End-of-life practices in European intensive care units: the Ethicus Study

Staff and family response to end-of-life care in the ICU

PURPOSE OF REVIEW

End-of-life (EOL) care can be stressful for clinicians as well as patients and their relatives. Decisions to withhold or withdraw life-sustaining therapy vary widely depending on culture, beliefs and organizational norms. The following review will describe the current understanding of the problem and give an overview over interventional studies.

RECENT FINDINGS

EOL care is a risk factor for clinician burnout; poor work conditions contribute to emotional exhaustion and intent to leave. The impact of EOL care on families is part of the acute Family Intensive Care Unit Syndrome (FICUS) and the Post Intensive Care Syndrome-Family (PICS-F). Family-centered care (FCC) acknowledges the importance of relatives in the ICU. Several interventions have been evaluated, but evidence for their effectiveness is at best moderate. Some interventions even increased family stress. Interventional studies, which address clinician burnout are rare.

SUMMARY

EOL care is associated with negative outcomes for ICU clinicians and relatives, but strength of evidence for interventions is weak because we lack understanding of associated factors like work conditions, organizational issues or individual attitudes. In order to develop complex interventions that can successfully mitigate stress related to EOL care, more research is necessary, which takes into account all potential determinants.

[Non-beneficial therapy and emotional exhaustion in end-of-life care : Results of a survey among intensive care unit personnel]

BACKGROUND

End-of-life care (EOLC) in the intensive care unit (ICU) is becoming increasingly more common but ethical standards are compromised by growing economic pressure. It was previously found that perception of non-beneficial treatment (NBT) was independently associated with the core burnout dimension of emotional exhaustion. It is unknown whether factors of the work environment also play a role in the context of EOLC.

OBJECTIVE

Is the working environment associated with perception of NBT or clinician burnout?

MATERIAL AND METHODS

Physicians and nursing personnel from 11 German ICUs who took part in an international, longitudinal prospective observational study on EOLC in 2015-2016 were surveyed using validated instruments. Risk factors were obtained by multivariate multilevel analysis.

RESULTS

The participation rate was 49.8% of personnel working in the ICU at the time of the survey. Overall, 325 nursing personnel, 91 residents and 26 consulting physicians participated. Nurses perceived NBT more frequently than physicians. Predictors for the perception of NBT were profession, collaboration in the EOLC context, excessively high workload (each p ≤ 0.001) and the numbers of weekend working days per month (p = 0.012). Protective factors against burnout included intensive care specialization (p = 0.001) and emotional support within the team (p ≤ 0.001), while emotional exhaustion through contact with relatives at the end of life and a high workload were both increased (each p ≤ 0.001).

DISCUSSION

Using the example of EOLC, deficits in the work environment and stress factors were uncovered. Factors of the work environment are associated with perceived NBT. To reduce NBT and burnout, the quality of the work environment should be improved and intensive care specialization and emotional support within the team enhanced. Interprofessional decision-making among the ICU team and interprofessional collaboration should be improved by regular joint rounds and interprofessional case discussions. Mitigating stressful factors such as communication with relatives and high workload require allocation of respective resources.

Worldwide end-of-life practice for patients in ICUs

PURPOSE OF REVIEW

Published data and practice recommendations on end-of-life (EOL) generally reflect Western practice frameworks. Understanding worldwide practices is important because improving economic conditions are promoting rapid expansion of intensive care services in many previously disadvantaged regions, and increasing migration has promoted a new cultural diversity previously predominantly unicultural societies. This review explores current knowledge of similarities and differences in EOL practice between regions and possible causes and implications of these differences.

RECENT FINDINGS

Recent observational and survey data shows a marked variability in the practice of withholding and withdrawing life sustaining therapy worldwide. Some evidence supports the view that culture, religion, and socioeconomic factors influence EOL practice, and individually or together account for differences observed. There are also likely to be commonly desired values and expectations for EOL practice, and recent attempts at establishing where worldwide consensus may lie have improved our understanding of shared values and practices.

SUMMARY

Awareness of differences, understanding their likely complex causes, and using this knowledge to inform individualized care at EOL is likely to improve the quality of care for patients. Further research should clarify the causes of EOL practice variability, monitor trends, and objectively evaluate the quality of EOL practice worldwide.

Death, Devices, and Double Effect

Along with the growing utilization of the total artificial heart (TAH) comes a new set of ethical issues that have, surprisingly, received little attention in the literature: (1) How does one apply the criteria of irreversible cessation of circulatory function (a core concept in the Uniformed Determination of Death Act) given that a TAH rarely stops functioning on its own? (2) Can one appeal to the doctrine of double effect as an ethical rationale for turning off a TAH given that this action directly results in death? And, (3) On what ethical grounds can a physician turn off a TAH in view of the fact that either the intent of such an action or the outcome is always, and necessarily, death? The aim of this article is not to answer these questions but to highlight why these questions must be explored in some depth given the growing use of TAH technology.

Notes on the Development of the Slovenian Ethical Recommendations for Decision-Making on Treatment and Palliative Care of Patients at the End of Life in Intensive Care Medicine

OBJECTIVES

To describe the process of development of "Slovenian Ethical Recommendations for Decision-Making on Treatment and Palliative Care of Patients at the End of Life in Intensive Care Medicine" and its final outcomes.

DATA SOURCES

Personal experience and reflection, complemented by published data.

STUDY SELECTION

Not applicable.

DATA EXTRACTION

Not applicable.

DATA SYNTHESIS

Narrative, experiential reflection, literature review.

CONCLUSIONS

Slovenian ethical recommendations bring a small piece to a long tradition of ethical practice in a small European country. Despite the availability of informative international guiding documents on the issue, there are several specific good reasons for a small country or a region to develop its own unique guidelines (i.e., lack of local directives and legislation, unique cultural and political situation, need for development of professional expertise and terminology, and to educate healthcare providers). The authors strongly believe that our recommendations positively impact practice and will support best possible integrated palliative and end-of-life quality care with the ICU.

Non-invasive ventilation practices in children across Europe

OBJECTIVES

To describe the diversity in practice in non-invasive ventilation (NIV) in European pediatric intensive care units (PICUs).

WORKING HYPOTHESIS

No information about the use of NIV in Pediatrics across Europe is currently available, and there might be a wide variability regarding the approach.

STUDY DESIGN

Cross-sectional electronic survey.

METHODOLOGY

The survey was distributed to the ESPNIC mailing list and to researchers in different European centers.

RESULTS

One hundred one units from 23 countries participated. All respondent units used NIV. Almost all PICUs considered NIV as initial respiratory support (99.1%), after extubation (95.5% prophylactically, 99.1% therapeutically), and 77.5% as part of palliative care. Overall NIV use outside the PICUs was 15.5% on the ward, 20% in the emergency department, and 36.4% during transport. Regarding respiratory failure cause, NIV was delivered in pneumonia (97.3%), bronchiolitis (94.6%), bronchospasm (75.2%), acute pulmonary edema (84.1%), upper airway obstruction (76.1%), and in acute respiratory distress syndrome (91% if mild, 53.1% if moderate, and 5.3% if severe). NIV use in asthma was less frequent in Northern European units in comparison to Central and Southern European PICUs (P = 0.007). Only 47.7% of the participants had a written protocol about NIV use. Bilevel NIV was applied mostly through an oronasal mask (44.4%), and continuous positive airway pressure through nasal cannulae (39.8%). If bilevel NIV was required, 62.3% reported choosing pressure support (vs assisted pressure-controlled ventilation) in infants; and 74.5% in older children.

CONCLUSIONS

The present study shows that NIV is a widespread technique in European PICUs. Practice across Europe is variable.

End-of-life decisions in emergency patients: prevalence, outcome and physician effect

BACKGROUND

End-of-life decisions (EOLD) represent potentially highly consequential decisions often made in acute situations, such as 'do not attempt resuscitation' (DNAR) choices at emergency presentation.

AIM

We investigated DNAR decisions in an emergency department (ED) to assess prevalence, associated patient characteristics, potential medical and economic consequences and estimate contributions of patients and physicians to DNAR decisions.

DESIGN

Single-centre retrospective observation, including ED patients with subsequent hospitalization between 2012 and 2016. Primary outcome was a DNAR decision and associated patient characteristics. Secondary outcomes were mortality, admission to intensive care unit and use of resources.

METHODS

Associations between DNAR and patient characteristics were analysed using logistic mixed effects models, results were reported as odds ratios (OR). Median odds ratios (MOR) were used to estimate patient and physician contributions to variability in DNAR.

RESULTS

Patients of 10 458 were attended by 315 physicians. DNAR was the choice in 23.3% of patients. Patients' characteristics highly associated with DNAR were age (OR = 4.0, 95% CI = 3.6-4.3) and non-trauma presentation (OR = 2.3, 95% CI = 1.9-2.9). In-hospital mortality was significantly higher (OR = 5.4, CI = 4.0-7.3), and use of resources was significantly lower (OR = 0.7, CI = 0.6-0.8) in patients choosing DNAR. There was a significant effect on DNAR by both patient (MOR = 1.8) and physician (MOR = 2.0).

CONCLUSIONS

DNAR choices are common in emergency patients and closely associated with age and non-trauma presentation. Mortality was significantly higher, and use of resources significantly lower in DNAR patients. Evidence of a physician effect raises questions about the choice autonomy of emergency patients in the process of EOLD.

First Scandinavian Protocol for Controlled Donation After Circulatory Death Using Normothermic Regional Perfusion

BACKGROUND

Donation after circulatory death (DCD) can increase the pool of available organs for transplantation. This pilot study evaluates the implementation of a controlled DCD (cDCD) protocol using normothermic regional perfusion in Norway.

METHODS

Patients aged 16 to 60 years that are in coma with documented devastating brain injury in need of mechanical ventilation, who would most likely attain cardiac arrest within 60 minutes after extubation, were eligible. With the acceptance from the next of kin and their wish for organ donation, life support was withdrawn and cardiac arrest observed. After a 5-minute no-touch period, extracorporeal membrane oxygenation for post mortem regional normothermic regional perfusion was established. Cerebral and cardiac reperfusion was prevented by an aortic occlusion catheter. Measured glomerular filtration rates 1 year postengraftment were compared between cDCD grafts and age-matched grafts donated after brain death (DBD).

RESULTS

Eight cDCD were performed from 2014 to 2015. Circulation ceased median 12 (range, 6-24) minutes after withdrawal of life-sustaining treatment. Fourteen kidneys and 2 livers were retrieved and subsequently transplanted. Functional warm ischemic time was 26 (20-51) minutes. Regional perfusion was applied for 97 minutes (54-106 minutes). Measured glomerular filtration rate 1 year postengraftment was not significantly different between cDCD and donation after brain death organs, 75 (65-76) vs 60 (37-112) mL/min per 1.73 m2 (P = 0.23). No complications have been observed in the 2 cDCD livers.

CONCLUSION

A protocol for cDCD is successfully established in Norway. Excellent transplant outcomes have encouraged us to continue this work addressing the shortage of organs for transplantation.

Withholding or withdrawing of life-sustaining therapy in older adults (≥ 80 years) admitted to the intensive care unit

PURPOSE

To document and analyse the decision to withhold or withdraw life-sustaining treatment (LST) in a population of very old patients admitted to the ICU.

METHODS

This prospective study included intensive care patients aged ≥ 80 years in 309 ICUs from 21 European countries with 30-day mortality follow-up.

RESULTS

LST limitation was identified in 1356/5021 (27.2%) of patients: 15% had a withholding decision and 12.2% a withdrawal decision (including those with a previous withholding decision). Patients with LST limitation were older, more frail, more severely ill and less frequently electively admitted. Patients with withdrawal of LST were more frequently male and had a longer ICU length of stay. The ICU and 30-day mortality were, respectively, 29.1 and 53.1% in the withholding group and 82.2% and 93.1% in the withdrawal group. LST was less frequently limited in eastern and southern European countries than in northern Europe. The patient-independent factors associated with LST limitation were: acute ICU admission (OR 5.77, 95% CI 4.32-7.7), Clinical Frailty Scale (CFS) score (OR 2.08, 95% CI 1.78-2.42), increased age (each 5 years of increase in age had a OR of 1.22 (95% CI 1.12-1.34) and SOFA score [OR of 1.07 (95% CI 1.05-1.09 per point)]. The frequency of LST limitation was higher in countries with high GDP and was lower in religious countries.

CONCLUSIONS

The most important patient variables associated with the instigation of LST limitation were acute admission, frailty, age, admission SOFA score and country.

TRIAL REGISTRATION

ClinicalTrials.gov (ID: NTC03134807).

Hemodialysis as a life-sustaining treatment at the end of life

The Act on Decisions on Life-Sustaining Treatment for Patients in Hospice and Palliative Care or at the End of Life came into effect on February 4th, 2018, in South Korea. Based on the Act, all Koreans over the age of 19 years can decide whether to refuse life-sustaining treatments at the end of life via advance directive or physician orders. Hemodialysis is one of the options designated in the Act as a life-sustaining treatment that can be withheld or withdrawn near death. However, hemodialysis has unique features. So, it is not easy to determine the best candidates for withholding/withdrawing hemodialysis at the end of life. Thus, it is necessary to investigate the meaning and implications of hemodialysis at the end of life with ethical consideration of futility and withholding or withdrawal of intervention.

A Randomized Trial of a Family-Support Intervention in Intensive Care Units

BACKGROUND

Surrogate decision makers for incapacitated, critically ill patients often struggle with decisions related to goals of care. Such decisions cause psychological distress in surrogates and may lead to treatment that does not align with patients' preferences.

METHODS

We conducted a stepped-wedge, cluster-randomized trial involving patients with a high risk of death and their surrogates in five intensive care units (ICUs) to compare a multicomponent family-support intervention delivered by the interprofessional ICU team with usual care. The primary outcome was the surrogates' mean score on the Hospital Anxiety and Depression Scale (HADS) at 6 months (scores range from 0 to 42, with higher scores indicating worse symptoms). Prespecified secondary outcomes were the surrogates' mean scores on the Impact of Event Scale (IES; scores range from 0 to 88, with higher scores indicating worse symptoms), the Quality of Communication (QOC) scale (scores range from 0 to 100, with higher scores indicating better clinician-family communication), and a modified Patient Perception of Patient Centeredness (PPPC) scale (scores range from 1 to 4, with lower scores indicating more patient- and family-centered care), as well as the mean length of ICU stay.

RESULTS

A total of 1420 patients were enrolled in the trial. There was no significant difference between the intervention group and the control group in the surrogates' mean HADS score at 6 months (11.7 and 12.0, respectively; beta coefficient, -0.34; 95% confidence interval [CI], -1.67 to 0.99; P=0.61) or mean IES score (21.2 and 20.3; beta coefficient, 0.90; 95% CI, -1.66 to 3.47; P=0.49). The surrogates' mean QOC score was better in the intervention group than in the control group (69.1 vs. 62.7; beta coefficient, 6.39; 95% CI, 2.57 to 10.20; P=0.001), as was the mean modified PPPC score (1.7 vs. 1.8; beta coefficient, -0.15; 95% CI, -0.26 to -0.04; P=0.006). The mean length of stay in the ICU was shorter in the intervention group than in the control group (6.7 days vs. 7.4 days; incidence rate ratio, 0.90; 95% CI, 0.81 to 1.00; P=0.045), a finding mediated by the shortened mean length of stay in the ICU among patients who died (4.4 days vs. 6.8 days; incidence rate ratio, 0.64; 95% CI, 0.52 to 0.78; P<0.001).

CONCLUSIONS

Among critically ill patients and their surrogates, a family-support intervention delivered by the interprofessional ICU team did not significantly affect the surrogates' burden of psychological symptoms, but the surrogates' ratings of the quality of communication and the patient- and family-centeredness of care were better and the length of stay in the ICU was shorter with the intervention than with usual care. (Funded by the UPMC Health System and the Greenwall Foundation; PARTNER ClinicalTrials.gov number, NCT01844492 .).

Physician-Assisted Suicide and Euthanasia

Conclusions:

Physicians have a duty to eliminate pain and suffering, not the person with the pain and suffering. Solutions for suffering lie in improving palliative care and social conditions and addressing the reasons for PAS-E requests. They should not include changing medical practice to allow PAS-E.

COPD is independently associated with 6-month survival in patients who have life support withheld in intensive care

BACKGROUND

In-hospital outcomes following decisions of withholding or withdrawing in Intensive Care Unit (ICU) patients have been previously assessed, little is known about outcomes after ICU and hospital discharge. Our objective was to report the 6-month outcomes of discharged patients who had treatment limitations in a general ICU and to identify prognostic factors of survival.

METHODS

We retrospectively collected the data of patients discharged from the ICU for whom life support was withheld from 2009 to 2011. We assessed the survival status of all patients at 6 months post-discharge and their duration of survival. Survivors and non-survivors were compared using univariate and multivariate analyses by Cox's proportional hazard model.

RESULTS

One hundred fourteen patients were included. The survival rate at 6 months was 58.8%. Survival was associated with acute respiratory failure (48% vs 19%, P = .006), a history of COPD (40% vs 21%, P = .03) and a lower SAPS II score (44 vs 49, P = .006). We identified a history of COPD as a prognostic factor for survival in the multivariate analysis (HR = 2.1; IC 95% 1.02-4.36, P = .04).

CONCLUSION

A total of 58.8% of patients for whom life-sustaining therapies were withheld in the ICU survived for at least 6 months after discharge. Patients with COPD appeared to have a significantly higher survival rate. The decision to withhold life support in patients should not lead to a cessation of post-ICU care and to non-readmission of COPD patients.

One-year mortality after recovery from critical illness: A retrospective cohort study

Rationale

Factors associated with one-year mortality after recovery from critical illness are not well understood. Clinicians generally lack information regarding post-hospital discharge outcomes of patients from the intensive care unit, which may be important when counseling patients and families.

Objective

We sought to determine which factors among patients who survived for at least 30 days post-ICU admission are associated with one-year mortality.

Methods

Single-center, longitudinal retrospective cohort study of all ICU patients admitted to a tertiary-care academic medical center from 2001–2012 who survived ≥30 days from ICU admission. Cox’s proportional hazards model was used to identify the variables that are associated with one-year mortality. The primary outcome was one-year mortality.

Results

32,420 patients met the inclusion criteria and were included in the study. Among patients who survived to ≥30 days, 28,583 (88.2%) survived for greater than one year, whereas 3,837 (11.8%) did not. Variables associated with decreased one-year survival include: increased age, malignancy, number of hospital admissions within the prior year, duration of mechanical ventilation and vasoactive agent use, sepsis, history of congestive heart failure, end-stage renal disease, cirrhosis, chronic obstructive pulmonary disease, and the need for renal replacement therapy. Numerous effect modifications between these factors were found.

Conclusion

Among survivors of critical illness, a significant number survive less than one year. More research is needed to help clinicians accurately identify those patients who, despite surviving their acute illness, are likely to suffer one-year mortality, and thereby to improve the quality of the decisions and care that impact this outcome.

Factors related to limitation of life support within 48h of intensive care unit admission: A multicenter study

OBJECTIVE

To determine factors related to limitations on life support within 48h of intensive care unit (ICU) admission.

STUDY DESIGN

Prospective multicenter study.

SETTING

Eleven ICUs.

PATIENTS

All patients who died and/or had limitations on life support after ICU admission during a four-month period.

VARIABLES

Patient characteristics, hospital characteristics, characteristics of limitations on life support. Time-to-first-limitation was classified as early (<48h of admission) or late (≥48h). We performed univariate, multivariate analyses and CHAID (chi-square automatic interaction detection) analysis of variables associated with limitation of life support within 48h of ICU admission.

RESULTS

3335 patients were admitted; 326 (9.8%) had limitations on life support. A total of 344 patients died; 247 (71.8%) had limitations on life support (range among centers, 58.6%-84.2%). The median (p25-p75) time from admission to initial limitation was 2 (0-7) days. CHAID analysis found that the modified Rankin score was the variable most closely related with early limitations. Among patients with Rankin >2, early limitations were implemented in 71.7% (OR=2.5; 95% CI: 1.5-4.4) and lung disease was the variable most strongly associated with early limitations (OR=12.29; 95% CI: 1.63-255.91). Among patients with Rankin ≤2, 48.8% had early limitations; patients admitted after emergency surgery had the highest rate of early limitations (66.7%; OR=2.4; 95% CI: 1.1-5.5).

CONCLUSION

Limitations on life support are common, but the practice varies. Quality of life has the greatest impact on decisions to limit life support within 48h of admission.

Consensus statement for cancer patients requiring intensive care support

This consensus statement is directed to intensivists, hematologists, and oncologists caring for critically ill cancer patients and focuses on the management of these patients.

Medical end-of-life practices in Swiss cultural regions: a death certificate study

BACKGROUND

End-of-life decisions remain controversial. Switzerland, with three main languages shared with surrounding countries and legal suicide assistance, allows exploration of the effects of cultural differences on end-of-life practices within the same legal framework.

METHODS

We conducted a death certificate study on a nationwide continuous random sample of Swiss residents. Using an internationally standardized tool, we sent 4998, 2965, and 1000 anonymous questionnaires to certifying physicians in the German-, French-, and Italian-speaking regions.

RESULTS

The response rates were 63.5%, 51.9%, and 61.7% in the German-, French-, and Italian-speaking regions, respectively. Non-sudden, expected deaths were preceded by medical end-of-life decisions (MELDs) more frequently in the German- than in the French- or Italian-speaking region (82.3% vs. 75.0% and 74.0%, respectively), mainly due to forgoing life-prolonging treatment (70.0%, 59.8%, 57.4%). Prevalence of assisted suicide was similar in the German- and French-speaking regions (1.6%, 1.2%), with no cases reported in the Italian-speaking region. Patient involvement was smaller in the Italian- than in the French- and German-speaking regions (16.0%, 31.2%, 35.6%). Continuous deep sedation was more frequent in the Italian- than in the French- and German-speaking regions (34.4%, 26.9%, 24.5%), and was combined with MELDs in most cases.

CONCLUSION

We found differences in MELD prevalence similar to those found between European countries. On an international level, MELDs are comparably frequent in all regions of Switzerland, in line with the greater role given to patient autonomy. Our findings show how cultural contexts and legislation can interact in shaping the prevalence of MELDs.

Conscientious Non-objection in Intensive Care

Discussions of conscientious objection (CO) in healthcare often concentrate on objections to interventions that relate to reproduction, such as termination of pregnancy or contraception. Nevertheless, questions of conscience can arise in other areas of medicine. For example, the intensive care unit is a locus of ethically complex and contested decisions. Ethical debate about CO usually concentrates on the issue of whether physicians should be permitted to object to particular courses of treatment; whether CO should be accommodated. In this article, I focus on the question of how clinicians ought to act: should they provide or support a course of action that is contrary to their deeply held moral beliefs? I discuss two secular examples of potential CO in intensive care, and propose that clinicians should adopt a norm of conscientious non-objection (CNO). In the face of divergent values and practice, physicians should set aside their personal moral beliefs and not object to treatment that is legally and professionally accepted and provided by their peers. Although there may be reason to permit conscientious objections in healthcare, conscientious non-objection should be encouraged, taught, and supported.

[Palliative care : Challenges in the intensive care unit]

Intensive care unit (ICU) stays often result due to an acute, potentially life-threatening illness or aggravation of a chronic life-threatening illness. In many cases, ICU patients die after life-sustaining treatments are withdrawn or withheld. When patients are asked, they prefer to die at home, although logistic and medical problems often prevent this. Therefore, attention focuses on care at the end of life in the ICU. Despite many efforts to improve the quality of care, evidence suggests that the quality in hospitals varies significantly and that palliative care in the ICU has not significantly improved over time. In this review, aspects of palliative care that are specific to ICU patients are discussed.

Limitation of life support techniques at admission to the intensive care unit: a multicenter prospective cohort study

Purpose

To determine the frequency of limitations on life support techniques (LLSTs) on admission to intensive care units (ICU), factors associated, and 30-day survival in patients with LLST on ICU admission.

Methods

This prospective observational study included all patients admitted to 39 ICUs in a 45-day period in 2011. We recorded hospitals’ characteristics (availability of intermediate care units, usual availability of ICU beds, and financial model) and patients’ characteristics (demographics, reason for admission, functional status, risk of death, and LLST on ICU admission (withholding/withdrawing; specific techniques affected)). The primary outcome was 30-day survival for patients with LLST on ICU admission. Statistical analysis included multilevel logistic regression models.

Results

We recruited 3042 patients (age 62.5 ± 16.1 years). Most ICUs (94.8%) admitted patients with LLST, but only 238 (7.8% [95% CI 7.0–8.8]) patients had LLST on ICU admission; this group had higher ICU mortality (44.5 vs. 9.4% in patients without LLST; p < 0.001). Multilevel logistic regression showed a contextual effect of the hospital in LLST on ICU admission (median OR = 2.30 [95% CI 1.59–2.96]) and identified the following patient-related variables as independent factors associated with LLST on ICU admission: age, reason for admission, risk of death, and functional status. In patients with LLST on ICU admission, 30-day survival was 38% (95% CI 31.7–44.5). Factors associated with survival were age, reason for admission, risk of death, and number of reasons for LLST on ICU admission.

Conclusions

The frequency of ICU admission with LLST is low but probably increasing; nearly one third of these patients survive for ≥ 30 days.

Electronic supplementary material

The online version of this article (10.1186/s40560-018-0283-y) contains supplementary material, which is available to authorized users.

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

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.

External validation of prediction models for time to death in potential donors after circulatory death

Predicting time to death in controlled donation after circulatory death (cDCD) donors following withdrawal of life-sustaining treatment (WLST) is important but poses a major challenge. The aim of this study is to determine factors predicting time to circulatory death within 60 minutes after WSLT and validate previously developed prediction models. In a single-center retrospective study, we used the data of 92 potential cDCD donors. Multivariable regression analysis demonstrated that absent cough-, corneal reflex, lower morphine dosage, and midazolam use were significantly associated with death within 60 minutes (area under the curve [AUC] 0.89; 95% confidenence interval [CI] 0.87-0.91). External validation of the logistic regression models of de Groot et al (AUC 0.86; 95% CI 0.77-0.95), Wind et al (AUC 0.62; 95% CI 0.49-0.76), Davila et al (AUC 0.80; 95% CI 0.708-0.901) and the Cox regression model by Suntharalingam et al (Harrell's c-index 0.63), exhibited good discrimination and could fairly identify which patients died within 60 minutes. Previous prediction models did not incorporate the process of WLST. We believe that future studies should also include the process of WLST as an important predictor.

Clinical practices to promote sleep in the ICU: A multinational survey

PURPOSE

To describe sleep assessment and strategies to promote sleep in adult ICUs in ten countries.

METHODS

Multicenter, self-administered survey sent to nurse managers.

RESULTS

Response rate was 66% with 522 ICUs providing data. 'Lying quietly with closed eyes' was the characteristic most frequently perceived as indicative of sleep by >60% of responding ICUs in all countries except Italy. Few ICUs (9%) had a protocol for sleep management or used sleep questionnaires (1%). Compared to ICUs in Northern Europe, those in central Europe were more likely to have a sleep promoting protocol (p < 0.001), and to want to implement a protocol (p < 0.001). In >80% of responding ICUs, the most common non-pharmacological sleep-promoting interventions were reducing ICU staff noise, light, and nurse interventions at night; only 18% used earplugs frequently. Approximately 50% of ICUs reported sleep medication selection and assessment of effect were performed by physicians and nurses collaboratively. A multivariable model identified perceived nursing influence on sleep decision-making was associated with asking patients or family about sleep preferences (p = 0.004).

CONCLUSIONS

We found variation in sleep promotion interventions across European regions with few ICUs using sleep assessment questionnaires or sleep promoting protocols. However, many ICUs perceive implementation of sleep protocols important, particularly those in central Europe.

The patient needing prolonged mechanical ventilation: a narrative review

BACKGROUND

Progress in management has improved hospital mortality of patients admitted to the intensive care units, but also the prevalence of those patients needing weaning from prolonged mechanical ventilation, and of ventilator assisted individuals. The result is a number of difficult clinical and organizational problems for patients, caregivers and health services, as well as high human and financial resources consumption, despite poor long-term outcomes. An effort should be made to improve the management of these patients. This narrative review summarizes the main concepts in this field.

MAIN BODY

There is great variability in terminology and definitions of prolonged mechanical ventilation.There have been several recent developments in the field of prolonged weaning: ventilatory strategies, use of protocols, early mobilisation and physiotherapy, specialised weaning units.There are few published data on discharge home rates, need of home mechanical ventilation, or long-term survival of these patients.Whether artificial nutritional support improves the outcome for these chronic critically ill patients, is unclear and controversial how these data are reported on the optimal time of initiation of parenteral vs enteral nutrition.There is no consensus on time of tracheostomy or decannulation. Despite several individualized, non-comparative and non-validated decannulation protocols exist, universally accepted protocols are lacking as well as randomised controlled trials on this critical issue. End of life decisions should result from appropriate communication among professionals, patients and surrogates and national legislations should give clear indications.

CONCLUSION

Present medical training of clinicians and locations like traditional intensive care units do not appear enough to face the dramatic problems posed by these patients. The solutions cannot be reserved to professionals but must involve also families and all other stakeholders. Large multicentric, multinational studies on several aspects of management are needed.

The practice of intensive care in Latin America: a survey of academic intensivists

Background

Intensive care medicine is a relatively young discipline that has rapidly grown into a full-fledged medical subspecialty. Intensivists are responsible for managing an ever-increasing number of patients with complex, life-threatening diseases. Several factors may influence their performance, including age, training, experience, workload, and socioeconomic context. The aim of this study was to examine individual- and work-related aspects of the Latin American intensivist workforce, mainly with academic appointments, which might influence the quality of care provided. In consequence, we conducted a cross-sectional study of intensivists at public and private academic and nonacademic Latin American intensive care units (ICUs) through a web-based electronic survey submitted by email. Questions about personal aspects, work-related topics, and general clinical workflow were incorporated.

Results

Our study comprised 735 survey respondents (53% return rate) with the following country-specific breakdown: Brazil (29%); Argentina (19%); Chile (17%); Uruguay (12%); Ecuador (9%); Mexico (7%); Colombia (5%); and Bolivia, Peru, Guatemala, and Paraguay combined (2%). Latin American intensivists were predominantly male (68%) young adults (median age, 40 [IQR, 35–48] years) with a median clinical ICU experience of 10 (IQR, 5–20) years. The median weekly workload was 60 (IQR, 47–70) h. ICU formal training was between 2 and 4 years. Only 63% of academic ICUs performed multidisciplinary rounds. Most intensivists (85%) reported adequate conditions to manage patients with septic shock in their units. Unsatisfactory conditions were attributed to insufficient technology (11%), laboratory support (5%), imaging resources (5%), and drug shortages (5%). Seventy percent of intensivists participated in research, and 54% read scientific studies regularly, whereas 32% read no more than one scientific study per month. Research grants and pharmaceutical sponsorship are unusual funding sources in Latin America. Although Latin American intensivists are mostly unsatisfied with their income (81%), only a minority (27%) considered changing to another specialty before retirement.

Conclusions

Latin American intensivists constitute a predominantly young adult workforce, mostly formally trained, have a high workload, and most are interested in research. They are under important limitations owing to resource constraints and overt dissatisfaction. Latin America may be representative of other world areas with similar challenges for intensivists. Specific initiatives aimed at addressing these situations need to be devised to improve the quality of critical care delivery in Latin America.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-1956-6) contains supplementary material, which is available to authorized users.

Intensive care decision-making: Identifying the challenges and generating solutions to improve inter-specialty referrals to critical care

Introduction

Decision-making regarding admission to UK intensive care units is challenging. Demand for beds exceeds capacity, yet the need to provide emergency cover creates pressure to build redundancy into the system. Guidelines to aid clinical decision-making are outdated, resulting in an over-reliance on professional judgement. Although clinicians are highly skilled, there is variability in intensive care unit decision-making, especially at the inter-specialty level wherein cognitive biases contribute to disagreement.

Method

This research is the first to explore intensive care unit referral and admission decision-making using the Critical Decision Method interviewing technique. We interviewed intensive care unit (n = 9) and non-intensive care unit (n = 6) consultants about a challenging referral they had dealt with in the past where there was disagreement about the patient's suitability for intensive care unit.

Results

We present: (i) a description of the referral pathway; (ii) challenges that appear to derail referrals (i.e. process issues, decision biases, inherent stressors, post-decision consequences) and (iii) potential solutions to improve this process.

Discussion

This research provides a foundation upon which interventions to improve inter-specialty decision-making can be based.

Enteral Feeding Practices in Infants With Congenital Heart Disease Across European PICUs: A European Society of Pediatric and Neonatal Intensive Care Survey

OBJECTIVES

To describe enteral feeding practices in pre and postoperative infants with congenital heart disease in European PICUs.

DESIGN

Cross-sectional electronic survey.

SETTING

European PICUs that admit infants with congenital heart disease pre- and postoperatively.

PARTICIPANTS

One senior PICU physician or designated person per unit.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Fifty-nine PICUs from 18 European countries responded to the survey. PICU physicians were involved in the nutritional care of children with congenital heart disease in most (76%) PICUs, but less than 60% of units had a dedicated dietician. Infants with congenital heart disease were routinely fed preoperatively in only 63% of the PICUs, due to ongoing concerns around prostaglandin E1 infusion, the presence of umbilical venous and/or arterial catheters, and the use of vasoactive drugs. In three quarters of the PICUs (76%), infants were routinely fed during the first 24 hours postoperatively. Units cited, the most common feeding method, both pre and postoperatively, was intermittent bolus feeds via the gastric route. Importantly, 69% of European PICUs still did not have written guidelines for feeding, but this varied for pre and postoperative patients.

CONCLUSIONS

Wide variations in practices exist in the nutritional care between European PICUs, which reflects the absence of local protocols and scientific society-endorsed guidelines. This is likely to contribute to suboptimal energy delivery in this particularly vulnerable group.

Impact of training on intensive care providers' attitudes and knowledge regarding limitation of life-support treatment and organ donation after circulatory death

The limitation of life-sustaining treatment is common practice in critical care units, and organ donation after circulatory death has come to be included as an option within this care plan. Lack of knowledge and misunderstandings can raise barriers between health-care providers (e.g., confusion about professional roles, lack of collaboration, doubts about the legality of the process, and not respecting patients' wishes in the decision-making process). The aim of the present study was to determine the knowledge and attitudes of intensive care physicians and nurses before and after a multidisciplinary online training program. A cross-sectional study was performed, and comparisons between the two groups were made using a χ² -test for categorical data and unpaired t-test or Mann-Whitney rank sum test for continuous data according to its distribution. Training benefited both professional categories, helping nurses to be more open-minded and willing to collaborate, while physicians became more aware of nurses' presence and the need to collaborate with them.

Knowledge and Attitude of ER and Intensive Care Unit Physicians toward Do-Not-Resuscitate in a Tertiary Care Center in Saudi Arabia: A Survey Study

Introduction

Only a few studies from Arab Muslim countries address do-not-resuscitate (DNR) practice. The knowledge of physicians about the existing policy and the attitude towards DNR were surveyed.

Objective

The objective of this study is to identify the knowledge of the participants of the local DNR policy and barriers of addressing DNR including religious background.

Methods

A questionnaire has been distributed to Emergency Room (ER) and Intensive Care Unit (ICU) physicians.

Results

A total of 112 physicians mostly Muslims (97.3%). About 108 (96.4%) were aware about the existence of DNR policy in our institute. 107 (95.5%) stated that DNR is not against Islamic. Only (13.4%) of the physicians have advance directives and (90.2%) answered they will request to be DNR if they have terminal illness. Lack of patients and families understanding (51.8%) and inadequate training (35.7%) were the two most important barriers for effective DNR discussion. Patients and families level of education (58.0%) and cultural factors (52.7%) were the main obstacles in initiating a DNR order.

Conclusions

There is a lack of knowledge about DNR policy which makes the optimization of DNR process difficult. Most physicians wish DNR for themselves and their patients at the end of life, but only a few of them have advance directives. The most important barriers for initializing and discussing DNR were lack of patient understanding, level of education, and the culture of patients. Most of the Muslim physicians believe that DNR is not against Islamic rules. We suggest that the DNR concept should be a part of any training program.

Palliative Care for Patients Dying in the Intensive Care Unit with Chronic Lung Disease Compared with Metastatic Cancer

RATIONALE

Palliative care has been focused largely on patients with cancer, and yet patients with chronic lung diseases also have high morbidity and mortality. The majority of deaths in intensive care units (ICUs) follow decisions to withhold or withdraw life-sustaining treatments, suggesting that palliative care is critically important in this setting.

OBJECTIVES

We explored differences in receipt of elements of palliative care among patients with interstitial lung disease (ILD) and chronic obstructive pulmonary disease (COPD) who die in ICUs compared with patients with cancer.

METHODS

We identified patients with COPD, ILD, or metastatic cancer who died in the ICUs of 15 Seattle-area hospitals between 2003 and 2008. We used robust multivariable logistic and linear regression to compare differences in receipt of elements of palliative care and length of stay.

MEASUREMENTS AND MAIN RESULTS

Compared with patients with cancer, patients with COPD were more likely to receive cardiopulmonary resuscitation before death and patients with ILD were less likely to have documentation of pain assessment in the last day of life. Patients with ILD and COPD were less likely to have a do-not-resuscitate order in place at the time of death and less likely to have documentation of discussions about prognosis than patients with cancer. Patients with COPD had longer hospital lengths of stay, and patients with COPD and ILD had longer ICU lengths of stay.

CONCLUSIONS

Among patients who die in the ICU, patients with ILD and COPD receive fewer elements of palliative care and have longer lengths of stay than patients with cancer. These findings identify areas for improvement in caring for patients with chronic lung diseases. Clinical trial registered with www.clinicaltrials.gov (NCT00685893).

What are the ethical aspects surrounding the collegial decisional process in limiting and withdrawing treatment in intensive care?

The decision to limit or withdraw life-support treatment is an integral part of the job of a physician working in the intensive care unit, and of the approach to care. However, this decision is influenced by a number of factors. It is widely accepted that a medical decision that will ultimate lead to end-of-life in the intensive care unit (ICU) must be shared between all those involved in the care process, and should give precedence to the patient's wishes (either directly expressed by the patient or in written form, such as advance directives), and taking into account the opinion of the patient's family, including the surrogate if the patient is no longer capable of expressing themselves. A number of questions still remain unanswered regarding how decisions to limit or withdraw treatment are taken in daily practice, especially when this decision can be anticipated. We discuss here the collegial procedure for decision-making, in particular in the context of recent French legislation on end-of-life issues. We describe how collegial decision-making procedures should be carried out, and what points are covered in shared discussions regarding decisions to limit or withdraw life-sustaining therapies.

A few realistic questions raised by organ retrieval in the intensive care unit

Organ transplantation saves the lives of many persons who would otherwise die from end-stage organ disease. The increasing demand for donated organs has led to a renewed interest in donation after circulatory determination of death (CDD). In many countries (including France), terminally ill patients who die of circulatory arrest after a planned withdrawal of life support may be considered as organ donors under certain conditions. While having equal responsibility towards the potential donor and the persons awaiting a transplant, caregivers may experience an ethical dilemma between the responsibility to deliver the best care to the dying, and the need to retrieve the organs. Once it has been established that the patient wishes to be a donor, we assume that end-of-life care and organ donation may have convergent goals when they contribute to transforming a comfortable death into a chance of life for others in need.

Early Withdrawal Decision-Making in Patients with Coma After Cardiac Arrest: A Qualitative Study of Intensive Care Clinicians

INTRODUCTION

Neurologists are often asked to define prognosis in comatose patients. However, comatose patients following cardiac arrest are usually cared for by cardiologists or intensivists, and it is their approach that will influence decisions regarding withdrawal of life-sustaining interventions (WLSI). We observed that factors leading to these decisions vary across specialties and considered whether they could result in self-fulfilling prophecies and early WLSI. We conducted a hypothesis-generating qualitative study to identify factors used by non-neurologists to define prognosis in these patients and construct an explanatory model for how early WLSI might occur.

METHODS

This was a single-center qualitative study of intensivists caring for cardiac arrest patients with hypoxic-ischemic coma. Thirty attending physicians (n = 16) and fellows (n = 14) from cardiac (n = 8), medical (n = 6), surgical (n = 10), and neuro (n = 6) intensive care units underwent semi-structured interviews. Interview transcripts were analyzed using grounded theory techniques.

RESULTS

We found three components of early WLSI among non-neurointensivists: (1) development of fixed negative opinions; (2) early framing of poor clinical pictures to families; and (3) shortened windows for judging recovery potential. In contrast to neurointensivists, non-neurointensivists' negative opinions were frequently driven by patients' lack of consciousness and cardiopulmonary resuscitation circumstances. Both groups were influenced by age and comorbidities.

CONCLUSIONS

The results demonstrate that factors influencing prognostication differ across specialties. Some differ from those recommended by published guidelines and may lead to self-fulfilling prophecies and early WLSI. Better understanding of this framework would facilitate educational interventions to mitigate this phenomenon and its implications on patient care.

Association Between Immigrant Status and End-of-Life Care in Ontario, Canada

IMPORTANCE

People who immigrate face unique health literacy, communication, and system navigation challenges, and they may have diverse preferences that influence end-of-life care.

OBJECTIVE

To examine end-of-life care provided to immigrants to Canada in the last 6 months of their life.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study (April 1, 2004, to March 31, 2015) included 967 013 decedents in Ontario, Canada, using validated linkages between health and immigration databases to identify immigrant (since 1985) and long-standing resident cohorts.

EXPOSURES

All decedents who immigrated to Canada between 1985 and 2015 were classified as recent immigrants, with subgroup analyses assessing the association of time since immigration, and region of birth, with end-of-life care.

MAIN OUTCOMES AND MEASURES

Location of death and intensity of care received in the last 6 months of life. Analysis included modified Poisson regression with generalized estimating equations, adjusting for age, sex, socioeconomic position, causes of death, urban and rural residence, and preexisting comorbidities.

RESULTS

Among 967 013 decedents of whom 47 514 (5%) immigrated since 1985, sex, socioeconomic status, urban (vs rural) residence, and causes of death were similar, while long-standing residents were older than immigrant decedents (median [interquartile range] age, 75 [58-84] vs 80 [68-87] years). Recent immigrant decedents were overall more likely to die in intensive care (15.6% vs 10.0%; difference, 5.6%; 95% CI, 5.2%-5.9%) after adjusting for differences in age, sex, income, geography, and cause of death (relative risk, 1.30; 95% CI, 1.27-1.32). In their last 6 months of life, recent immigrant decedents experienced more intensive care admissions (24.9% vs 19.2%; difference, 5.7%; 95% CI, 5.3%-6.1%), hospital admissions (72.1% vs 68.2%; difference, 3.9%; 95% CI, 3.5%-4.3%), mechanical ventilation (21.5% vs 13.6%; difference, 7.9%; 95% CI, 7.5%-8.3%), dialysis (5.5% vs 3.4%; difference, 2.1%; 95% CI, 1.9%-2.3%), percutaneous feeding tube placement (5.5% vs 3.0%; difference, 2.5%; 95% CI, 2.3%-2.8%), and tracheostomy (2.3% vs 1.1%; difference, 1.2%; 95% CI, 1.1%-1.4%). Relative risk of dying in intensive care for recent immigrants compared with long-standing residents varied according to recent immigrant region of birth from 0.84 (95% CI, 0.74-0.95) among those born in Northern and Western Europe to 1.96 (95% CI, 1.89-2.05) among those born in South Asia.

CONCLUSIONS AND RELEVANCE

Among decedents in Ontario, Canada, recent immigrants were significantly more likely to receive aggressive care and to die in an intensive care unit compared with other residents. Further research is needed to understand the mechanisms behind this association.

Admission to Intensive Care for Palliative Care or Potential Organ Donation: Demographics, Circumstances, Outcomes, and Resource Use

Supplemental Digital Content is available in the text.

Objectives:

To describe the characteristics, circumstances, change over time, resource use, and outcomes of patients admitted to ICUs in Australia and New Zealand for the purposes of “palliative care of a dying patient” or “potential organ donation,” and compare with actively managed ICU patients.

Design:

A retrospective study of data from the Australian and New Zealand Intensive Care Society Adult Patient Database and a nested cohort analysis of a single center.

Setting:

One hundred seventy-seven ICUs in Australia and New Zealand and a nested analysis of one university-affiliated hospital ICU in Melbourne, VIC, Australia.

Patients:

Three thousand seven hundred “palliative care of a dying patient” and 1,115 “potential organ donation” patients from 2007 to 2016. The nested cohort included 192 patients.

Interventions:

No interventions. Data extracted included patient demographics, diagnoses, length of stay, circumstances, and outcome of admission.

Measurements and Main Results:

ICU admissions for “palliative care of a dying patient” and “potential organ donation” increased from 179 in 2007 to 551 in 2016 and from 44 in 2007 to 174 in 2016 in each respective group, though only the “potential organ donation” cohort showed an increase in proportion of total ICU admissions. Lengths of stay in ICU were a mean of 33.8 hours (median, 17.5; interquartile range, 6.4–38.8) and 44.7 hours (26.6; 16.0–44.6), respectively, compared with 74.2 hours (41.5; 21.7–77.0) in actively managed patients. Hospital mortality was 86.6% and 95.9%, respectively. In the nested cohort of 192 patients, facilitating family discussions about goals of treatment and organ donation represented the most common reason for ICU admission.

Conclusions:

Patients admitted to ICU to manage end-of-life care represent a small proportion of overall ICU admissions, with an increasing proportion of “potential organ donation” admissions. They have shorter ICU lengths of stay than actively managed patients, suggesting resource use for these patients is not disproportionate.

Terminal weaning or immediate extubation for withdrawing mechanical ventilation in critically ill patients (the ARREVE observational study)

PURPOSE

The relative merits of immediate extubation versus terminal weaning for mechanical ventilation withdrawal are controversial, particularly regarding the experience of patients and relatives.

METHODS

This prospective observational multicentre study (ARREVE) was done in 43 French ICUs to compare terminal weaning and immediate extubation, as chosen by the ICU team. Terminal weaning was a gradual decrease in the amount of ventilatory assistance and immediate extubation was extubation without any previous decrease in ventilatory assistance. The primary outcome was posttraumatic stress symptoms (Impact of Event Scale Revised, IES-R) in relatives 3 months after the death. Secondary outcomes were complicated grief, anxiety, and depression symptoms in relatives; comfort of patients during the dying process; and job strain in staff.

RESULTS

We enrolled 212 (85.5%) relatives of 248 patients with terminal weaning and 190 relatives (90.5%) of 210 patients with immediate extubation. Immediate extubation was associated with airway obstruction and a higher mean Behavioural Pain Scale score compared to terminal weaning. In relatives, IES-R scores after 3 months were not significantly different between groups (31.9 ± 18.1 versus 30.5 ± 16.2, respectively; adjusted difference, -1.9; 95% confidence interval, -5.9 to 2.1; p = 0.36); neither were there any differences in complicated grief, anxiety, or depression scores. Assistant nurses had lower job strain scores in the immediate extubation group.

CONCLUSIONS

Compared to terminal weaning, immediate extubation was not associated with differences in psychological welfare of relatives when each method constituted standard practice in the ICU where it was applied. Patients had more airway obstruction and gasps with immediate extubation.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01818895.

The ideas about advanced life support and affecting factors at the end-stage of life in a hospital in Turkey

Background

The participation of the people in health decisions may be structured in various levels. One of these is participation in decisions for the treatment. “Advanced directives” is one of the examples for the participation in decisions for the treatment.

Aim

We wanted to determine the decisions on advanced life support at the end-stage of life in case of a life-threatening illness for the people themselves and their first degree relatives and the factors effecting these decisions.

Design and setting

The cross-sectional study was conducted with volunteers among patients and patient relatives who applied to all polyclinics of the Ankara Numune Training and Research Hospital except the emergency, oncology and psychiatry polyclinics between 15.12.2012 and 15.03.2013.

Method

A questionnaire, the Hospital Anxiety Depression (HAD) scale, and Templer’s Death Anxiety Scale (TDA) were applied to all individuals. SPSS for Win. Ver. 17.0 and MS-Excel 2010 Starter software bundles were used for all statistical analysis and calculations.

Results

The participants want both themselves and their first degree relatives included in end-stage decision-making process. Therefore, the patients and their families should be informed adequately during decision making process and quality communication must be provided.

Conclusion

Participants who have given their end-stage decisions previously want to be treated according to these decisions. This desire can just be possible by advanced directives.When moral and material loads of end-stage process are taken into consideration, countries, in which advanced directives are practiced, should be examined well and participants’ desire should be evaluated in terms of practicability.

The impact of healthcare professionals' personality and religious beliefs on the decisions to forego life sustaining treatments: an observational, multicentre, cross-sectional study in Greek intensive care units

OBJECTIVES

To assess the opinion of intensive care unit (ICU) personnel and the impact of their personality and religious beliefs on decisions to forego life-sustaining treatments (DFLSTs).

SETTING

Cross-sectional, observational, national study in 18 multidisciplinary Greek ICUs, with >6 beds, between June and December 2015.

PARTICIPANTS

149 doctors and 320 nurses who voluntarily and anonymously answered the End-of-Life (EoL) attitudes, Personality (EPQ) and Religion (SpREUK) questionnaires. Multivariate analysis was used to detect the impact of personality and religious beliefs on the DFLSTs.

RESULTS

The participation rate was 65.7%. Significant differences in DFLSTs between doctors and nurses were identified. 71.4% of doctors and 59.8% of nurses stated that the family was not properly informed about DFLST and the main reason was the family's inability to understand medical details. 51% of doctors expressed fear of litigation and 47% of them declared that this concern influenced the information given to family and nursing staff. 7.5% of the nurses considered DFLSTs dangerous, criminal or illegal. Multivariate logistic regression identified that to be a nurse and to have a high neuroticism score were independent predictors for preferring the term 'passive euthanasia' over 'futile care' (OR 4.41, 95% CI 2.21 to 8.82, p<0.001, and OR 1.59, 95% CI 1.03 to 2.72, p<0.05, respectively). Furthermore, to be a nurse and to have a high-trust religious profile were related to unwillingness to withdraw mechanical ventilation. Fear of litigation and non-disclosure of the information to the family in case of DFLST were associated with a psychoticism personality trait (OR 2.45, 95% CI 1.25 to 4.80, p<0.05).

CONCLUSION

We demonstrate that fear of litigation is a major barrier to properly informing a patient's relatives and nursing staff. Furthermore, aspects of personality and religious beliefs influence the attitudes of ICU personnel when making decisions to forego life-sustaining treatments.

Factors associated with life-sustaining treatment restriction in a general intensive care unit

Purpose

Few previous studies have investigated associations between clinical variables available after 24 hours in the intensive care unit (ICU), including the Charlson Comorbidity Index (CCI), and decisions to restrict life-sustaining treatment. The aim of this study was to identify factors associated with the life-sustaining treatment restriction and to explore if CCI contributes to explaining decisions to restrict life-sustaining treatment in the ICU at a university hospital in Norway from 2007 to 2009.

Methods

Patients’ Simplified Acute Physiology Score II (SAPS II), age, sex, type of admission, and length of hospital stay prior to being admitted to the unit were recorded. We retrospectively registered the CCI for all patients based on the medical records prior to the index stay. A multivariable logistic regression analysis was used to assess factors associated with treatment restriction during the ICU stay.

Results

We included 936 patients, comprising 685 (73%) medical, 204 (22%) unscheduled and 47 (5%) scheduled surgical patients. Treatment restriction was experienced by 241 (26%) patients during their ICU stay. The variables that were significantly associated with treatment restriction in multivariable analysis were older age (odds ratio [OR] = 1.48 per 10 years, 95% confidence interval [CI] = 1.28–1.72 per 10 years), higher SAPS II (OR = 1.05, 95% CI = 1.04–1.07) and CCI values relative to the reference of CCI = 0: CCI = 2 (OR = 2.08, 95% CI = 1.20–3.61) and CCI≥3 (OR = 2.72, 95% CI = 1.65–4.47).

Conclusions

In multivariable analysis, older age, greater illness severity after 24 h in the ICU and greater comorbidity at hospital admission were independently associated with subsequent life-sustaining treatment restriction. The CCI score contributed additional information independent of the SAPS II illness severity rating.

[Traumatized relatives of intensive care patients]

Relatives are not only visitors in the intensive care unit, but provide support and care for patients at the end of life, and serve as an important source of information for clinicians. They are confronted, often unexpectedly and unprepared, with life-threatening illness, death and dying and life-threatening decisions to limit therapy. Thus, they are often substantially burdened themselves and are in need of support. It is undisputed that communication with relatives can have an adaptive or also traumatic influence on the experience gained.

End-of-life perceptions among physicians in intensive care units managed by anesthesiologists in Germany: a survey about structure, current implementation and deficits

Background

Structural aspects and current practice about end-of-life (EOL) decisions in German intensive care units (ICUs) managed by anesthesiologists are unknown. A survey among intensive care anesthesiologists has been conducted to explore current practice, barriers and opinions on EOL decisions in ICU.

Methods

In November 2015, all members of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and the Association of German Anesthesiologists (BDA) were asked to participate in an online survey to rate the presence or absence and the importance of 50 items. Answers were grouped into three categories considering implementation and relevance: Category 1 reflects high implementation and high relevance, Category 2 low and low, and Category 3 low and high.

Results

Five-hundred and forty-one anesthesiologists responded. Only four items reached ≥90% agreement as being performed “yes, always” or “mostly”, and 29 items were rated “very” or “more important”. A profound discrepancy between current practice and attributed importance was revealed. Twenty-eight items attributed to Category 1, six to Category 2 and sixteen to Category 3. Items characterizing the most urgent need for improvement (Category 3) referred to patient outcome data, preparation of health care directives and interdisciplinary discussion, standard operating procedures, implementation of practical instructions and inclusion of nursing staff and families in the process.

Conclusion

The present survey affirms an urgent need for improvement in EOL practice in German ICUs focusing on advanced care planning, distinct aspects of changing goals of care, implementation of standard operating procedures, continuing education and reporting of outcome data.

Electronic supplementary material

The online version of this article (doi:10.1186/s12871-017-0384-5) contains supplementary material, which is available to authorized users.

Similar 5-Year Estimated Glomerular Filtration Rate Between Kidney Transplants From Uncontrolled and Controlled Donors After Circulatory Death-A Dutch Cohort Study

BACKGROUND

Organ shortage persists despite a high rate of donation after circulatory death (DCD) in the Netherlands. The median waiting time for a deceased donor kidney in 2013 was 3.5 years. Most DCD kidneys are from controlled DCD (cDCD; Maastricht category III). Experience with uncontrolled donors after cardiac death (uDCD), that is, donors with an unexpected and irreversible cardiac arrest (Maastricht categories I and II), is increasing; and its effect on transplant outcomes needs evaluation.

METHODS

We used the Dutch Organ Transplantation Registry to include recipients (≥18 years old) from all Dutch centers who received transplants from 2002 to 2012 with a first DCD kidney. We compared transplant outcome in uDCD (n = 97) and cDCD (n = 1441).

RESULTS

Primary nonfunction in uDCD was higher than in the cDCD (19.6% vs 9.6%, P < 0.001, respectively). Delayed graft function was also higher in uDCD than in cDCD, but not significantly (73.7% vs 63.3%, P = .074, respectively). If censored for primary nonfunction, estimated glomerular filtration rates after 1 year and 5 years were comparable between uDCD and cDCD (1 year: uDCD, 44.3 (23.4) mL/min/m and cDCD, 45.8 (24.1) mL/min/m; P = 0.621; 5 years: uDCD, 49.1 (25.6) mL/min/m and cDCD, 47.7 (21.7) mL/min/m; P = 0.686). The differences in primary nonfunction between kidneys from uDCD and cDCD were explained by differences in the first warm ischemic period, cold ischemic time, and donor age.

CONCLUSIONS

We conclude that uDCD kidneys have potential for excellent function and can constitute a valuable extension of the donor pool. However, further efforts are necessary to address the high rate of primary nonfunction.

How Spain Reached 40 Deceased Organ Donors per Million Population

With 40 donors and more than 100 transplant procedures per million population in 2015, Spain holds a privileged position worldwide in providing transplant services to its patient population. The Spanish success derives from a specific organizational approach to ensure the systematic identification of opportunities for organ donation and their transition to actual donation and to promote public support for the donation of organs after death. The Spanish results are to be highlighted in the context of the dramatic decline in the incidence of brain death and the changes in end-of-life care practices in the country since the beginning of the century. This prompted the system to conceive the 40 donors per million population plan, with three specific objectives: (i) promoting the identification and early referral of possible organ donors from outside of the intensive care unit to consider elective non-therapeutic intensive care and incorporate the option of organ donation into end-of-life care; (ii) facilitating the use of organs from expanded criteria and non-standard risk donors; and (iii) developing the framework for the practice of donation after circulatory death. This article describes the actions undertaken and their impact on donation and transplantation activities.