560-572. [PMID: 21879213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
We present the revised guidelines for newborn and paediatric resuscitation for Singapore. The 2010 International Liaison Committee on Resuscitation consensus on science as well as the main recommendations from the European Resuscitation Council and American Heart Association were debated and discussed. The final recommendations for the Singapore National Resuscitation Council were derived after carefully reviewing the current available evidence in the literature and balancing the local clinical climate of practice. In addition, much effort was spent on aligning the paediatric and neonatal recommendations with the adult (especially Basic Cardiac Life Support) recommendations.
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35
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Craig KJ, Day MP. Are you up to date on the latest BLS and ACLS guidelines? Nursing 2011; 41:40-44. [PMID: 21487275 DOI: 10.1097/01.nurse.0000395207.72990.df] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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36
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Hori S. [New evidences in the 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care with Treatment Recommendations]. Nihon Rinsho 2011; 69:605-611. [PMID: 21591411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Key changes in Guideline 2010 by Japanese Resuscitation Council were described and the reasons of the change were explained based on 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care with Treatment Recommendations. In BLS, the value of chest compression was further emphasized and it became an initial skill of CPR In ALS, post resuscitation care was systemized by incorporating hypothermia, PCI, and other diagnostic and therapeutic modalities. Indication of hypothermia was further expanded to non-VF categories. Use of AED was expanded to infant. Education, Implementation and Teams were newly included as a chapter to promote the knowledge and skill of resuscitation science into the society.
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Affiliation(s)
- Shingo Hori
- Emergency and Critical Care Medicine, Keio University, School of Medicine
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37
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Kaneko I. [Advanced cardiovascular life support in AHA Guidelines 2010: Key changes from Guidelines 2005]. Nihon Rinsho 2011; 69:623-629. [PMID: 21591414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
In cardiopulmonary cerebral resuscitation (CPCR), advanced cardiovascular life support(ACLS) is a part of "chain of survival" and effects on resuscitation outcome as the interventions which increase the likehood of ROSC and as the continuing step to the post -cardiac arrest care. In order to build effective ACLS intervention, quality of basic life support is essential throughout the resuscitation effort. Based on quality CPR, ACLS providers should optimize the outcome by the integrated strategy that is consist of appropriate "drug therapy", qualified"advanced airway management", and accurate "physiologic monitoring". In this article, ACLS in American Heart Association(AHA) 2010 guidelines was reviewed and key changes from the 2005 guidelines are extracted. Not only guideline itself but training designed on the valid recommendations of guidelines are important to achieve competency of ACLS teams and better outcome of resuscitation.
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Affiliation(s)
- Ichiro Kaneko
- Kyoto Medical Center, National Hospital Organization
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38
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Muguruma T. [Pediatric advanced life support]. Nihon Rinsho 2011; 69:630-637. [PMID: 21591415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Important changes or points of emphasis in the recommendations for pediatric advanced life support are as follows. In infants and children with no signs of life, healthcare providers should begin CPR unless they can definitely palpate a pulse within 10 seconds. New evidence documents the important role of ventilations in CPR for infants and children. Rescuers should provide conventional CPR for in-hospital and out-of-hospital pediatric cardiac arrests. The initial defibrillation energy dose of 2 to 4J/kg of either monophasic or biphasic waveform. Both cuffed and uncuffed tracheal tubes are acceptable for infants and children undergoing emergency intubation. Monitoring capnography/capnometry is recommended to confirm proper endotracheal tube position.
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Affiliation(s)
- Takashi Muguruma
- Division of Acute and Critical Care, National Center for Child Health and Development
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39
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Morita K. [Pediatric basic life support]. Nihon Rinsho 2011; 69:618-622. [PMID: 21591413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The new international consensus and guidelines were published by American Heart Association in October 2010. These guidelines include many important changes in pediatric basic life support(BLS) based on many evidences. Especially in children, asphyxial cardiac arrest has been more common than cardiac arrest and only one third to one half victims can receive bystander cardiopulmonary resuscitation(CPR). According to new guidelines, "CAB" (Chest compressions/Circulation, Airway, and Breathing/ventilation) is recommended instead of "ABC" sequence. In addition, pediatric chain of survival is revised and the section of "Look, Listen, Feel" is deleted. These changes are recommended in order to simplify training with the hope that more pediatric victims will consequently receive bystander CPR.
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Affiliation(s)
- Kouji Morita
- Department of Pediatrics, Showa University School of Medicine
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40
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Abstract
Some older individuals lack sufficient present cognitive and/or emotional ability to make and express autonomous decisions personally. In those situations, health-care providers routinely turn to available formal or informal surrogates who often must apply the best interests standard in making decisions for the incapacitated person. This article contends that defining the best interests standard of surrogate decision-making for older adults in terms of optimal or ideal choices (truly the patient's "best" interests) frequently sets out an unrealizable goal for surrogates to satisfy. Instead, a decision-making standard based on the incapacitated person's "therapeutic" interests is more realistic and hence more honest to adopt and apply from legal, ethical, and medical perspectives.
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Affiliation(s)
- Marshall B Kapp
- Center for Innovative Collaboration in Medicine & Law, Florida State University, 1115 W Call St, Ste 2350-F, Tallahassee, FL 32306-4300, USA.
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41
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Dreyer A, Førde R, Nortvedt P. Life-prolonging treatment in nursing homes: how do physicians and nurses describe and justify their own practice? J Med Ethics 2010; 36:396-400. [PMID: 20558436 DOI: 10.1136/jme.2010.036244] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
BACKGROUND Making the right decisions, while simultaneously showing respect for patient autonomy, represents a great challenge to nursing home staff in the issues of life-prolonging treatment, hydration, nutrition and hospitalisation to dying patents in end-of-life. OBJECTIVES To study how physicians and nurses protect nursing home patients' autonomy in end-of-life decisions, and how they justify their practice. DESIGN A qualitative descriptive design with analysis of the content of transcribed in-depth interviews with physicians and nurses. PARTICIPANTS Nine physicians and ten nurses in 10 nursing homes in Norway. RESULTS AND INTERPRETATIONS Assessment of the patient's competence to consent to treatment is almost absent. The physicians build their practice on the principles of beneficence and nonmaleficence. Nurses tend to trust the patients' rejection of life support, even when the patients have difficulty speaking or suffer from dementia. Relatives were, according to the health personnel, included in decision-making processes to a very limited extent. However, futile life support is sometimes provided contrary to the physicians' judgement of what constitutes the patient's best interest on occasions when they are pressurised by next of kin. CONCLUSIONS The study reveals a need to improve decision-making routines according to ethical ideals and legislation. Conflicts between relatives and healthcare professionals in the decision-making process deflect the focus from searching for the best possible treatment for the terminal patient. Further discussion is required as to whether the concept of autonomy is applicable in situations in which the patient is impaired and dying.
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Affiliation(s)
- A Dreyer
- Department of General Practice and Community Medicine, Aalesund University College/Section for Medical Ethics, University of Oslo, Bredelia 8, Aalesund 6018, Norway.
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43
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Moratti S. Management of conflicts with the parents over administration of life-prolonging treatment in Dutch NICUs. Med Law 2010; 29:289-301. [PMID: 22462291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
In the Neonatal Intensive Care Unit (NICU) setting, the patient's parents and the medical team dispute sometimes over the administration of life-prolonging treatment to be provided to the patient. This article focuses on the situation where the parents insist on the treatment, whereas the doctors are of the opinion that the prospects for the future of the baby are too poor to justify (further) artificial prolongation of life. The article provides an informative background on the regulation of the decision-making process in relations with the administration of life-prolonging treatment in Dutch neonatology. It also presents the results of a set of interviews with Dutch neonatologists. These results suggest that the doctors are very inclined to take the parents' preferences into account.
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Affiliation(s)
- Sofia Moratti
- Department of Legal Theory, Faculty of Law, P.O. Box 9700 AS, University of Groningen, The Netherlands
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44
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Abstract
This contribution describes the regulation of end-of-life decisions in neonatology in the Netherlands. An account is given of the process of formulating rules, which includes a report by the Dutch Association for Paediatrics, two Court rulings, a report by a Consultation Group appointed by the Ministry of Health and a professional Protocol regulating deliberate ending of life in neonatology that was subsequently adopted as the regulation of this type of decision-making at the national level. The paper presents Dutch and comparative data on the attitude of the medical profession towards end-of-life decisions in neonatology and the frequency of such decisions in medical practice.
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Affiliation(s)
- Sofia Moratti
- Department of Legal Theory, University of Groningen, The Netherlands.
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45
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American College of Surgeons, Committee on Trauma, American College of Emergency Physicians, National Association of EMS Physicians, Pediatric Equipment Guidelines Committee, American Academy of Pediatrics. Equipment for ambulances. Bull Am Coll Surg 2009; 94:23-9. [PMID: 19718968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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46
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Ruygrok ML, Byyny RL, Haukoos JS. Validation of 3 termination of resuscitation criteria for good neurologic survival after out-of-hospital cardiac arrest. Ann Emerg Med 2009; 54:239-47. [PMID: 19157652 DOI: 10.1016/j.annemergmed.2008.11.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2008] [Revised: 11/03/2008] [Accepted: 11/12/2008] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE Several termination of resuscitation criteria have been proposed to identify patients who will not survive to hospital discharge after out-of-hospital cardiac arrest. However, only 1 set has been derived to specifically predict survival to hospital discharge with good neurologic function. The objectives of this study were to externally validate the basic life support (BLS) termination of resuscitation, advanced life support (ALS) termination of resuscitation, and neurologic termination of resuscitation criteria and compare their abilities to predict survival to hospital discharge with good neurologic function after out-of-hospital cardiac arrest. METHODS This was a secondary analysis of the Denver Cardiac Arrest Registry. Consecutive adult nontraumatic cardiac arrest patients in Denver County from January 1, 2003, through December 31, 2004, were included in the study. The BLS termination of resuscitation, ALS termination of resuscitation, and neurologic termination of resuscitation criteria were applied to the cohort, and their predictive proportions and 95% confidence intervals (CIs) were calculated for each set of criteria. RESULTS Of the 715 patients included in this study, the median age was 65 years (interquartile range 52 to 78 years), and 69% were male patients. In addition, 223 (31%) had return of spontaneous circulation, 175 (24%) survived to hospital admission, 58 (8%) survived to hospital discharge, and 42 (6%) survived to hospital discharge with good neurologic function. The proportion of patients with good neurologic survival to hospital discharge correctly identified for continued resuscitation was 100% (95% CI 92% to 100%) for all 3 termination of resuscitation criteria. The proportion of patients with poor neurologic survival to hospital discharge or no survival to hospital discharge correctly identified as eligible for termination of resuscitation was 36% (95% CI 32% to 40%) with the BLS termination of resuscitation criteria, 25% (95% CI 22% to 29%) with the ALS termination of resuscitation criteria, and 6% (95% CI 4% to 8%) with the neurologic termination of resuscitation criteria. Use of the BLS termination of resuscitation criteria would have reduced transport of the largest number of patients. CONCLUSION All 3 termination of resuscitation criteria had equally high abilities to identify patients requiring continued resuscitation. The BLS termination of resuscitation criteria, however, had the best combined ability to predict good neurologic survival and poor neurologic survival or death. These findings and the relative simplicity of the BLS termination of resuscitation criteria support their use.
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Wiese CHR, Wilke H, Bahr J, Graf BM. Practical examination of bystanders performing Basic Life Support in Germany: a prospective manikin study. BMC Emerg Med 2008; 8:14. [PMID: 19021907 PMCID: PMC2600625 DOI: 10.1186/1471-227x-8-14] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Accepted: 11/20/2008] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND In an out-of-hospital emergency situation bystander intervention is essential for a sufficient functioning of the chain of rescue. The basic measures of cardiopulmonary resuscitation (Basic Life Support - BLS) by lay people are therefore definitely part of an effective emergency service of a patient needing resuscitation. Relevant knowledge is provided to the public by various course conceptions. The learning success concerning a one day first aid course ("LSM" course in Germany) has not been much investigated in the past. We investigated to what extent lay people could perform BLS correctly in a standardised manikin scenario. An aim of this study was to show how course repetitions affected success in performing BLS. METHODS The "LSM course" was carried out in a standardised manner. We tested prospectively 100 participants in two groups (Group 1: Participants with previous attendance of a BLS course; Group 2: Participants with no previous attendance of a BLS course) in their practical abilities in BLS after the course. Success parameter was the correct performance of BLS in accordance with the current ERC guidelines. RESULTS Twenty-two (22%) of the 100 investigated participants obtained satisfactory results in the practical performance of BLS. Participants with repeated participation in BLS obtained significantly better results (Group 1: 32.7% vs. Group 2: 10.4%; p < 0.01) than course participants with no relevant previous knowledge. CONCLUSION Only 22% of the investigated participants at the end of a "LSM course" were able to perform BLS satisfactorily according to the ERC guidelines. Participants who had previously attended comparable courses obtained significantly better results in the practical test. Through regular repetitions it seems to be possible to achieve, at least on the manikin, an improvement of the results in bystander resuscitation and, consequently, a better patient outcome. To validate this hypothesis further investigations are recommended by specialised societies.
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Affiliation(s)
- Christoph HR Wiese
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University Medical Centre Göttingen, Germany
| | - Henryk Wilke
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University Medical Centre Göttingen, Germany
| | - Jan Bahr
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University Medical Centre Göttingen, Germany
| | - Bernhard M Graf
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University Medical Centre Göttingen, Germany
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Abstract
Advanced Trauma Life Support (ATLS) is a concept for rapid initial assessment and primary management of an injured patient, starting at the time of injury and continuing through initial assessment, lifesaving interventions, re-evaluation, stabilization and, when needed, transfer to a trauma centre. Despite some shortcomings, it is the only standardized concept for emergency room management, which is internationally accepted. Because of its simple and clear structure, it is flexible and can be universally integrated into existing emergency room algorithms under consideration of local, regional as well as national and international peculiarities in the sense of a "common language of trauma". Under these aspects ATLS also seems to be a valid concept for Europe.
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Affiliation(s)
- M Helm
- Abteilung für Anästhesiologie und Intensivmedizin, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89070 Ulm.
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Novillo A, Ladenheim RI, Galante M, Isola IM, Musi ME, Naguel V, Rodríguez P. [Limitation of life-sustaining treatment. A prospective study in a clinical ward]. Medicina (B Aires) 2008; 68:437-441. [PMID: 19147425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
The purpose of this study is to describe the limiting life-sustaining treatment process of patients admitted to a general ward. A prospective descriptive study was designed. The setting was the general ward of universitary hospital. Study participants were patients assisted by the internal medicine department during a 60-consecutive days period who had limitations of life sustaining treatments. During the study period, 402 patients were hospitalized, 62 (15%) of them had limitations of life support care. The median patient age of the last group was 86 years (78-90), 66% were women and the length of stay was 12 days (8-18). A low quality of life was the most frequent cause of limitation (69%). Information about the limitations was provided to 43 families (69%) and 8 patients (13%). The primary care physician participated in the decision in 50% of the cases, while the attending physician, the resident in charge, patient's family and patients themselves participated in 50%, 40%, 42% and 11% of the cases respectively. The decision of limiting life-sustaining treatments was recorded in seven patient's charts (11%). Seventeen (27%) patients with limitations died during the hospital stay while 44 (71%) were discharged. In conclusion, we found a frequent life sustaining treatment limitation in our patients. These decisions did not follow a uniform or systemized process. The need of guidelines to sort the medical and ethical challenges imposed to the medical team is undeniable.
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Affiliation(s)
- Abel Novillo
- Centro de Educación Médica e Investigaciones Clínicas Norberto Quirno (CEMIC), Buenos Aires
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