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Gotanda H, Ikesu R, Walling AM, Zhang JJ, Xu H, Reuben DB, Wenger NS, Damberg CL, Zingmond DS, Jena AB, Gross N, Tsugawa Y. Association between physician age and patterns of end-of-life care among older Americans. J Am Geriatr Soc 2024; 72:2070-2081. [PMID: 38721884 PMCID: PMC11226372 DOI: 10.1111/jgs.18939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 04/03/2024] [Accepted: 04/15/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND End-of-life (EOL) care patterns may differ by physician age given differences in how physicians are trained or changes associated with aging. We sought to compare patterns of EOL care delivered to older Americans according to physician age. METHODS We conducted a cross-sectional study of a 20% sample of Medicare fee-for-service beneficiaries aged ≥66 years who died in 2016-2019 (n = 487,293). We attributed beneficiaries to the physician who had >50% of primary care visits during the last 6 months of life. We compared beneficiary-level outcomes by physician age (<40, 40-49, 50-59, or ≥60) in two areas: (1) advance care planning (ACP) and palliative care; and (2) high-intensity care at the EOL. RESULTS Beneficiaries attributed to younger physicians had slightly higher proportions of billed ACP (adjusted proportions, 17.1%, 16.1%, 15.5%, and 14.0% for physicians aged <40, 40-49, 50-59, and ≥60, respectively; p-for-trend adjusted for multiple comparisons <0.001) and palliative care counseling or hospice use in the last 180 days of life (64.5%, 63.6%, 61.9%, and 60.8%; p-for-trend <0.001). Similarly, physicians' younger age was associated with slightly lower proportions of emergency department visits (57.4%, 57.0%, 57.4%, and 58.1%; p-for-trend <0.001), hospital admissions (51.2%, 51.1%, 51.4%, and 52.1%; p-for-trend <0.001), intensive care unit admissions (27.8%, 27.9%, 28.2%, and 28.3%; p-for-trend = 0.03), or mechanical ventilation or cardiopulmonary resuscitation (14.2, 14.9%, 15.2%, and 15.3%; p-for-trend <0.001) in the last 30 days of life, and in-hospital death (20.2%, 20.6%, 21.3%, and 21.5%; p-for-trend <0.001). CONCLUSIONS We found that differences in patterns of EOL care between beneficiaries cared for by younger and older physicians were small, and thus, not clinically meaningful. Future research is warranted to understand the factors that can influence patterns of EOL care provided by physicians, including initial and continuing medical education.
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Affiliation(s)
- Hiroshi Gotanda
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Ryo Ikesu
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA
- Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, CA
| | - Anne M. Walling
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Jessica J. Zhang
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Haiyong Xu
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - David B Reuben
- Multicampus Program in Geriatric Medicine and Gerontology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Neil S. Wenger
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | - David S. Zingmond
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Anupam B. Jena
- Department of Health Care Policy, Harvard Medical School, Boston, MA
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | | | - Yusuke Tsugawa
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA
- Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA
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Nadeau M, Chabot D, Breton M, Guertin JR, Harvey Labbé L, Roberge D, Lefebvre G, Mallet M, Beaulieu S, Kavanagh É, Cloutier N, Garant P, Bélanger L, Vaillancourt S, Boumenna T, Bareil K, Savard J, Simonyan D, Ulrich Singbo MN, Berthelot S. Development of a Patient-Reported Experience Measure Tool for Ambulatory Patients With Acute Unexpected Needs: The APEX Questionnaire. J Patient Exp 2024; 11:23743735241229373. [PMID: 38618513 PMCID: PMC11010752 DOI: 10.1177/23743735241229373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024] Open
Abstract
Background: The aim of this study was to develop a patient-reported experience measure (PREM) for comparing the experience of care received by ambulatory patients with acute unexpected needs presenting in emergency departments (EDs), walk-in clinics, and primary care practices. Methods: The Ambulatory Patient EXperience (APEX) questionnaire was developed using a 5-phase mixed-methods approach. The questionnaire was pretested by asking potential users to rate its clarity, usefulness, redundancy, content and face validities, and discrimination on a 9-point scale (1 = strongly disagree to 9 = strongly agree). The pre-final version was then tested in a pilot study. Results: The final questionnaire is composed of 61 questions divided into 7 sections. In the pretest (n = 25), median responses were 8 and above for all dimensions assessed. In the pilot study, 63 participants were enrolled. Adjusted results show that access, cleanliness, and feeling treated with respect and dignity by nurses and physicians were significantly better in the clinics than in the ED. Conclusion: We developed a questionnaire to assess and compare experience of ambulatory care in different clinical settings.
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Affiliation(s)
- Myriam Nadeau
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Département de médecine de famille et de médecine d’urgence, Université Laval, Québec, QC, Canada
- CHU de Québec-Université Laval, Québec, QC, Canada
| | - Dominique Chabot
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Mylaine Breton
- Département des sciences de la santé communautaire, Faculté de médecine et des sciences de la santé, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Jason R. Guertin
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Département de médecine sociale et préventive, Université Laval, Québec, QC, Canada
| | | | | | - Gabrielle Lefebvre
- Direction de la santé publique, CIUSSS de la Capitale-Nationale, Québec, QC, Canada
| | - Myriam Mallet
- Centre de valorisation et d'exploitation de la donnée du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Sandrine Beaulieu
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Éric Kavanagh
- École de design, Université Laval, Québec, QC, Canada
| | | | | | - Lynda Bélanger
- CHU de Québec-Université Laval, Québec, QC, Canada
- École de design, Université Laval, Québec, QC, Canada
| | | | - Tarek Boumenna
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Kathryn Bareil
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Joanie Savard
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - David Simonyan
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | | | - Simon Berthelot
- Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Département de médecine de famille et de médecine d’urgence, Université Laval, Québec, QC, Canada
- CHU de Québec-Université Laval, Québec, QC, Canada
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Jivraj NK, Hill AD, Shieh MS, Hua M, Gershengorn HB, Ferrando-Vivas P, Harrison D, Rowan K, Lindenauer PK, Wunsch H. Use of Mechanical Ventilation Across 3 Countries. JAMA Intern Med 2023; 183:824-831. [PMID: 37358834 PMCID: PMC10294017 DOI: 10.1001/jamainternmed.2023.2371] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 04/19/2023] [Indexed: 06/27/2023]
Abstract
Importance The ability to provide invasive mechanical ventilation (IMV) is a mainstay of modern intensive care; however, whether rates of IMV vary among countries is unclear. Objective To estimate the per capita rates of IMV in adults across 3 high-income countries with large variation in per capita intensive care unit (ICU) bed availability. Design, Setting, and Participants This cohort study examined 2018 data of patients aged 20 years or older who received IMV in England, Canada, and the US. Exposure The country in which IMV was received. Main Outcomes and Measures The main outcome was the age-standardized rate of IMV and ICU admissions in each country. Rates were stratified by age, specific diagnoses (acute myocardial infarction, pulmonary embolus, upper gastrointestinal bleed), and comorbidities (dementia, dialysis dependence). Data analyses were conducted between January 1, 2021, and December 1, 2022. Results The study included 59 873 hospital admissions with IMV in England (median [IQR] patient age, 61 [47-72] years; 59% men, 41% women), 70 250 in Canada (median [IQR] patient age, 65 [54-74] years; 64% men, 36% women), and 1 614 768 in the US (median [IQR] patient age, 65 [54-74] years; 57% men, 43% women). The age-standardized rate per 100 000 population of IMV was the lowest in England (131; 95% CI, 130-132) compared with Canada (290; 95% CI, 288-292) and the US (614; 95% CI, 614-615). Stratified by age, per capita rates of IMV were more similar across countries among younger patients and diverged markedly in older patients. Among patients aged 80 years or older, the crude rate of IMV per 100 000 population was highest in the US (1788; 95% CI, 1781-1796) compared with Canada (694; 95% CI, 679-709) and England (209; 95% CI, 203-214). Concerning measured comorbidities, 6.3% of admitted patients who received IMV in the US had a diagnosis of dementia (vs 1.4% in England and 1.3% in Canada). Similarly, 5.6% of admitted patients in the US were dependent on dialysis prior to receiving IMV (vs 1.3% in England and 0.3% in Canada). Conclusions and Relevance This cohort study found that patients in the US received IMV at a rate 4 times higher than in England and twice that in Canada in 2018. The greatest divergence was in the use of IMV among older adults, and patient characteristics among those who received IMV varied markedly. The differences in overall use of IMV among these countries highlight the need to better understand patient-, clinician-, and systems-level choices associated with the varied use of a limited and expensive resource.
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Affiliation(s)
- Naheed K. Jivraj
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Ontario, Canada
| | - Andrea D. Hill
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Meng-Shiou Shieh
- Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School, Baystate, Springfield, Massachusetts
| | - May Hua
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Hayley B. Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, Florida
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Paloma Ferrando-Vivas
- Intensive Care National Audit & Research Centre, Napier House, London, United Kingdom
| | - David Harrison
- Intensive Care National Audit & Research Centre, Napier House, London, United Kingdom
| | - Kathy Rowan
- Intensive Care National Audit & Research Centre, Napier House, London, United Kingdom
| | - Peter K. Lindenauer
- Department of Healthcare Delivery and Population Sciences, University of Massachusetts Chan Medical School, Baystate, Springfield, Massachusetts
| | - Hannah Wunsch
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Ontario, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Friedrich JO, Harhay MO, Angus DC, Burns KEA, Cook DJ, Fergusson DA, Finfer S, Hébert P, Rowan K, Rubenfeld G, Marshall JC. Mortality As a Measure of Treatment Effect in Clinical Trials Recruiting Critically Ill Patients. Crit Care Med 2023; 51:222-230. [PMID: 36661450 DOI: 10.1097/ccm.0000000000005721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES All-cause mortality is a common measure of treatment effect in ICU-based randomized clinical trials (RCTs). We sought to understand the performance characteristics of a mortality endpoint by evaluating its temporal course, responsiveness to differential treatment effects, and impact when used as an outcome measure in trials of acute illness. DATA SOURCES We searched OVID Medline for RCTs published from 1990 to 2018. STUDY SELECTION We reviewed RCTs that had randomized greater than or equal to 100 patients, were published in one of five high-impact general medical or eight critical care journals, and reported mortality at two or more distinct time points. We excluded trials recruiting pediatric or neonatal patients and cluster RCTs. DATA EXTRACTION Mortality by randomization group was recorded from the article or estimated from survival curves. Trial impact was assessed by inclusion of results in clinical practice guidelines. DATA SYNTHESIS From 2,592 potentially eligible trials, we included 343 RCTs (228,784 adult patients). While one third of all deaths by 180 days had occurred by day 7, the risk difference between study arms continued to increase until day 60 (p = 0.01) and possibly day 90 (p = 0.07) and remained stable thereafter. The number of deaths at ICU discharge approximated those at 28-30 days (95% [interquartile range [IQR], 86-106%]), and deaths at hospital discharge approximated those at 60 days (99% [IQR, 94-104%]). Only 13 of 43 interventions (30.2%) showing a mortality benefit have been adopted into widespread clinical practice. CONCLUSIONS Our findings provide a conceptual framework for choosing a time horizon and interpreting mortality outcome in trials of acute illness. Differential mortality effects persist for 60 to 90 days following recruitment. Location-based measures approximate time-based measures for trials conducted outside the United States. The documentation of a mortality reduction has had a modest impact on practice.
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Affiliation(s)
- Jan O Friedrich
- Department of Critical Care Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Michael O Harhay
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Derek C Angus
- CRISMA Centre, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Karen E A Burns
- Department of Critical Care Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | | | | | | | - Paul Hébert
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Kathy Rowan
- The Intensive Care National Audit and Resource Centre (ICNARC), London, United Kingdom
| | - Gordon Rubenfeld
- Department of Critical Care Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - John C Marshall
- Department of Critical Care Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Department of Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
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Fiester A. Reducing Moral Distress by Teaching Healthcare Providers the Concepts of Values Pluralism and Values Imposition. THE JOURNAL OF CLINICAL ETHICS 2023; 34:296-306. [PMID: 37991731 DOI: 10.1086/727437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
AbstractThere is a clear need for interventions that reduce moral distress among healthcare providers (HCPs), given the high prevalence of moral distress and the far-ranging negative consequences it has for them. Healthcare ethics consultants are frequently called upon to manage moral distress, especially among nursing staff. Recently, researchers have both broadened the definition of moral distress and demarcated subcategories of the phenomenon with the intent of creating more targeted and effective interventions. One of the most frequently occurring subcategories of moral distress in this new taxonomy has been labeled "moral-constraint distress," though scholars have argued that not all constraints on HCPs' moral agency are inappropriate given the often-competing healthcare values of patients, families, and clinical staff. To attempt to reduce the instances of moral distress in cases in which the constraints on HCPs' moral agency are justified, we propose an intervention that focuses on shifting the HCPs' "frame of reference" on moral-constraint distress, teaching HCPs how to distinguish unjustified and justified constraints on their moral agency. The anchors of this blueprint for reducing moral-constraint distress are the philosophical concepts of "values pluralism" and "values imposition." The rationale for this intervention is that, in situations where the constraint on moral agency is justified but the experience of moral distress could nevertheless be severe, the emphasis needs to be on helping the HCP to "think differently" rather than "act differently."
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6
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Palma A, Aliaga-Castillo V, Bascuñan L, Rojas V, Ihl F, Medel JN. An Intensive Care Unit Team Reflects on End-of-Life Experiences With Patients and Families in Chile. Am J Crit Care 2022; 31:24-32. [PMID: 34972854 DOI: 10.4037/ajcc2022585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Deaths in the intensive care unit (ICU) represent an experience of suffering for patients, their families, and professionals. End-of-life (EOL) care has been added to the responsibilities of the ICU team, but the evidence supporting EOL care is scarce, and there are many barriers to implementing the clinical recommendations that do exist. OBJECTIVES To explore the experiences and perspectives of the various members of an ICU care team in Chile regarding the EOL care of their patients. METHODS A qualitative study was performed in the ICU of a high-complexity academic urban hospital. The study used purposive sampling with focus groups as a data collection method. A narrative analysis based on grounded theory was done. RESULTS Four discipline-specific focus groups were conducted; participants included 8 nurses, 6 nursing assistants, 8 junior physicians, and 6 senior physicians. The main themes that emerged in the analysis were emotional impact and barriers to carrying out EOL care. The main barriers identified were cultural difficulties related to decision-making, lack of interprofessional clinical practice, and lack of effective communication. Communication difficulties within the team were described along with lack of self-efficacy for family-centered communication. CONCLUSION These qualitative findings expose gaps in care that must be filled to achieve high-quality EOL care in the ICU. Significant emotional impact, barriers related to EOL decision-making, limited interprofessional clinical practice, and communication difficulties were the main findings cross-referenced.
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Affiliation(s)
- Alejandra Palma
- Alejandra Palma is a palliative care physician, Departamento de Medicina Interna Norte, Sección de Cuidados Continuos y Paliativos, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Verónica Aliaga-Castillo
- Verónica Aliaga-Castillo is a physical therapist, Departamento de Kinesiología, Facultad de Medicina, Univer sidad de Chile, Santiago, Chile
| | - Luz Bascuñan
- Luz Bascuñan is a psychologist, Departamento de Bioética y Humanidades Médicas, Facultad de Medicina, Universidad de Chile
| | - Verónica Rojas
- Verónica Rojas is a licensed nurse, Departamento de Medicina Interna Norte, Unidad de Pacientes Críticos, Hospital Clínico Universidad de Chile, and Proyecto Internacional de Investigación para la Humaniza ción de los Cuidados Intensivos (Proyecto HU-CI), España
| | - Fernando Ihl
- Fernando Ihl is a palliative care physician, Departamento de Medicina Interna Norte, Sección de Cuidados Continuos y Paliativos, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Juan Nicolás Medel
- Juan Nicolás Medel is a critical care physician, Departa mento de Medicina Interna Norte, Unidad de Pacientes Críti cos, Hospital Clínico Universidad de Chile
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Hastening Death in Canadian ICUs: End-of-Life Care in the Era of Medical Assistance in Dying. Crit Care Med 2021; 50:742-749. [PMID: 34605780 DOI: 10.1097/ccm.0000000000005359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Since 2016, Canada has allowed for euthanasia based on strict criteria under federal medical assistance in dying legislation. The purpose of this study was to determine how Canadian intensivists perceive medical assistance in dying and whether they believe their approach to withdrawal of life-sustaining therapies has changed following introduction of medical assistance in dying. DESIGN Electronic survey. SETTING Participants were recruited from 11 PICU programs and 14 adult ICU programs across Canada. All program leaders for whom contact information was available were approached for participation. PARTICIPANTS We invited intensivists and critical care trainees employed between December 2019 and May 2020 to participate using a snowball sampling technique in which department leaders distributed study information. All responses were anonymous. Quantitative data were analyzed using descriptive statistics. Categorical variables were analyzed using Pearson chi-square test. INTERVENTIONS Not applicable. MEASUREMENTS AND MAIN RESULTS We obtained 150 complete questionnaires (33% response rate), of which 50% were adult practitioners and 50% pediatric. Most were from academic centers (81%, n = 121). Of respondents, 86% (n = 130) were familiar with medical assistance in dying legislation, 71% in favor, 14% conflicted, and 11% opposed. Only 5% (n = 8) thought it had influenced their approach to withdrawal of life-sustaining therapies. Half of participants had no standardized protocol for withdrawal of life-sustaining therapies in their unit, and 41% (n = 62) had observed medications given in disproportionately high doses during withdrawal of life-sustaining therapies, with 13% having personally administered such doses. Most (80%, n = 120) had experienced explicit requests from families to hasten death, and almost half (47%, n = 70) believed it was ethically permissible to intentionally hasten death following withdrawal of life-sustaining therapies. CONCLUSIONS Most Canadian intensivists surveyed do not think that medical assistance in dying has changed their approach to end of life in the ICU. A significant minority are ethically conflicted about the current approach to assisted dying/euthanasia in Canada. Almost half believe it is ethical to intentionally hasten death during withdrawal of life-sustaining therapies if death is expected.
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8
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Garg A, Soto AL, Knies AK, Kolenikov S, Schalk M, Hammer H, White DB, Holloway RG, Sheth KN, Fraenkel L, Hwang DY. Predictors of Surrogate Decision Makers Selecting Life-Sustaining Therapy for Severe Acute Brain Injury Patients: An Analysis of US Population Survey Data. Neurocrit Care 2021; 35:468-479. [PMID: 33619667 PMCID: PMC8380750 DOI: 10.1007/s12028-021-01200-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 01/29/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Patients with a severe acute brain injury admitted to the intensive care unit often have a poor neurological prognosis. In these situations, a clinician is responsible for conducting a goals-of-care conversation with the patient's surrogate decision makers. The diversity in thought and background of surrogate decision makers can present challenges during these conversations. For this reason, our study aimed to identify predictive characteristics of US surrogate decision makers' favoring life-sustaining treatment (LST) over comfort measures only for patients with severe acute brain injury. METHODS We analyzed data from a cross-sectional survey study that had recruited 1588 subjects from an online probability-based US population sample. Seven hundred and ninety-two subjects had randomly received a hypothetical scenario regarding a relative intubated with severe acute brain injury with a prognosis of severe disability but with the potential to regain some consciousness. Seven hundred and ninety-six subjects had been randomized to a similar scenario in which the relative was projected to remain vegetative. For each scenario, we conducted univariate analyses and binary logistic regressions to determine predictors of LST selection among available respondent characteristics. RESULTS 15.0% of subjects selected LST for the severe disability scenario compared to 11.4% for the vegetative state scenario (p = 0.07), with those selecting LST in both groups expressing less decisional certainty. For the severe disability scenario, independent predictors of LST included having less than a high school education (adjusted OR = 2.87, 95% CI = 1.23-6.76), concern regarding prognostic accuracy (7.64, 3.61-16.15), and concern regarding the cost of care (4.07, 1.80-9.18). For the vegetative scenario, predictors included the youngest age group (30-44 years, 3.33, 1.02-10.86), male gender (3.26, 1.75-6.06), English as a second language (2.94, 1.09-7.89), Evangelical Protestant (3.72, 1.28-10.84) and Catholic (4.01, 1.72-9.36) affiliations, and low income (< $25 K). CONCLUSION Several demographic and decisional characteristics of US surrogate decision makers predict LST selection for patients with severe brain injury with varying degrees of poor prognosis. Surrogates concerned about the cost of medical care may nevertheless be inclined to select LST, albeit with high levels of decisional uncertainty, for patients projected to have severe disabilities.
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Affiliation(s)
- Anisha Garg
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Alexandria L Soto
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, PO Box 208018, New Haven, CT, 06520, USA
| | - Andrea K Knies
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | | | | | - Douglas B White
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert G Holloway
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, USA
| | - Kevin N Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, PO Box 208018, New Haven, CT, 06520, USA
- Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT, USA
| | - Liana Fraenkel
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
- Section of Rheumatology, Yale School of Medicine, New Haven, CT, USA
| | - David Y Hwang
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, PO Box 208018, New Haven, CT, 06520, USA.
- Center for Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, New Haven, CT, USA.
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9
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Occurrence and timing of withdrawal of life-sustaining measures in traumatic brain injury patients: a CENTER-TBI study. Intensive Care Med 2021; 47:1115-1129. [PMID: 34351445 PMCID: PMC8486724 DOI: 10.1007/s00134-021-06484-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 07/14/2021] [Indexed: 12/16/2022]
Abstract
Background In patients with severe brain injury, withdrawal of life-sustaining measures (WLSM) is common in intensive care units (ICU). WLSM constitutes a dilemma: instituting WLSM too early could result in death despite the possibility of an acceptable functional outcome, whereas delaying WLSM could unnecessarily burden patients, families, clinicians, and hospital resources. We aimed to describe the occurrence and timing of WLSM, and factors associated with timing of WLSM in European ICUs in patients with traumatic brain injury (TBI). Methods The CENTER-TBI Study is a prospective multi-center cohort study. For the current study, patients with traumatic brain injury (TBI) admitted to the ICU and aged 16 or older were included. Occurrence and timing of WLSM were documented. For the analyses, we dichotomized timing of WLSM in early (< 72 h after injury) versus later (≥ 72 h after injury) based on recent guideline recommendations. We assessed factors associated with initiating WLSM early versus later, including geographic region, center, patient, injury, and treatment characteristics with univariable and multivariable (mixed effects) logistic regression. Results A total of 2022 patients aged 16 or older were admitted to the ICU. ICU mortality was 13% (n = 267). Of these, 229 (86%) patients died after WLSM, and were included in the analyses. The occurrence of WLSM varied between regions ranging from 0% in Eastern Europe to 96% in Northern Europe. In 51% of the patients, WLSM was early. Patients in the early WLSM group had a lower maximum therapy intensity level (TIL) score than patients in the later WLSM group (median of 5 versus 10) The strongest independent variables associated with early WLSM were one unreactive pupil (odds ratio (OR) 4.0, 95% confidence interval (CI) 1.3–12.4) or two unreactive pupils (OR 5.8, CI 2.6–13.1) compared to two reactive pupils, and an Injury Severity Score (ISS) if over 41 (OR per point above 41 = 1.1, CI 1.0–1.1). Timing of WLSM was not significantly associated with region or center. Conclusion WLSM occurs early in half of the patients, mostly in patients with severe TBI affecting brainstem reflexes who were severely injured. We found no regional or center influences in timing of WLSM. Whether WLSM is always appropriate or may contribute to a self-fulfilling prophecy requires further research and argues for reluctance to institute WLSM early in case of any doubt on prognosis. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06484-1.
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10
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Todorov A, Kaufmann F, Arslani K, Haider A, Bengs S, Goliasch G, Zellweger N, Tontsch J, Sutter R, Buddeberg B, Hollinger A, Zemp E, Kaufmann M, Siegemund M, Gebhard C, Gebhard CE. Gender differences in the provision of intensive care: a Bayesian approach. Intensive Care Med 2021; 47:577-587. [PMID: 33884452 PMCID: PMC8139895 DOI: 10.1007/s00134-021-06393-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 03/24/2021] [Indexed: 12/23/2022]
Abstract
Purpose It is currently unclear whether management and outcomes of critically ill patients differ between men and women. We sought to assess the influence of age, sex and diagnoses on the probability of intensive care provision in critically ill cardio- and neurovascular patients in a large nationwide cohort in Switzerland. Methods Retrospective analysis of 450,948 adult patients with neuro- and cardiovascular disease admitted to all hospitals in Switzerland between 01/2012 and 12/2016 using Bayesian modeling. Results For all diagnoses and populations, median ages at admission were consistently higher for women than for men [75 (64;82) years in women vs. 68 (58;77) years in men, p < 0.001]. Overall, women had a lower likelihood to be admitted to an intensive care unit (ICU) than men, despite being more severely ill [odds ratio (OR) 0.78 (0.76–0.79)]. ICU admission probability was lowest in women aged > 65 years (OR women:men 0.94 (0.89–0.99), p < 0.001). Women < 45 years had a similar ICU admission probability as men in the same age category [OR women:men 1.03 (0.94–1.13)], in spite of more severe illness. The odds to die were significantly higher in women than in men per unit increase in Simplified Acute Physiology Score (SAPS) II (OR 1.008 [1.004–1.012]). Conclusion In the care of the critically ill, our study suggests that women are less likely to receive ICU treatment regardless of disease severity. Underuse of ICU care was most prominent in younger women < 45 years. Although our study has several limitations that are imposed by the limited data available from the registries, our findings suggest that current ICU triage algorithms could benefit from careful reassessment. Further, and ideally prospective, studies are needed to confirm our findings. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06393-3.
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Affiliation(s)
- Atanas Todorov
- Intensive Care Unit, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland.,Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Fabian Kaufmann
- Intensive Care Unit, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Ketina Arslani
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Ahmed Haider
- Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Susan Bengs
- Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Georg Goliasch
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Núria Zellweger
- Intensive Care Unit, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Janna Tontsch
- Intensive Care Unit, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Raoul Sutter
- Intensive Care Unit, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland.,Department of Clinical Research, University Hospital Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Bigna Buddeberg
- Department of Anesthesiology, University Hospital Basel, Basel, Switzerland
| | - Alexa Hollinger
- Intensive Care Unit, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Elisabeth Zemp
- University of Basel, Basel, Switzerland.,Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Mark Kaufmann
- Department of Anesthesiology, University Hospital Basel, Basel, Switzerland
| | - Martin Siegemund
- Intensive Care Unit, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland.,Department of Clinical Research, University Hospital Basel, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Cathérine Gebhard
- Department of Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland.,Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Caroline E Gebhard
- Intensive Care Unit, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland.
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11
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Sprung CL, Jennerich AL, Joynt GM, Michalsen A, Curtis JR, Efferen LS, Leonard S, Metnitz B, Mikstacki A, Patil N, McDermid RC, Metnitz P, Mularski RA, Bulpa P, Avidan A. The Influence of Geography, Religion, Religiosity and Institutional Factors on Worldwide End-of-Life Care for the Critically Ill: The WELPICUS Study. J Palliat Care 2021:8258597211002308. [PMID: 33818159 DOI: 10.1177/08258597211002308] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To evaluate the association between provider religion and religiosity and consensus about end-of-life care and explore if geographical and institutional factors contribute to variability in practice. MATERIALS AND METHODS Using a modified Delphi method 22 end-of-life issues consisting of 35 definitions and 46 statements were evaluated in 32 countries in North America, South America, Eastern Europe, Western Europe, Asia, Australia and South Africa. A multidisciplinary, expert group from specialties treating patients at the end-of-life within each participating institution assessed the association between 7 key statements and geography, religion, religiosity and institutional factors likely influencing the development of consensus. RESULTS Of 3049 participants, 1366 (45%) responded. Mean age of respondents was 45 ± 9 years and 55% were females. Following 2 Delphi rounds, consensus was obtained for 77 (95%) of 81 definitions and statements. There was a significant difference in responses across geographical regions. South African and North American respondents were more likely to encourage patients to write advance directives. Fewer Eastern European and Asian respondents agreed with withdrawing life-sustaining treatments without consent of patients or surrogates. While respondent's religion, years in practice or institution did not affect their agreement, religiosity, physician specialty and responsibility for end-of-life decisions did. CONCLUSIONS Variability in agreement with key consensus statements about end-of-life care is related primarily to differences among providers, with provider-level variations related to differences in religiosity and specialty. Geography also plays a role in influencing some end-of-life practices. This information may help understanding ethical dilemmas and developing culturally sensitive end-of-life care strategies.
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Affiliation(s)
- Charles L Sprung
- Department of Anesthesiology, Critical Care Medicine, and Pain Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ann L Jennerich
- Division of Pulmonary, Critical Care and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Gavin M Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Andrej Michalsen
- Department of Anaesthesiology and Critical Care Medicine, Tettnang Hospital, Tettnang, Germany
| | - J Randall Curtis
- Division of Pulmonary, Critical Care and Sleep Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Linda S Efferen
- Department of Medicine, Stony Brook Medicine, Stony Brook, NY, USA
| | - Sara Leonard
- Department of Anaesthesia and Critical Care, King's College Hospital, London, UK
| | - Barbara Metnitz
- Austrian Centre for Documentation and Quality Assurance in Intensive Care Medicine, Vienna, Austria
| | - Adam Mikstacki
- Faculty of Health Sciences, Poznan University of Medical Sciences, Poznan, Poland
| | - Namrata Patil
- Division of Thoracic Surgery and Division of Trauma, Burn and Critical Care, Department of Surgery, Brigham & Women's Hospital, Boston, MA, USA
| | - Robert C McDermid
- Division of Critical Care, University of Alberta, Edmonton, Alberta, Canada
| | - Philipp Metnitz
- Clinical Department of General Anaesthesiology, Emergency and Intensive Care Medicine, LKH-University Hospital of Graz, Medical University of Graz, Graz, Austria
| | - Richard A Mularski
- The Center for Health Research Kaiser Permanente Northwest, Portland, OR, USA
| | - Pierre Bulpa
- Intensive Care Unit of Mont-Godinne University Hospital, CHU UCL Namur, Université Catholique de Louvain, Yvoir, Belgium
| | - Alexander Avidan
- Department of Anesthesiology, Critical Care Medicine, and Pain Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
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12
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Dahine J, Hébert PC, Ziegler D, Chenail N, Ferrari N, Hébert R. Practices in Triage and Transfer of Critically Ill Patients: A Qualitative Systematic Review of Selection Criteria. Crit Care Med 2020; 48:e1147-e1157. [PMID: 32858530 PMCID: PMC7493782 DOI: 10.1097/ccm.0000000000004624] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To identify and appraise articles describing criteria used to prioritize or withhold a critical care admission. DATA SOURCES PubMed, Embase, Medline, EBM Reviews, and CINAHL Complete databases. Gray literature searches and a manual review of references were also performed. Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed. STUDY SELECTION We sought all articles and abstracts of original research as well as local, provincial, or national policies on the topic of ICU resource allocation. We excluded studies whose population of interest was neonatal, pediatric, trauma, or noncritically ill. Screening of 6,633 citations was conducted. DATA EXTRACTION Triage and/or transport criteria were extracted, based on type of article, methodology, publication year, and country. An appraisal scale was developed to assess the quality of identified articles. We also developed a robustness score to further appraise the robustness of the evidence supporting each criterion. Finally, all criteria were extracted, evaluated, and grouped by theme. DATA SYNTHESIS One-hundred twenty-nine articles were included. These were mainly original research (34%), guidelines (26%), and reviews (21%). Among them, we identified 200 unique triage and transport criteria. Most articles highlighted an exclusion (71%) rather than a prioritization mechanism (17%). Very few articles pertained to transport of critically ill patients (4%). Criteria were classified in one of four emerging themes: patient, condition, physician, and context. The majority of criteria used were nonspecific. No study prospectively evaluated the implementation of its cited criteria. CONCLUSIONS This systematic review identified 200 criteria classified within four themes that may be included when devising triage programs including the coronavirus disease 2019 pandemic. We identified significant knowledge gaps where research would assist in improving existing triage criteria and guidelines, aiming to decrease arbitrary decisions and variability.
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Affiliation(s)
- Joseph Dahine
- Département de médecine spécialisée, Centre intégré de santé et services sociaux de Laval (CISSS de Laval), Hôpital Cité-de-la-Santé, Université de Montréal, Laval, QC, Canada
| | - Paul C. Hébert
- Département de médecine, Centre Hospitalier de l’Université de Montréal, Université de Montréal et Centre de Recherche, Montreal, QC, Canada
| | - Daniela Ziegler
- Bibliothèque, Centre hospitalier de l’Université de Montréal, Montreal, QC, Canada
| | | | - Nicolay Ferrari
- Centre de recherche du Centre hospitalier de l’Université de Montréal, Montreal, QC, Canada
| | - Réjean Hébert
- Department of Health Management, Evaluation and Policy, School of Public Health, Université de Montréal, Montreal, QC, Canada
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13
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Agreement With Consensus Statements on End-of-Life Care: A Description of Variability at the Level of the Provider, Hospital, and Country. Crit Care Med 2020; 47:1396-1401. [PMID: 31305497 DOI: 10.1097/ccm.0000000000003922] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To develop an enhanced understanding of factors that influence providers' views about end-of-life care, we examined the contributions of provider, hospital, and country to variability in agreement with consensus statements about end-of-life care. DESIGN AND SETTING Data were drawn from a survey of providers' views on principles of end-of-life care obtained during the consensus process for the Worldwide End-of-Life Practice for Patients in ICUs study. SUBJECTS Participants in Worldwide End-of-Life Practice for Patients in ICUs included physicians, nurses, and other providers. Our sample included 1,068 providers from 178 hospitals and 31 countries. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We examined views on cardiopulmonary resuscitation and withholding/withdrawing life-sustaining treatments, using a three-level linear mixed model of responses from providers within hospitals within countries. Of 1,068 providers from 178 hospitals and 31 countries, 1% strongly disagreed, 7% disagreed, 11% were neutral, 44% agreed, and 36% strongly agreed with declining to offer cardiopulmonary resuscitation when not indicated. Of the total variability in those responses, 98%, 0%, and 2% were explained by differences among providers, hospitals, and countries, respectively. After accounting for provider characteristics and hospital size, the variance partition was similar. Results were similar for withholding/withdrawing life-sustaining treatments. CONCLUSIONS Variability in agreement with consensus statements about end-of-life care is related primarily to differences among providers. Acknowledging the primary source of variability may facilitate efforts to achieve consensus and improve decision-making for critically ill patients and their family members at the end of life.
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14
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van Veen E, van der Jagt M, Citerio G, Stocchetti N, Epker JL, Gommers D, Burdorf L, Menon DK, Maas AIR, Lingsma HF, Kompanje EJO. End-of-life practices in traumatic brain injury patients: Report of a questionnaire from the CENTER-TBI study. J Crit Care 2020; 58:78-88. [PMID: 32387842 DOI: 10.1016/j.jcrc.2020.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 03/30/2020] [Accepted: 04/06/2020] [Indexed: 11/17/2022]
Abstract
PURPOSE We aimed to study variation regarding specific end-of-life (EoL) practices in the intensive care unit (ICU) in traumatic brain injury (TBI) patients. MATERIALS AND METHODS Respondents from 67 hospitals participating in The Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study completed several questionnaires on management of TBI patients. RESULTS In 60% of the centers, ≤50% of all patients with severe neurological damage dying in the ICU, die after withdrawal of life-sustaining measures (LSM). The decision to withhold/withdraw LSM was made following multidisciplinary consensus in every center. Legal representatives/relatives played a role in the decision-making process in 81% of the centers. In 82% of the centers, age played a role in the decision to withhold/withdraw LSM. Furthermore, palliative therapy was initiated in 79% of the centers after the decision to withdraw LSM was made. Last, withholding/withdrawing LSM was, generally, more often considered after more time had passed, in a patient with TBI, who remained in a very poor prognostic condition. CONCLUSION We found variation regarding EoL practices in TBI patients. These results provide insight into variability regarding important issues pertaining to EoL practices in TBI, which can be useful to stimulate discussions on EoL practices, comparative effectiveness research, and, ultimately, development of recommendations.
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Affiliation(s)
- Ernest van Veen
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Medical Ethics and Philosophy of Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy; San Gerardo Hospital, ASST-Monza, Italy.
| | - Nino Stocchetti
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy; Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, Milan, Italy.
| | - Jelle L Epker
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Diederik Gommers
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Lex Burdorf
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - David K Menon
- Department of Anaesthesia, University of Cambridge, Cambridge, United Kingdom.
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium.
| | - Hester F Lingsma
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Erwin J O Kompanje
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Medical Ethics and Philosophy of Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands.
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15
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Elizabeth Wilcox M, Donnelly JP, Lone NI. Understanding gender disparities in outcomes after sepsis. Intensive Care Med 2020; 46:796-798. [PMID: 32072302 DOI: 10.1007/s00134-020-05961-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 02/05/2020] [Indexed: 02/01/2023]
Affiliation(s)
- M Elizabeth Wilcox
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada. .,Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada.
| | - John P Donnelly
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Nazir I Lone
- Usher Institute, University of Edinburgh, Edinburgh, UK.,Department of Critical Care, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
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16
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Tsuda K, Higuchi A, Yokoyama E, Kosugi K, Komatsu T, Kami M, Tanimoto T. Physician Decision-Making Patterns and Family Presence: Cross-Sectional Online Survey Study in Japan. Interact J Med Res 2019; 8:e12781. [PMID: 31493327 PMCID: PMC6764328 DOI: 10.2196/12781] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 05/13/2019] [Accepted: 07/21/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Due to a low birth rate and an aging population, Japan faces an increase in the number of elderly people without children living in single households. These elderly without a spouse and/or children encounter a lack of caregivers because most sources of care for the elderly in Japan are not provided by private agencies but by family members. However, family caregivers not only help with daily living but are also key participants in treatment decision making. The effect of family absence on treatment decision making has not been elucidated, although more elderly people will not have family members to make surrogate decisions on their behalf. OBJECTIVE The aim is to understand the influence of family absence on treatment decision making by physicians through a cross-sectional online survey with three hypothetical vignettes of patients. METHODS We conducted a cross-sectional online survey among Japanese physicians using three hypothetical vignettes. The first vignette was about a 65-year-old man with alcoholic liver cirrhosis and the second was about a 78-year-old woman with dementia, both of whom developed pneumonia with consciousness disturbance. The third vignette was about a 70-year-old woman with necrosis of her lower limb. Participants were randomly assigned to either of the two versions of the questionnaires-with family or without family-but methods were identical otherwise. Participants chose yes or no responses to questions about whether they would perform the presented medical procedures. RESULTS Among 1112 physicians, 454 (40.8%) completed the survey; there were no significant differences in the baseline characteristics between groups. Significantly fewer physicians had a willingness to perform dialysis (odds ratio [OR] 0.55, 95% CI 0.34-0.80; P=.002) and artificial ventilation (OR 0.51, 95% CI 0.35-0.75; P<.001) for a patient from vignette 1 without family. In vignette 2, fewer physicians were willing to perform artificial ventilation (OR 0.59, 95% CI 0.39-0.90; P=.02). In vignette 3, significantly fewer physicians showed willingness to perform wound treatment (OR 0.51, 95% CI 0.31-0.84; P=.007), surgery (OR 0.35, 95% CI 0.22-0.57; P<.001), blood transfusion (OR 0.45, 95% CI 0.31-0.66; P<.001), vasopressor (OR 0.49, 95% CI 0.34-0.72; P<.001), dialysis (OR 0.38, 95% CI 0.24-0.59; P<.001), artificial ventilation (OR 0.25, 95% CI 0.15-0.40; P<.001), and chest compression (OR 0.29, 95% CI 0.18-0.47; P<.001) for a patient without family. CONCLUSIONS Elderly patients may have treatments withheld because of the absence of family, highlighting the potential importance of advance care planning in the era of an aging society with a declining birth rate.
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Affiliation(s)
- Kenji Tsuda
- Medical Governance Research Institute, Minatoku, Japan
| | - Asaka Higuchi
- Medical Governance Research Institute, Minatoku, Japan
| | - Emi Yokoyama
- Graduate School of Education, Seisa University, Yokohama, Japan
| | | | | | - Masahiro Kami
- Medical Governance Research Institute, Minatoku, Japan
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17
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Ramos JGR, Vieira RD, Tourinho FC, Ismael A, Ribeiro DC, de Medeiro HJ, Forte DN. Withholding and Withdrawal of Treatments: Differences in Perceptions between Intensivists, Oncologists, and Prosecutors in Brazil. J Palliat Med 2019; 22:1099-1105. [PMID: 30973293 DOI: 10.1089/jpm.2018.0554] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background: Legal concerns have been implicated in the occurrence of variability in decisions of limitations of medical treatment (LOMT) before death. Objective: We aimed to assess differences in perceptions between physicians and prosecutors toward LOMT. Measurements: We sent a survey to intensivists, oncologists, and prosecutors from Brazil, from February 2018 to May 2018. Respondents rated the degree of agreement with withholding or withdrawal of therapies in four different vignettes portraying a patient with terminal lung cancer. We measured the difference in agreement between respondents. Results: There were 748 respondents, with 522 (69.8%) intensivists, 106 (14.2%) oncologists, and 120 (16%) prosecutors. Most respondents agreed with withhold of chemotherapy (95.2%), withhold of mechanical ventilation (MV) (90.2%), and withdrawal of MV (78.4%), but most (75%) disagreed with withdrawal of MV without surrogate's consent. Prosecutors were less likely than intensivists and oncologists to agree with withhold of chemotherapy (95.7% vs. 99.2% vs. 100%, respectively, p < 0.001) and withhold of MV (82.4% vs. 98.3% vs. 97.9%, respectively, p < 0.001), whereas intensivists were more likely to agree with withdrawal of MV than oncologists (87.1% vs. 76.1%, p = 0.002). Moreover, prosecutors were more likely to agree with withholding of active cancer treatment than with withholding of MV [difference (95% confidence interval, CI) = 13.2% (5.2 to 21.6), p = 0.001], whereas physicians were more likely to agree with withholding than with withdrawal of MV [difference (95% CI) = 10.9% (7.8 to 14), p < 0.001]. Conclusions: This study found differences and agreements in perceptions toward LOMT between prosecutors, intensivists, and oncologists, which may inform the discourse aimed at improving end-of-life decisions.
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Affiliation(s)
- João Gabriel Rosa Ramos
- Intensive Care Unit, Hospital Sao Rafael, Salvador, Brazil.,Palliative Care Team, Hospital Sao Rafael, Salvador, Brazil.,Clinica Florence Hospice and Rehabilitation Center, Salvador, Brazil
| | | | | | - Andre Ismael
- Prosecution Service at Distrito Federal e Territorios, Brasilia, Brazil
| | | | | | - Daniel Neves Forte
- Teaching and Research on Palliative Care Program, Hospital Sirio-Libanes, Sao Paulo, Brazil
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18
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Rocker G, Dunbar S. Withholding or Withdrawal of Life Support: The Canadian Critical Care Society Position Paper. J Palliat Care 2019. [DOI: 10.1177/082585970001601s10] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Graeme Rocker
- Canadian Critical Care Society Provincial Representative for Nova Scotia
| | - Scott Dunbar
- Postgraduate Diploma in Medical Law and Medical Ethics, (KCL), and Fellow in Bioethics, Cleveland Clinic Foundation, Ohio, and Medical Ethicist, Halifax, Nova Scotia, Canada
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19
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Masri C, Farrell CA, Lacroix J, Rocker G, Shemie SD. Decision Making and End-of-Life Care in Critically Ill Children. J Palliat Care 2019. [DOI: 10.1177/082585970001601s09] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives 1) To comment on the medical literature on decision making regarding end-of-life therapy, 2) to analyze the data on disagreement about such therapy, including palliative care, and withholding and withdrawal practices for critically ill children in the pediatric intensive care unit (PICU), and 3) to make some general recommendations. Data Sources and Study Selection All papers published in peer-reviewed journals, and all chapters on end-of-life therapy, or on conflict between parents and caregivers about end-of-life decisions in the PICU were retrieved. Results We found three case series, three systematic descriptive studies, two qualitative studies, four surveys, and many legal opinions, editorials, reviews, guidelines, and book chapters. The main determinants of end-of-life decisions are the child's age, premorbid cognitive condition and functional status, pain or discomfort, probability of survival, and quality of life. Risk factors in persistent conflict between parents and caregivers about end-of-life care include a grave underlying condition or an unexpected and severe event. Conclusion Making decisions about end-of-life care is a frequent event in the PICU. Children may need both intensive care and palliative care concurrently at different stages of their illness. Disagreements are more likely to be resolved if the root cause of the conflict is better understood.
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Affiliation(s)
- Christian Masri
- Pediatric Intensive Care Unit, Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, Quebec
| | - Catherine Ann Farrell
- Pediatric Intensive Care Unit, Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, Quebec
| | - Jacques Lacroix
- Pediatric Intensive Care Unit, Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Montreal, Quebec
| | - Graeme Rocker
- Department of Medicine, The Queen Elizabeth II Health Center, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia
| | - Sam D. Shemie
- Pediatric Intensive Care Unit, The Hospital For Sick Children, and Department of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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20
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Keenan SP, Mawdsley C, Plotkin D, Webster GK, Priestap F. Withdrawal of Life Support: How the Family Feels, and Why. J Palliat Care 2019. [DOI: 10.1177/082585970001601s08] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The objectives of this study were to develop an instrument to assess the satisfaction of family members with withdrawal of life support (WLS), and to determine which factors are associated with greater levels of satisfaction. To do this, we developed a self-administered questionnaire that was sent to the next-of-kin of intensive care unit (ICU) patients dying following WLS. Over a six-month period, 69 patients died following WLS in the ICU. Three letters were returned “address unknown”, 33 did not respond, and 33 responded, of whom 29 agreed to participate (29/66 = 44% of those contacted). Of these, 24 (83%) strongly agreed with the patient's death being compassionate and dignified, one moderately agreed, one mildly agreed, one was neutral and two strongly disagreed. Items associated with greater satisfaction included: the process of WLS being well explained, WLS proceeding as expected, patient appearing comfortable, family/friends prepared for the decision, appropriate person initiating discussion, adequate privacy during WLS, chance to voice concerns. The study suggests factors that are important to consider in ensuring family comfort with the process of withdrawing life support.
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Affiliation(s)
- Sean P. Keenan
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, British Columbia, Division of Critical Care Medicine, Department of Medicine, London Health Sciences Centre, University of Western Ontario, and Critical Care Research Network (CCR-Net), London Health Sciences Centre, London, Ontario
| | - Cathy Mawdsley
- Critical Care Research Network (CCR-Net), London Health Sciences Centre, and Critical Care Program, London Health Sciences Centre, University of Western Ontario, London, Ontario
| | - Donna Plotkin
- Critical Care Research Network (CCR-Net), London Health Sciences Centre, Department of Social Work, London Health Sciences Centre, University of Western Ontario, London, Ontario
| | - Gregory K. Webster
- Critical Care Research Network (CCR-Net), London Health Sciences Centre, London, Ontario
| | - Fran Priestap
- Critical Care Research Network (CCR-Net), London Health Sciences Centre, London, Ontario, Canada
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21
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Katz NT, Sacks BH, Le BH, Hynson JL. Pre-emptive prescription of medications for the management of potential, catastrophic events in patients with a terminal illness: A survey of palliative medicine doctors. Palliat Med 2019; 33:178-186. [PMID: 30369278 DOI: 10.1177/0269216318809668] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Distressing and potentially life-threatening events, such as significant external bleeding, may occur in patients with a known terminal condition. These events are often referred to as catastrophic or crisis events. Pharmacological management varies and there is little evidence to guide practice. Aim: The aim of this study was to explore Australasian palliative medicine doctors’ approaches to pre-emptive prescription of medications to manage catastrophic events. Design: Anonymous survey data were collected electronically. Setting/Participants: Australian and New Zealand palliative medicine fellows and trainees were surveyed. Results: Surveys were completed by 121 doctors; 108 (89.2%) who care for adult patients only and 13 (10.8%) who care for paediatric patients or paediatric and adult patients. In all, 74 (61.2%) respondents pre-emptively prescribed medications at least five times per year, and most orders were never administered. Significant visible bleeding and severe, acute airway obstruction were almost universally considered catastrophic events. Many respondents expressed concern about the lack of evidence to guide pre-emptive medication prescription in this setting. Clinicians reported adverse events related to pre-emptive medication orders being available ( n = 30, 24.8%), as well as orders not being available ( n = 61, 50.4%). Conclusion: Our study supports the need for guidelines, as well as formal education programmes for medical trainees and nursing staff about this important area of practice.
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Affiliation(s)
- Naomi T Katz
- 1 Victorian Paediatric Palliative Care Program, Royal Children's Hospital, Melbourne, VIC, Australia.,2 Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia.,3 Clinical Paediatrics Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Bronwyn H Sacks
- 1 Victorian Paediatric Palliative Care Program, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Brian H Le
- 4 Parkville Integrated Palliative Care Service, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Jenny L Hynson
- 1 Victorian Paediatric Palliative Care Program, Royal Children's Hospital, Melbourne, VIC, Australia.,2 Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia.,3 Clinical Paediatrics Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
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22
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Does Calculated Prognostic Estimation Lead to Different Outcomes Compared With Experience-Based Prognostication in the ICU? A Systematic Review. Crit Care Explor 2019; 1:e0004. [PMID: 32166250 DOI: 10.1097/cce.0000000000000004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Little is known about the impact of providing calculator/guideline based versus clinical experiential-based prognostic estimates to patients/caregivers in the ICU. We sought to determine whether studies have compared types of prognostic estimation in the ICU and associations with outcomes. Data Sources Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, databases searched were PubMed, Embase, Web of Science, and Cochrane Library. The search was run on January 4, 2016, and April 12, 2017. References for included articles were searched. Study Selection Studies meeting the following criteria were included in the analysis: communication of prognostic estimates, a comparator group, and in the adult ICU setting. Data Extraction Titles/abstracts were reviewed by two researchers. We identified 10,704 articles of which 10 met inclusion criteria. Seven of the studies included estimates obtained from calculators/guidelines and three were based on subjective estimation wherein clinicians were asked to estimate prognosis based on experience. Only the seven using calculated/guideline based estimation were used for pooled analysis. Of these, one was a randomized trial, and six were nonrandomized before/after studies. All of the studies communicated the calculated/guideline-based estimates to the clinician. Two studies involved the communication of calculated prognostic estimates to the ICU physicians for all ICU patients. Four included identification of high-risk patients based on guidelines or review of historical local data which triggered a palliative care/ethics consultation, and one study included communication to physicians about guideline based likely outcomes for neurologic recovery for patients with out-of-hospital cardiac arrest survivors. The comparator arm in all studies was usual care without protocolized prognostication. Data Synthesis Included studies were assessed for risk of bias. The most common outcomes measured were hospital mortality; do-not-resuscitate status; and medical ICU length of stay. In pooled analyses, there was an association between calculated/guideline based prognostic estimation and decreased medical ICU length of stay as well as increased do-not-resuscitate status, but no difference in hospital mortality. Conclusions Protocolized assessment of calculator/guideline based prognosis in ICU patients is associated with decreased medical ICU length of stay and increased do-not-resuscitate status but does not have a significant effect on mortality. Future studies should explore how communicating these estimates to physicians changes behaviors including communication to patients/families and whether calculator/guideline based prognostication is associated with improved patient and family rated outcomes.
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23
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Abstract
The ability of intensive care to replace or support vital organ function has resulted in some patients surviving for long periods of time without improvement or a terminal event. In patients with no realistic chance of survival, decisions to withdraw or withhold life-sustaining therapies are commonly made. Withdrawal of life support at the patient's request is lawful at common law and, in some states of Australia, by legal statute. In the intensive care setting though, it is more common for therapy to be withdrawn because the therapy is of no perceived benefit or not in the patient's best interests. However, in Australia there is little case law and very little legislation to direct the decision of whether to withdraw life-sustaining therapy on the grounds of futility or the patient's best interests. The legislation that does exist in Australia, as well as law from other jurisdictions, largely places responsibility for the decision to withdraw therapy on the doctor in charge of the patient's care. However much weight is frequently placed on the wishes of the family. Disagreements between family and clinicians over decisions to withdraw therapy are unusual and generally resolve over time. However if disagreement persists, it may be advisable to apply to the courts for a declaratory judgement, given the tenuous legal basis of withdrawal of life-sustaining therapy in Australia and the uncertainty over the courts’ view of the role of the patient's family in the decision-making process.
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Affiliation(s)
- R J Young
- Intensive Care Unit, Royal Adelaide Hospital, North Terrace, Adelaide, S.A. 5000
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24
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Bracken-Roche D, Shevell M, Racine E. Understanding and addressing barriers to communication in the context of neonatal neurologic injury: Exploring the ouR-HOPE approach. HANDBOOK OF CLINICAL NEUROLOGY 2019; 162:511-528. [PMID: 31324327 DOI: 10.1016/b978-0-444-64029-1.00024-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Predicting neurologic outcomes for neonates with acute brain injury is essential for guiding the development of treatment goals and appropriate care plans in collaboration with parents and families. Prognostication helps parents imagine their child's possible future and helps them make ongoing treatment decisions in an informed way. However, great uncertainty surrounds neurologic prognostication for neonates, as well as biases and implicit attitudes that can impact clinicians' prognoses, all of which pose significant challenges to evidence-based prognostication in this context. In order to facilitate greater attention to these challenges and guide their navigation, this chapter explores the practice principles captured in the ouR-HOPE approach. This approach proposes the principles of Reflection, Humility, Open-mindedness, Partnership, and Engagement and related self-assessment questions to encourage clinicians to reflect on their practices and to engage with others in responding to challenges. We explore the meaning of each principle through five clinical cases involving neonatal neurologic injury, decision making, and parent-clinician communication. The ouR-HOPE approach should bring more cohesion to the sometimes disparate concerns reported in the literature and encourage clinicians and teams to consider its principles along with other guidelines and practices they find to be particularly helpful in guiding communication with parents and families.
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Affiliation(s)
- Dearbhail Bracken-Roche
- Neuroethics Research Unit, Institut de recherches cliniques de Montréal, Montréal, QC, Canada
| | - Michael Shevell
- Department of Pediatrics and Department of Neurology and Neurosurgery, McGill University, Montréal, QC, Canada.
| | - Eric Racine
- Neuroethics Research Unit, Institut de recherches cliniques de Montréal, Montréal, QC, Canada
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Ramos JGR, Dias RD, Passos RDH, Batista PBP, Forte DN. Prognostication in urgent intensive care unit referrals: a cohort study. BMJ Support Palliat Care 2018; 10:118-121. [PMID: 30171040 DOI: 10.1136/bmjspcare-2018-001567] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 08/06/2018] [Accepted: 08/15/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Prognostication is an essential ability to clinicians. Nevertheless, it has been shown to be quite variable in acutely ill patients, potentially leading to inappropriate care. We aimed to assess the accuracy of physician's prediction of hospital mortality in acutely deteriorating patients referred for urgent intensive care unit (ICU) admission. METHODS Prospective cohort of acutely ill patients referred for urgent ICU admission in an academic, tertiary hospital. Physicians' prognosis assessments were recorded at ICU referral. Prognosis was assessed as survival without severe disabilities, survival with severe disabilities or no survival. Prognosis was further dichotomised in good prognosis (survival without severe disabilities) or poor prognosis (survival with severe disabilities or no survival) for prediction of hospital mortality. RESULTS There were 2374 analysed referrals, with 2103 (88.6%) patients with complete data on mortality and physicians' prognosis. There were 593 (34.4%), 215 (66.4%) and 51 (94.4%) deaths in the groups ascribed a prognosis of survival without disabilities, survival with severe disabilities or no survival, respectively (p<0.001). Sensitivity was 31%, specificity was 91% and the area under the receiver operating characteristic curve was 0.61 for prediction of mortality. After multivariable analysis, severity of illness, performance status and ICU admission were associated with an increased likelihood of incorrect classification, while worse predicted prognosis was associated with a lower chance of incorrect classification. CONCLUSIONS Physician's prediction was associated with hospital mortality, but overall accuracy was poor, mainly due to low sensitivity to detect risk of poor prognosis.
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Affiliation(s)
- Joao Gabriel Rosa Ramos
- Medical Sciences PhD Program, University of São Paulo Medical School, São Paulo, Brazil .,Intensive Care Unit, Hospital São Rafael, Salvador, Brazil.,Clinica Florence (Hospice and Rehabilitation Service), Salvador, Brazil
| | - Roger Daglius Dias
- Emergency Department, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Paulo, Brazil.,Emergency Department, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Paulo Benigno Pena Batista
- Intensive Care Unit, Hospital São Rafael, Salvador, Brazil.,UNIME Medical School, Lauro de Freitas, Brazil
| | - Daniel Neves Forte
- Medical Sciences PhD Program, University of São Paulo Medical School, São Paulo, Brazil.,Hospital Sirio-Libanes, Sao Paulo, Brazil
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26
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Leblanc G, Boutin A, Shemilt M, Lauzier F, Moore L, Potvin V, Zarychanski R, Archambault P, Lamontagne F, Léger C, Turgeon AF. Incidence and impact of withdrawal of life-sustaining therapies in clinical trials of severe traumatic brain injury: A systematic review. Clin Trials 2018; 15:398-412. [PMID: 29865897 DOI: 10.1177/1740774518771233] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Most deaths following severe traumatic brain injury follow decisions to withdraw life-sustaining therapies. However, the incidence of the withdrawal of life-sustaining therapies and its potential impact on research data interpretation have been poorly characterized. The aim of this systematic review was to assess the reporting and the impact of withdrawal of life-sustaining therapies in randomized clinical trials of patients with severe traumatic brain injury. Methods We searched Medline, Embase, Cochrane Central, BIOSIS, and CINAHL databases and references of included trials. All randomized controlled trials published between January 2002 and August 2015 in the six highest impact journals in general medicine, critical care medicine, and neurocritical care (total of 18 journals) were considered for eligibility. Randomized controlled trials were included if they enrolled adult patients with severe traumatic brain injury (Glasgow Coma Scale ≤ 8) and reported data on mortality. Our primary objective was to assess the proportion of trials reporting the withdrawal of life-sustaining therapies in a publication. Our secondary objectives were to describe the overall mortality rate, the proportion of deaths following the withdrawal of life-sustaining therapies, and to assess the impact of the withdrawal of life-sustaining therapies on trial results. Results From 5987 citations retrieved, we included 41 randomized trials (n = 16,364, ranging from 11 to 10,008 patients). Overall mortality was 23% (range = 3%-57%). Withdrawal of life-sustaining therapies was reported in 20% of trials (8/41, 932 patients in trials) and the crude number of deaths due to the withdrawal of life-sustaining therapies was reported in 17% of trials (7/41, 884 patients in trials). In these trials, 63% of deaths were associated with the withdrawal of life-sustaining therapies (105/168). An analysis carried out by imputing a 4% differential rate in instances of withdrawal of life-sustaining therapies between study groups yielded different results and conclusions in one third of the trials. Conclusion Data on the withdrawal of life-sustaining therapies are incompletely reported in randomized controlled trials of patients with severe traumatic brain injury. Given the high proportion of deaths due to the withdrawal of life-sustaining therapies in severe traumatic brain injury patients, and the potential of this medical decision to influence the results of clinical trials, instances of withdrawal of life-sustaining therapies should be systematically reported in clinical trials in this group of patients.
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Affiliation(s)
- Guillaume Leblanc
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,2 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Amélie Boutin
- 3 Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Michèle Shemilt
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - François Lauzier
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,2 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada.,4 Department of Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Lynne Moore
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,3 Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Véronique Potvin
- 2 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Ryan Zarychanski
- 5 Department of Internal Medicine, Sections of Critical Care Medicine, Haematology and Medical Oncology, Faculty of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Patrick Archambault
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,2 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada.,6 Department of Family and Emergency Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - François Lamontagne
- 7 Department of Medicine, Faculty of Medicine, University of Sherbrooke, Sherbrooke, QC, Canada.,8 Centre de recherche du CHU de Sherbrooke, Sherbrooke, QC, Canada
| | - Caroline Léger
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Alexis F Turgeon
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,2 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
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27
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Wang CH, Huang PW, Hung CY, Lee SH, Kao CY, Wang HM, Hung YS, Su PJ, Kuo YC, Hsieh CH, Chou WC. Clinical Factors Associated With Adherence to the Premedication Protocol for Withdrawal of Mechanical Ventilation in Terminally Ill Patients: A 4-Year Experience at a Single Medical Center in Asia. Am J Hosp Palliat Care 2018; 35:772-779. [DOI: 10.1177/1049909117732282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Chao-Hui Wang
- Department of Nursing, Chang Gung Medical Foundation at Linkou, Guishan, Taoyuan, Taiwan
| | - Pei-Wei Huang
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Guishan, Taoyuan, Taiwan
| | - Chia-Yen Hung
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Guishan, Taoyuan, Taiwan
- Department of Hema-Oncology, Division of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Shu-Hui Lee
- Department of Nursing, Chang Gung Medical Foundation at Linkou, Guishan, Taoyuan, Taiwan
| | - Chen-Yi Kao
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Guishan, Taoyuan, Taiwan
| | - Hung-Ming Wang
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Guishan, Taoyuan, Taiwan
| | - Yu-Shin Hung
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Guishan, Taoyuan, Taiwan
| | - Po-Jung Su
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Guishan, Taoyuan, Taiwan
| | - Yung-Chia Kuo
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Guishan, Taoyuan, Taiwan
| | - Chia-Hsun Hsieh
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Guishan, Taoyuan, Taiwan
| | - Wen-Chi Chou
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Guishan, Taoyuan, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Guishan, Taoyuan, Taiwan
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28
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International Practice Variation in Weaning Critically Ill Adults from Invasive Mechanical Ventilation. Ann Am Thorac Soc 2018; 15:494-502. [DOI: 10.1513/annalsats.201705-410oc] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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Hung YS, Lee SH, Hung CY, Wang CH, Kao CY, Wang HM, Chou WC. Clinical characteristics and survival outcomes of terminally ill patients undergoing withdrawal of mechanical ventilation. J Formos Med Assoc 2017; 117:798-805. [PMID: 29032021 DOI: 10.1016/j.jfma.2017.09.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 09/29/2017] [Accepted: 09/30/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Withdrawal of mechanical ventilation is an important, but rarely explored issue in Asia during end-of-life care. This study aimed to describe the clinical characteristics and survival outcomes of terminally ill patients undergoing withdrawal of mechanical ventilation in Taiwan. METHODS One-hundred-thirty-five terminally ill patients who had mechanical ventilation withdrawn between 2013 and 2016, from a medical center in Taiwan, were enrolled. Patients' clinical characteristics and survival outcomes after withdrawal of mechanical ventilation were analyzed. RESULTS The three most common diagnoses were organic brain lesion, advanced cancer, and newborn sequelae. The initiator of the withdrawal process was family, medical personnel, and patient him/herself. The median survival time was 45 min (95% confidence interval, 33-57 min) after the withdrawal of mechanical ventilation, and 102 patients (75.6%) died within one day after extubation. The median time from diagnosis of disease to receiving life-sustaining treatment and artificial ventilation support, receiving life-sustaining treatment and artificial ventilation support to "Withdrawal meeting," "Withdrawal meeting" to ventilator withdrawn, and ventilator withdrawn to death was 12.1 months, 19 days, 1 day, and 0 days, respectively. Patients with a diagnosis of advanced cancer and withdrawal initiation by the patients themselves had a significantly shorter time interval between receiving life-sustaining treatment and artificial ventilation support to "Withdrawal meeting" compared to those with non-cancer diseases and withdrawal initiation by family or medical personnel. CONCLUSION This study is the first observational study to describe the patients' characteristics and elaborate on the survival outcome of withdrawal of mechanical ventilation in patients who are terminally ill in an Asian population. Understanding the clinical characteristics and survival outcomes of mechanical ventilation withdrawal might help medical personnel provide appropriate end-of-life care and help patients/families decide about the withdrawal process earlier.
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Affiliation(s)
- Yu-Shin Hung
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taiwan
| | - Shu-Hui Lee
- Department of Nursing, Chang Gung Medical Foundation at Linkou, Taiwan
| | - Chia-Yen Hung
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taiwan; Department of Hematology-Oncology, Division of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Chao-Hui Wang
- Department of Nursing, Chang Gung Medical Foundation at Linkou, Taiwan
| | - Chen-Yi Kao
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taiwan
| | - Hung-Ming Wang
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taiwan
| | - Wen-Chi Chou
- Department of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taiwan.
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Addario BJ, Fadich A, Fox J, Krebs L, Maskens D, Oliver K, Schwartz E, Spurrier-Bernard G, Turnham T. Patient value: Perspectives from the advocacy community. Health Expect 2017; 21:57-63. [PMID: 28940536 PMCID: PMC5750698 DOI: 10.1111/hex.12628] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2017] [Indexed: 11/29/2022] Open
Abstract
All health-care systems are under financial pressure and many have therefore developed value frameworks to assist decision making regarding access to treatment. Unfortunately, many frameworks simply reflect the clinically focused values held by health-care professionals rather than outcomes that also matter to patients. It is difficult to define one single homogeneous set of patient values as these are shaped by social, religious and cultural factors, and health-care environment, as well as many factors such as age, gender, education, family and friends and personal finances. Instead of focusing on an aggregated set of values, frameworks should attempt to incorporate the broader range of outcomes that patients may regard as more relevant. Patient advocates are well placed to advise assessment bodies on how particular therapies will impact the patient population under consideration and should be closely involved in developing value frameworks. In this paper, a group of patient advocates explore the varying definitions of patient value and make positive recommendations for working together to strengthen the patient voice in this area. The authors call on framework developers, the patient advocacy and research communities, the health-care industry and decision-makers to undertake specific actions to ensure patient value is included in current and future value frameworks. This is justified on compassionate and economic grounds: better health outcomes result when patients receive treatment tailored to individual needs. Paying attention to the patient perspective also results in better use of resources-a goal that should appeal to all stakeholders.
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Affiliation(s)
- Bonnie J Addario
- Bonnie J Addario Lung Cancer Foundation (ALCF), San Carlos, CA, USA
| | - Ana Fadich
- Men's Health Network, Washington, DC, USA
| | - Jesme Fox
- Roy Castle Lung Cancer Foundation, Liverpool, UK
| | - Linda Krebs
- International Society of Nurses in Cancer Care, Vancouver, BC, Canada
| | - Deborah Maskens
- International Kidney Cancer Coalition (IKCC), Co-founder Kidney Cancer Canada, Guelph, Ontario, Canada
| | - Kathy Oliver
- International Brain Tumour Alliance (IBTA), Surrey, UK
| | - Erin Schwartz
- Strategic Partnerships and Communications, The Max Foundation, Seattle, WA, USA
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31
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Ntantana A, Matamis D, Savvidou S, Marmanidou K, Giannakou M, Gouva Μ, Nakos G, Koulouras V. 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. BMJ Open 2017; 7:e013916. [PMID: 28733295 PMCID: PMC5577864 DOI: 10.1136/bmjopen-2016-013916] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Asimenia Ntantana
- ICU “Papageorgiou” General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Matamis
- ICU “Papageorgiou” General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Savvoula Savvidou
- ICU “Papageorgiou” General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Kyriaki Marmanidou
- ICU “Papageorgiou” General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Maria Giannakou
- ICU AHEPA University Hospital of Thessaloniki, Thessaloniki, Greece
| | - Μary Gouva
- Technological Educational Institutes of Ipeirus, Thanaseika, Greece
| | - George Nakos
- ICU University Hospital of Ioannina, Ioannina, Greece
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Racine E, Bell E, Farlow B, Miller S, Payot A, Rasmussen LA, Shevell MI, Thomson D, Wintermark P. The 'ouR-HOPE' approach for ethics and communication about neonatal neurological injury. Dev Med Child Neurol 2017; 59:125-135. [PMID: 27915463 DOI: 10.1111/dmcn.13343] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/21/2016] [Indexed: 11/26/2022]
Abstract
Predicting neurological outcomes of neonates with acute brain injury is an essential component of shared decision-making, in order to guide the development of treatment goals and appropriate care plans. It can aid parents in imagining the child's future, and guide timely and ongoing treatment decisions, including shifting treatment goals and focusing on comfort care. However, numerous challenges have been reported with respect to evidence-based practices for prognostication such as biases about prognosis among clinicians. Additionally, the evaluation or appreciation of living with disability can differ, including the well-known disability paradox where patients self-report a good quality of life in spite of severe disability. Herein, we put forward a set of five practice principles captured in the "ouR-HOPE" approach (Reflection, Humility, Open-mindedness, Partnership, and Engagement) and related questions to encourage clinicians to self-assess their practice and engage with others in responding to these challenges. We hope that this proposal paves the way to greater discussion and attention to ethical aspects of communicating prognosis in the context of neonatal brain injury.
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Affiliation(s)
- Eric Racine
- Institut de recherches cliniques de Montréal, Montréal, Canada.,Université de Montréal, Montréal, Canada.,McGill University, Montréal, Canada
| | - Emily Bell
- Institut de recherches cliniques de Montréal, Montréal, Canada
| | - Barbara Farlow
- The DeVeber Institute for Bioethics and Social Research, Toronto, Canada.,Patients for Patient Safety Canada, Edmonton, Canada
| | - Steven Miller
- Hospital for Sick Children, Toronto, Canada.,University of Toronto, Toronto, Canada
| | - Antoine Payot
- Université de Montréal, Montréal, Canada.,CHU Sainte-Justine, Montréal, Canada
| | | | - Michael I Shevell
- McGill University, Montréal, Canada.,Montreal Children's Hospital, Montréal, Canada
| | - Donna Thomson
- NeuroDevNet/Kids Brain Health Network, Vancouver, Canada
| | - Pia Wintermark
- McGill University, Montréal, Canada.,Montreal Children's Hospital, Montréal, Canada
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Rasmussen LA, Bell E, Racine E. A Qualitative Study of Physician Perspectives on Prognostication in Neonatal Hypoxic Ischemic Encephalopathy. J Child Neurol 2016; 31:1312-9. [PMID: 27377309 DOI: 10.1177/0883073816656400] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 05/24/2016] [Indexed: 12/16/2022]
Abstract
Hypoxic ischemic encephalopathy is the most frequent cause of neonatal encephalopathy and yields a great degree of morbidity and mortality. From an ethical and clinical standpoint, neurological prognosis is fundamental in the care of neonates with hypoxic ischemic encephalopathy. This qualitative study explores physician perspectives about neurological prognosis in neonatal hypoxic ischemic encephalopathy. This study aimed, through semistructured interviews with neonatologists and pediatric neurologists, to understand the practice of prognostication. Qualitative thematic content analysis was used for data analysis. The authors report 2 main findings: (1) neurological prognosis remains fundamental to quality-of-life predictions and considerations of best interest, and (2) magnetic resonance imaging is presented to parents with a greater degree of certainty than actually exists. Further research is needed to explore both the parental perspective and, prospectively, the impact of different clinical approaches and styles to prognostication for neonatal hypoxic ischemic encephalopathy.
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Affiliation(s)
- Lisa Anne Rasmussen
- McGill University, Montréal, Québec, Canada Institut de recherches cliniques de Montréal, Montréal, Québec, Canada
| | - Emily Bell
- Institut de recherches cliniques de Montréal, Montréal, Québec, Canada
| | - Eric Racine
- McGill University, Montréal, Québec, Canada Institut de recherches cliniques de Montréal, Montréal, Québec, Canada Université de Montréal, Montréal, Québec, Canada
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Red Blood Cell Transfusion in the Postoperative Care of Pediatric Cardiac Surgery: Survey on Stated Practice. Pediatr Cardiol 2016; 37:1266-73. [PMID: 27377529 DOI: 10.1007/s00246-016-1427-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 05/26/2016] [Indexed: 10/21/2022]
Abstract
The optimal red blood cell transfusion threshold for postoperative pediatric cardiac surgery patients is unknown. This study describes the stated red blood cell transfusion practice of physicians who treat postoperative pediatric cardiac surgery patients in intensive care units. A scenario-based survey was sent to physicians involved in postoperative intensive care of pediatric cardiac surgery patients in all Canadian centers that perform such surgery. Respondents reported their red blood cell transfusion practice in four postoperative scenarios: acyanotic or cyanotic cardiac lesion, in a neonate or an infant. In part A of each scenario, the patient was critically ill, but stabilized; in part B, the patient became unstable. Response rate was 58 % (71 of 123), with 45 respondents indicating direct involvement in postoperative intensive care. There was a wide variability in stated transfusion threshold, ranging from <7.0-14.0 g/dL for stabilized cases. There was no significant difference between neonates and infants in stated transfusion threshold. The mean hemoglobin level below which respondents would transfuse a stabilized patient was 9 g/dL for acyanotic and 11.2 g/dL for cyanotic patients, a statistically significant difference (2.2 ± 0.9 g/dL, p < 0.001). All clinical determinants of instability significantly increased transfusion threshold. Hemodynamic instability increased transfusion threshold by 2.3 ± 1.3 g/dL in acyanotic patients and by 1.3 ± 1.1 g/dL in cyanotic patients. Cyanotic lesion and clinical instability, but not patient age, increased stated red blood cell transfusion threshold. Significant variation in reported red blood cell transfusion practice exists among physicians treating pediatric patients in intensive care following cardiac surgery.
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Svantesson M, Sjökvist P, Thorsén H, Ahlström G. Nurses’ and Physicians’ Opinions on Aggressiveness of Treatment for General Ward Patients. Nurs Ethics 2016; 13:147-62. [PMID: 16526149 DOI: 10.1191/0969733006ne861oa] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The aim of this study was to evaluate agreement between nurses’ and physicians’ opinions regarding aggressiveness of treatment and to investigate and compare the rationales on which their opinions were based. Structured interviews regarding 714 patients were performed on seven general wards of a university hospital. The data gathered were then subjected to qualitative and quantitative analyses. There was 86% agreement between nurses’ and physicians’ opinions regarding full or limited treatment when the answers given as ‘uncertain’ were excluded. Agreement was less (77%) for patients with a life expectancy of less than one year. Disagreements were not associated with professional status because the physicians considered limiting life-sustaining treatment as often as the nurses. A broad spectrum of rationales was given but the results focus mostly on those for full treatment. The nurses and the physicians had similar bases for their opinions. For the majority of the patients, medical rationales were used, but age and quality of life were also expressed as important determinants. When considering full treatment, nurses used quality-of-life rationales for significantly more patients than the physicians. Respect for patients’ wishes had a minor influence.
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Affiliation(s)
- Mia Svantesson
- Centre for Nursing Science, Orebro University Hospital, Sweden.
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van der Heide A, Vrakking A, van Delden H, Looman C, van der Maas P. Medical and Nonmedical Determinants of Decision Making about Potentially Life-Prolonging Interventions. Med Decis Making 2016; 24:518-24. [PMID: 15359001 DOI: 10.1177/0272989x04268952] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patient characteristics may influence medical decision making in various ways. The contribution of several patient characteristics to medical decision making was studied. Thirty oncologists, 29 nursing home physicians, and 22 cardiologistswere interviewed (overall response = 60%). Respondents were asked whether they would apply a specified intervention for a number of hypothetical seriously ill patients, who varied with respect to factors thatwere not relevant to the outcome of treatment. The condition that made patients clearly eligible for treatment was kept constant. In amultivariate regression model, patients with a better physical condition, a more obvious social role, and a lower age weremore likely to be treated thanwere other patients. Medical decision making is not exclusively based on empirical evidence but also related to morally complex issues such as patient age and social status.
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Affiliation(s)
- Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands.
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Siegler JE, Swaminathan B, Giruparajah M, Bosch J, Perera KS, Hart RG, Kasner SE. Age disparity in diagnostic evaluation of stroke patients: Embolic Stroke of Undetermined Source Global Registry Project. Eur Stroke J 2016; 1:130-138. [PMID: 31008275 DOI: 10.1177/2396987316652265] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 05/09/2016] [Indexed: 01/04/2023] Open
Abstract
Introduction: Incomplete evaluation of stroke patients may result in an unclear diagnosis. Our objective was to determine if older stroke patients more often undergo incomplete diagnostic evaluations versus younger patients in an international cohort. Patients and methods: The Embolic Stroke of Undetermined Source Global Registry was a retrospective cohort of consecutive stroke patients evaluated at 19 stroke centers in 19 countries. Diagnostic evaluation was considered as complete if the patient had, at a minimum, brain computed tomography or magnetic resonance imaging with evidence of infarction, extracranial and intracranial vascular imaging, electrocardiography, ≥24 h of cardiac rhythm monitoring, and echocardiography. Patients were diagnosed with Embolic Stroke of Undetermined Source if brain imaging confirmed a nonlacunar infarction and no stroke etiology was determined after complete evaluation. Completeness of evaluation was compared between patients ≥75 versus <75 years old. Results: The registry included 2132 patients with recent ischemic stroke during 2013-2014, of which 349 were diagnosed with Embolic Stroke of Undetermined Source. Embolic Stroke of Undetermined Source patients ≥75 years were less likely to undergo brain magnetic resonance imaging (74% versus 89%, p = 0.001), transesophageal echocardiography (22% versus 39%, p = 0.005), and combination transthoracic and transesophageal echocardiography (16% versus 32%, p = 0.005) compared with Embolic Stroke of Undetermined Source patients <75 years. Discussion: Our study has identified an international age disparity in fundamental diagnostic testing for older patients with stroke of unknown etiology. Some testing biases were affected by geographic location (e.g., brain MRI was less frequently used in European ESUS patients), whereas other testing was implemented less frequently in the elderly regardless of location (e.g., transesophageal echocardiogram). Conclusion: Older patients in this international cohort had less sophisticated diagnostic testing for stroke, despite advanced age being well established as an independent risk factor for recurrent stroke. This was a global problem and further investigations are warranted to explore the cause.
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Affiliation(s)
- James E Siegler
- Department of Neurology, University of Pennsylvania, Philadelphia, USA
| | | | - Mohana Giruparajah
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Canada
| | - Jackie Bosch
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Canada
| | - Kanjana S Perera
- Department of Medicine, McMaster University, Hamilton Health Sciences, Hamilton, Canada
| | - Robert G Hart
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, Canada
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, USA
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Withholding and withdrawal of life-sustaining treatments in low-middle-income versus high-income Asian countries and regions. Intensive Care Med 2016; 42:1118-27. [DOI: 10.1007/s00134-016-4347-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 03/30/2016] [Indexed: 10/22/2022]
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Ramos JGR, Perondi B, Dias RD, Miranda LC, Cohen C, Carvalho CRR, Velasco IT, Forte DN. Development of an algorithm to aid triage decisions for intensive care unit admission: a clinical vignette and retrospective cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:81. [PMID: 27036102 PMCID: PMC4818478 DOI: 10.1186/s13054-016-1262-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 03/08/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND Intensive care unit (ICU) admission triage is performed routinely and is often based solely on clinical judgment, which could mask biases. A computerized algorithm to aid ICU triage decisions was developed to classify patients into the Society of Critical Care Medicine's prioritization system. In this study, we sought to evaluate the reliability and validity of this algorithm. METHODS Nine senior physicians evaluated forty clinical vignettes based on real patients. The reference standard was defined as the priorities ascribed by two investigators with full access to patients' records. Agreement of algorithm-based priorities with the reference standard and with intuitive priorities provided by the physicians were evaluated. Correlations between algorithm prioritization and physicians' judgment of the appropriateness of ICU admissions in scarcity and nonscarcity settings were also evaluated. Validity was further assessed by retrospectively applying this algorithm to 603 patients with requests for ICU admission for association with clinical outcomes. RESULTS Agreement between algorithm-based priorities and the reference standard was substantial, with a median κ of 0.72 (interquartile range [IQR] 0.52-0.77). Algorithm-based priorities demonstrated higher interrater reliability (overall κ 0.61, 95% confidence interval [CI] 0.57-0.65; median percentage agreement 0.64, IQR 0.59-0.70) than physicians' intuitive prioritization (overall κ 0.51, 95% CI 0.47-0.55; median percentage agreement 0.49, IQR 0.44-0.56) (p = 0.001). Algorithm-based priorities were also associated with physicians' judgment of appropriateness of ICU admission (priorities 1, 2, 3, and 4 vignettes would be admitted to the last ICU bed in 83.7%, 61.2%, 45.2%, and 16.8% of the scenarios, respectively; p < 0.001) and with actual ICU admission, palliative care consultation, and hospital mortality in the retrospective cohort. CONCLUSIONS This ICU admission triage algorithm demonstrated good reliability and validity. However, more studies are needed to evaluate a difference in benefit of ICU admission justifying the admission of one priority stratum over the others.
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Affiliation(s)
- Joao Gabriel Rosa Ramos
- Medical sciences doctoral program, University of Sao Paulo Medical School, Sao Paulo, Brazil. .,Intensive Care Unit, Hospital Sao Rafael, Salvador, Brazil. .,UNIME Medical School, Lauro de Freitas, Brazil.
| | - Beatriz Perondi
- Emergency Department, Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Roger Daglius Dias
- Emergency Department, Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | | | - Claudio Cohen
- Bioethics Committee, Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil.,Discipline of Bioethics, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Carlos Roberto Ribeiro Carvalho
- Pulmonary Division, Heart Institute (InCor), Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Irineu Tadeu Velasco
- Intensive Care Unit, Emergency Medicine Discipline, Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Daniel Neves Forte
- Intensive Care Unit, Emergency Medicine Discipline, Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil.,Palliative Care Team, Hospital Sirio-Libanes, Sao Paulo, Brazil
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Dahine J, Mardini L, Jayaraman D. The Perceived Likelihood of Outcome of Critical Care Patients and Its Impact on Triage Decisions: A Case-Based Survey of Intensivists and Internists in a Canadian, Quaternary Care Hospital Network. PLoS One 2016; 11:e0149196. [PMID: 26871587 PMCID: PMC4752246 DOI: 10.1371/journal.pone.0149196] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Accepted: 01/28/2016] [Indexed: 11/18/2022] Open
Abstract
Introduction There is high variability amongst physicians’ assessments of appropriate ICU admissions, which may be based on potential assessments of benefit. We aimed to examine whether opinions over benefit of ICU admissions of critically ill medical inpatients differed based on physician specialty, namely intensivists and internists. Materials and Methods We carried out an anonymous, web-based questionnaire survey containing 5 typical ICU cases to all ICU physicians regardless of their base specialty as well as to all internists in 3 large teaching hospitals. For each case, we asked the participants to determine if the patient was an appropriate ICU admission and to assess different parameters (e.g. baseline function, likelihood of survival to ICU discharge, etc.). Agreement was measured using kappa values. Results 21 intensivists and 22 internists filled out the survey (response rate = 87.5% and 35% respectively). Predictions of likelihood of survival to ICU admission, hospital discharge and return to baseline were not significantly different between the two groups. However, agreement between individuals within each group was only slight to fair (kappa range = 0.09–0.22). There was no statistically significant difference in predicting ICU survival and prediction of survival to hospital discharge between both groups. The accuracy with which physicians predicted actual outcomes ranged between 35% and 100% and did not significantly differ between the two groups. A greater proportion of internists favoured non resuscitative measures (24.6% of intensivists and 46.9% internists [p = 0.002]). Conclusion In a case-based survey, physician specialty base did not affect assessments of ICU admission benefit or accuracy in outcome prediction, but resulted in a statistically significant difference in level of care assignments. Of note, significant disagreement amongst individuals in each group was found.
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Affiliation(s)
- Joseph Dahine
- Department of Critical Care, Royal Victoria Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Louay Mardini
- Department of Critical Care, Royal Victoria Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Dev Jayaraman
- Department of Critical Care, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
- Department of General Internal Medicine, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
- Department of Critical Care, Jewish General Hospital, Montreal, Quebec, Canada
- * E-mail:
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Bosslet GT, Pope TM, Rubenfeld GD, Lo B, Truog RD, Rushton CH, Curtis JR, Ford DW, Osborne M, Misak C, Au DH, Azoulay E, Brody B, Fahy BG, Hall JB, Kesecioglu J, Kon AA, Lindell KO, White DB. An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units. Am J Respir Crit Care Med 2015; 191:1318-30. [DOI: 10.1164/rccm.201505-0924st] [Citation(s) in RCA: 341] [Impact Index Per Article: 37.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
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Mark NM, Rayner SG, Lee NJ, Curtis JR. Global variability in withholding and withdrawal of life-sustaining treatment in the intensive care unit: a systematic review. Intensive Care Med 2015; 41:1572-85. [DOI: 10.1007/s00134-015-3810-5] [Citation(s) in RCA: 166] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 04/07/2015] [Indexed: 12/01/2022]
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van Beinum A, Hornby L, Ramsay T, Ward R, Shemie SD, Dhanani S. Exploration of Withdrawal of Life-Sustaining Therapy in Canadian Intensive Care Units. J Intensive Care Med 2015; 31:243-51. [PMID: 25680980 DOI: 10.1177/0885066615571529] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 12/03/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The process of controlled donation after circulatory death (cDCD) is strongly connected with the process of withdrawal of life-sustaining therapy. In addition to impacting cDCD success, actions comprising withdrawal of life-sustaining therapy have implications for quality of palliative care. We examined pilot study data from Canadian intensive care units to explore current practices of life-sustaining therapy withdrawal in nondonor patients and described variability in standard practice. DESIGN Secondary analysis of observational data collected for Determination of Death Practices in Intensive Care pilot study. SETTING Four Canadian adult intensive care units. PATIENTS Patients ≥18 years in whom a decision to withdraw life-sustaining therapy was made and substitute decision makers consented to study participation. Organ donors were excluded. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Prospective observational data on interventions withdrawn, drugs administered, and timing of life-sustaining therapy withdrawal was available for 36 patients who participated in the pilot study. Of the patients, 42% died in ≤1 hour; median length of time to death varied between intensive care units (39-390 minutes). Withdrawal of life-sustaining therapy processes appeared to follow a general pattern of vasoactive drug withdrawal followed by withdrawal of mechanical ventilation and extubation in most sites but specific steps varied. Approaches to extubation and weaning of vasoactive drugs were not consistent. Protocols detailing the process of life-sustaining therapy withdrawal were available for 3 of 4 sites and also exhibited differences across sites. CONCLUSIONS Standard practice of life-sustaining therapy withdrawal appears to differ between selected Canadian sites. Variability in withdrawal of life-sustaining therapy may have a potential impact both on rates of cDCD success and quality of palliative care.
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Affiliation(s)
- Amanda van Beinum
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Canada
| | - Laura Hornby
- Bertram Loeb Research Consortium in Organ and Tissue Donation, University of Ottawa, Ottawa, Canada
| | - Tim Ramsay
- Ottawa Hospital Research Institute Methods Center, Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Canada
| | | | - Sam D Shemie
- Bertram Loeb Research Consortium in Organ and Tissue Donation, University of Ottawa, Ottawa, Canada Division of Critical Care, Montreal Children's Hospital, McGill University, Montréal, Canada
| | - Sonny Dhanani
- Bertram Loeb Research Consortium in Organ and Tissue Donation, University of Ottawa, Ottawa, Canada CHEO Research Institute, Ottawa, Canada Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada
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Bell E, Rasmussen LA, Mazer B, Shevell M, Miller SP, Synnes A, Yager JY, Majnemer A, Muhajarine N, Chouinard I, Racine E. Magnetic resonance imaging (MRI) and prognostication in neonatal hypoxic-ischemic injury: a vignette-based study of Canadian specialty physicians. J Child Neurol 2015; 30:174-81. [PMID: 24789518 DOI: 10.1177/0883073814531821] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Magnetic resonance imaging (MRI) could improve prognostication in neonatal brain injury; however, factors beyond technical or scientific refinement may impact its use and interpretation. We surveyed Canadian neonatologists and pediatric neurologists using general and vignette-based questions about the use of MRI for prognostication in neonates with hypoxic-ischemic injury. There was inter- and intra-vignette variability in prognosis and in ratings about the usefulness of MRI. Severity of predicted outcome correlated with certainty about the outcome. A majority of physicians endorsed using MRI results in discussing prognosis with families, and most suggested that MRI results contribute to end-of-life decisions. Participating neonatologists, when compared to participating pediatric neurologists, had significantly less confidence in the interpretation of MRI by colleagues in neurology and radiology. Further investigation is needed to understand the complexity of MRI and of its application. Potential gaps relative to our understanding of the ethical importance of these findings should be addressed.
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Affiliation(s)
- Emily Bell
- Institut de recherches cliniques de Montréal, Montreal, Quebec, Canada
| | | | - Barbara Mazer
- Jewish Rehabilitation Hospital of Laval, Laval, Quebec, Canada
| | | | | | - Anne Synnes
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | - Eric Racine
- Institut de recherches cliniques de Montréal, Montreal, Quebec, Canada McGill University, Montreal, Quebec, Canada Université de Montréal, Montréal, Quebec, Canada
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Abstract
PURPOSE OF REVIEW The care of critically ill brain-injured patients is complex and requires careful balancing of cerebral and systemic treatment priorities. A growing number of studies have reported improved outcomes when patients are admitted to dedicated neurocritical care units (NCCUs). The reasons for this observation have not been definitively clarified. RECENT FINDINGS When recently published articles are combined with older literature, there have been more than 40 000 patients assessed in observational studies that compare neurological and general ICUs. Although results are heterogeneous, admission to NCCUs is associated with lower mortality and a greater chance of favorable recovery. These findings are remarkable considering that there are few interventions in neurocritical care that have been demonstrated to be efficacious in randomized trials. Whether the relationship is causal is still being elucidated but potential explanations include higher patient volume and, in turn, greater clinician experience; more emphasis on and adherence to protocols to avoid secondary brain injury; practice differences related to prognostication and withdrawal of life-sustaining interventions; and differences in the use and interpretation of neuroimaging and neuromonitoring data. SUMMARY Neurocritical care is an evolving field that is associated with improvements in outcomes over the past decade. Further research is required to determine how monitoring and treatment protocols can be optimized.
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Rodríguez Villar S, Barrientos Yuste RM. Long-term admission to the intensive care unit: a cost-benefit analysis. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2014; 61:489-496. [PMID: 24780651 DOI: 10.1016/j.redar.2014.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 02/19/2014] [Accepted: 02/25/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To assess outcomes in long-term ICU patients, with follow-ups carried out at one year post discharge, in order to calculate the costs incurred by the hospital in relation to the benefits gained. MATERIAL Of 3639 patients consecutively admitted over the course of three years to ICU, 235 (6.5%) were assessed for the purposes of the study, having spent a period exceeding 20 days in intensive care. METHOD The survey tool used was the Spanish Minimum Data Set (MDS). The length of ICU stay and hospital stay following discharge from ICU were calculated, and one year post discharge the patient/next of kin was contacted in order to carry out a follow-up survey on survival and functional status (according to GOS-E scale). RESULTS The 235 study patients had a mean stay of 37 days, occupied 34% of ICU beds available and consumed 29% of the ICU's economic resources ($14,400,175). Their stay on hospital wards was (mean) 33 days. Mortality in ICU and on hospital wards was 40% higher amongst older patients, and those with a higher APACHE II and Charlson index score. Mortality rates were three times higher among neurosurgical patients: mortality at follow-up was 25%, and only 21% recovered an acceptable functional status. CONCLUSIONS Mortality rates in long-term ICU patients are high, both during their hospital stay and in the first year post discharge. Surviving patients do not exhibit a good level of recovery, and consume a large proportion of economic resources.
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Affiliation(s)
- S Rodríguez Villar
- Intensive Care Medicine Department, Queen Elizabeth Hospital, London, United Kingdom.
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