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Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Heart Lung Transplant 2023; 42:e1-e64. [PMID: 36805198 DOI: 10.1016/j.healun.2022.10.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 10/28/2022] [Indexed: 02/08/2023] Open
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hannah Copeland
- Department of Cardiac Surgery, Lutheran Health Physicians, Fort Wayne, Indiana
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Gluck
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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2
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Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Card Fail 2023; 29:304-374. [PMID: 36754750 DOI: 10.1016/j.cardfail.2022.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hannah Copeland
- Department of Cardiac Surgery, Lutheran Health Physicians, Fort Wayne, Indiana
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Gluck
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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3
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Kaur R, Harmon E, Joseph A, Dhliwayo NL, Kramer N, Chen E. Palliative Ventilator Withdrawal Practices in an Inpatient Hospice Unit. Am J Hosp Palliat Care 2022:10499091221129827. [DOI: 10.1177/10499091221129827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Palliative ventilator withdrawal (PVW) involves removal of mechanical ventilation in patients not expected to survive to allow a peaceful death. This process traditionally occurs in Intensive Care Units (ICU) and recently has evolved to occur in Inpatient Hospice and Palliative Care Units (IPU). Objectives To describe the process and response of patients undergoing PVW in an IPU setting. Methods This is a longitudinal observational cohort study of adult patients who underwent PVW in an IPU from January 2021 through March 2022. Results Among 25 enrolled subjects, median age was 68 (IQR 62.5-76.5) years and 14 (56%) were females. Median time from PVW to death was 16.8 (IQR 2.6-100) hours. A registered nurse and attending physician were present in all the cases, while a respiratory therapist was present in 20 (80%) and chaplain in 9 (36%) of the cases. Before PVW, opioids and benzodiazepines were administered to 24 (96%) patients. Post PVW, respiratory distress was noted among 16 (64%) patients and medication was given to 15 (60%) patients for respiratory distress. There was a significant association between the presence of respiratory distress and administration of medication within 30 minutes after PVW ( P = .009). The rituals performed during PVW were reciting prayers for 11 (44%), playing music for 8 (32%), and observing silence for 6 (24%) of the patients. Conclusion This study describes the PVW practices in an IPU setting where a multidisciplinary team was present during PVW for most of the cases and two-third of the patients undergoing PVW experienced respiratory distress immediately after PVW.
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Affiliation(s)
- Ramandeep Kaur
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, IL, USA
| | - Elizabeth Harmon
- Department of Internal Medicine, Section of Palliative Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Augustin Joseph
- Department of Internal Medicine, Section of Palliative Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Nyembezi L Dhliwayo
- Department of Internal Medicine, Section of Palliative Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Neha Kramer
- Department of Internal Medicine, Section of Palliative Medicine, Rush University Medical Center, Chicago, IL, USA
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Elaine Chen
- Department of Internal Medicine, Section of Palliative Medicine, Rush University Medical Center, Chicago, IL, USA
- Department of Internal Medicine, Division of Pulmonary and Critical Care, Rush University Medical Center, Chicago, IL, USA
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Factors Associated With Quality of Death in Korean ICUs As Perceived by Medical Staff: A Multicenter Cross-Sectional Survey. Crit Care Med 2020; 47:1208-1215. [PMID: 31149962 DOI: 10.1097/ccm.0000000000003853] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Facilitating a high quality of death is an important aspect of comfort care for patients in ICUs. The quality of death in ICUs has been rarely reported in Asian countries. Although Korea is currently in the early stage after the implementation of the "well-dying" law, this seems to have a considerable effect on practice. In this study, we aimed to understand the status of quality of death in Korean ICUs as perceived by medical staff, and to elucidate factors affecting patient quality of death. DESIGN A multicenter cross-sectional survey study. SETTING Medical ICUs of two tertiary-care teaching hospitals and two secondary-care hospitals. PATIENTS Deceased patients from June 2016 to May 2017. INTERVENTIONS Relevant medical staff were asked to complete a translated Quality of Dying and Death questionnaire within 48 hours after a patient's death. A higher Quality of Dying and Death score (ranged from 0 to 100) corresponded to a better quality of death. MEASUREMENTS AND MAIN RESULTS A total of 416 completed questionnaires were obtained from 177 medical staff (66 doctors and 111 nurses) of 255 patients. All 20 items of the Quality of Dying and Death received low scores. Quality of death perceived by nurses was better than that perceived by doctors (33.1 ± 18.4 vs 29.7 ± 15.3; p = 0.042). Performing cardiopulmonary resuscitation and using inotropes within 24 hours before death were associated with poorer quality of death, whereas using analgesics was associated with better quality of death. CONCLUSIONS The quality of death of patients in Korean ICUs was considerably poorer than reported in other countries. Provision of appropriate comfort care, avoidance of unnecessary life-sustaining care, and permission for more frequent visits from patients' families may correspond to better quality of death in Korean medical ICUs. It is also expected that the new legislation would positively affect the quality of death in Korean ICUs.
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5
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Cho JY, Lee J, Lee SM, Park JH, Kim J, Kim Y, Lee SH, Park JS, Cho YJ, Yoon HI, Lee JH, Lee CT, Lee YJ. Transcultural Adaptation and Validation of Quality of Dying and Death Questionnaire in Medical Intensive Care Units in South Korea. Acute Crit Care 2018; 33:95-101. [PMID: 31723869 PMCID: PMC6849059 DOI: 10.4266/acc.2017.00612] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 03/30/2018] [Accepted: 05/03/2018] [Indexed: 01/04/2023] Open
Abstract
Background Providing palliative care to dying patients in the intensive care unit (ICU) has recently received much attention. Evaluating the quality of dying and death (QODD) is important for appropriate comfort care in the ICU. This study aimed to validate the Korean version of the QODD questionnaire. Methods This study included decedents in the ICUs of three tertiary teaching hospitals and one secondary hospital from June 2016 to May 2017. ICU staff members were asked to complete the translated QODD questionnaire and the visual analogue scale (VAS) questionnaire within 48 hours of patient death. The validation process consisted of evaluating construct validity, internal consistency, and interrater reliability. Results We obtained 416 completed questionnaires describing 255 decedents. The QODD score was positively correlated with the 100-VAS score (Pearson correlation coefficient, 0.348; P<0.001). An evaluation of the internal consistency presented favorable results (calculated Cronbach’s alpha if a given item exceeded 0.8 in all items). The interrater reliability revealed no concordance between doctors and nurses. Conclusions The QODD questionnaire was successfully translated and validated in Korean medical ICUs. We hope further studies that use this valuable instrument will be conducted in Korea.
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Affiliation(s)
- Jun Yeun Cho
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jinwoo Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sang-Min Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Ju-Hee Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Junghyun Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Medical Center, Seoul, Korea
| | - Youlim Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang Hoon Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jong Sun Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young-Jae Cho
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ho Il Yoon
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae Ho Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Choon-Taek Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yeon Joo Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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Suttle ML, Jenkins TL, Tamburro RF. End-of-Life and Bereavement Care in Pediatric Intensive Care Units. Pediatr Clin North Am 2017; 64:1167-1183. [PMID: 28941542 PMCID: PMC5747301 DOI: 10.1016/j.pcl.2017.06.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Most childhood deaths in the United States occur in hospitals. Pediatric intensive care clinicians must anticipate and effectively treat dying children's pain and suffering and support the psychosocial and spiritual needs of families. These actions may help family members adjust to their loss, particularly bereaved parents who often experience reduced mental and physical health. Candid and compassionate communication is paramount to successful end-of-life (EOL) care as is creating an environment that fosters meaningful family interaction. EOL care in the pediatric intensive care unit is associated with challenging ethical issues, of which clinicians must maintain a sound and working understanding.
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Affiliation(s)
- Markita L. Suttle
- Department of Critical Care Medicine, Nationwide Children's Hospital
| | - Tammara L. Jenkins
- Pediatric Trauma and Critical Illness Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development
| | - Robert F. Tamburro
- Pediatric Trauma and Critical Illness Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development
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Sulmasy DP, Hughes MT, Yenokyan G, Kub J, Terry PB, Astrow AB, Johnson JA, Ho G, Nolan MT. The Trial of Ascertaining Individual Preferences for Loved Ones' Role in End-of-Life Decisions (TAILORED) Study: A Randomized Controlled Trial to Improve Surrogate Decision Making. J Pain Symptom Manage 2017; 54:455-465. [PMID: 28712987 PMCID: PMC5632104 DOI: 10.1016/j.jpainsymman.2017.07.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 06/02/2017] [Accepted: 07/06/2017] [Indexed: 11/23/2022]
Abstract
CONTEXT Patients with terminal illnesses often require surrogate decision makers. Prior research has demonstrated high surrogate stress, and that despite standards promoting substituted judgment, most patients do not want their surrogates to make pure substituted judgments for them. It is not known how best to help loved ones fulfill the surrogate role. OBJECTIVES To test the effectiveness of an intervention to help surrogate decision makers. METHODS One hundred sixty-six patients (41% with amyotrophic lateral sclerosis and 59% with gastrointestinal cancers) and their surrogates at two university medical centers were randomized to an intensive nurse-directed discussion of the end-of-life decision control preferences of the patient (TAILORED) or a discussion of nutrition (CONTROL); 163 completed baseline interviews and underwent the intervention. RESULTS Twelve patients died during follow-up and 137 dyads completed the study. Post-intervention, using all available data, TAILORED patients and surrogates became more likely to endorse mutual surrogate decision making, that is, a balance of their own wishes and what the surrogate thinks best (adjusted odds compared with baseline for patients = 1.78, P = 0.04; adjusted odds for surrogates = 2.05, P = 0.03). CONTROL patients became 40% less likely to endorse mutual surrogate decision making (P = 0.08), and CONTROL surrogates did not change significantly from baseline (adjusted odds = 1.44, P = 0.28). Stress levels decreased for TAILORED surrogates (impact of events scale = 23.1 ± 14.6 baseline, 20.8 ± 15.3 f/u, P = 0.046), but not for CONTROL (P = 0.85), and post-intervention stress was lower for TAILORED than CONTROL (P = 0.04). Surrogates' confidence was uniformly high at baseline and did not change. Caregiver burden (Zarit) increased from 12.5 ± 6.5 to 14.7 ± 8.1 for TAILORED (P < 0.01), while not changing for CONTROL, yet satisfaction with involvement in decision making was higher at follow-up for TAILORED than for CONTROL (71% vs. 52%, P = 0.03). CONCLUSION TAILORED patients and surrogates who completed the study adopted a more mutual decision-making style, balancing their own wishes with what the surrogate thinks would be best for them. Surrogates reported less stress and more satisfaction. Confidence was high at baseline and did not change. There was a modest increase in caregiver burden. These findings suggest that interventions like TAILORED might positively impact surrogate decision making.
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Affiliation(s)
| | | | | | - Joan Kub
- Johns Hopkins University, Baltimore, Maryland
| | | | | | | | - Grace Ho
- Johns Hopkins University, Baltimore, Maryland
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8
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Family discussions on life-sustaining interventions in neurocritical care. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:397-408. [PMID: 28187812 DOI: 10.1016/b978-0-444-63600-3.00022-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Approximately 20% of all deaths in the USA occur in the intensive care unit (ICU) and the majority of ICU deaths involves decision of de-escalation of life-sustaining interventions. Life-sustaining interventions may include intubation and mechanical ventilation, artificial nutrition and hydration, antibiotic treatment, brain surgery, or vasoactive support. Decision making about goals of care can be defined as an end-of-life communication and the decision-making process between a clinician and a patient (or a surrogate decision maker if the patient is incapable) in an institutional setting to establish a plan of care. This process includes deciding whether to use life-sustaining treatments. Therefore, family discussion is a critical element in the decision-making process throughout the patient's stay in the neurocritical care unit. A large part of care in the neurosciences intensive care unit is discussion of proportionality of care. This chapter provides a stepwise approach to hold these conferences and discusses ways to do it effectively.
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Li P, Marsh JW, Boucek CD. Anesthesia Management for Palliative Surgery of Massive Hepatic Metastatic Melanoma. ACTA ACUST UNITED AC 2016; 6:189-92. [PMID: 26517233 DOI: 10.1213/xaa.0000000000000220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report the perioperative management of a patient with melanoma. Surgical intervention was withheld at multiple institutions because of the presence of metastases; the patient was undergoing experimental immunotherapy and had responded everywhere except in the liver. She underwent hepatic right trisegmentectomy to improve her quality of life and to allow resumption of immunotherapy. Dyspnea because of heart compression, pleural effusion, lung collapse, and pulmonary emboli improved. She died of late complications. This case highlights physiologic and ethical considerations.
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Affiliation(s)
- Pulsar Li
- From the *Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and †Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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10
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Wurmb T, Brederlau J. [Patients' declared intentions and emergency medicine]. Med Klin Intensivmed Notfmed 2015; 111:113-7. [PMID: 26374338 DOI: 10.1007/s00063-015-0086-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 07/27/2015] [Accepted: 08/01/2015] [Indexed: 10/23/2022]
Abstract
Patients with complex medical problems and acute life-threatening diseases deserve a physician with the capability of rapid decision making. Despite an emergency scenario with several unknown or uncertain variables an individual therapeutic plan needs to be defined for each patient. In order to achieve this goal the physician must define medical indications for each form of treatment. Secondly, the patients declared intentions must be respected concerning the previously defined medical indications; however, very often the patients' will is not known. It is very difficult to define an individual treatment plan especially if the patient is not able to adequately communicate. In these situations a custodian is helpful to find out the patients declared intentions towards the current medical situation. If there is no advance directive, family members often have to act as surrogates to find out what therapy goal is best for the individual patient. The patients' autonomy is a very highly respected ethical priority even when the ability for the otherwise usual practice of shared decision-making between physician and patient is compromised. Therefore, in order to do justice to this demanding situation it is necessary to deal with the characteristics of the physician-patient-relatives relationship in emergency medicine.
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Affiliation(s)
- T Wurmb
- Sektion Notfallmedizin der Klinik und Poliklinik für Anästhesiologie, Universitätsklinikum Würzburg, Oberdürrbacherstrasse 6, 97080, Würzburg, Deutschland.
| | - J Brederlau
- Klinik für Intensivmedizin, HELIOS Klinikum Berlin-Buch, Berlin, Deutschland.
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11
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Hartog CS, Schwarzkopf D, Riedemann NC, Pfeifer R, Guenther A, Egerland K, Sprung CL, Hoyer H, Gensichen J, Reinhart K. End-of-life care in the intensive care unit: a patient-based questionnaire of intensive care unit staff perception and relatives' psychological response. Palliat Med 2015; 29:336-45. [PMID: 25634628 DOI: 10.1177/0269216314560007] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Communication is a hallmark of end-of-life care in the intensive care unit. It may influence the impact of end-of-life care on patients' relatives. We aimed to assess end-of-life care and communication from the perspective of intensive care unit staff and relate it to relatives' psychological symptoms. DESIGN Prospective observational study based on consecutive patients with severe sepsis receiving end-of-life care; trial registration NCT01247792. SETTING/PARTICIPANTS Four interdisciplinary intensive care units of a German University hospital. Responsible health personnel (attendings, residents and nurses) were questioned on the day of the first end-of-life decision (to withdraw or withhold life-supporting therapies) and after patients had died or were discharged. Relatives were interviewed by phone after 90 days. RESULTS Overall, 145 patients, 610 caregiver responses (92% response) and 84 relative interviews (70% response) were analysed. Most (86%) end-of-life decisions were initiated by attendings and only 2% by nurses; 41% of nurses did not know enough about end-of-life decisions to communicate with relatives. Discomfort with end-of-life decisions was low. Relatives reported high satisfaction with decision-making and care, 87% thought their degree of involvement had been just right. However, 51%, 48% or 33% of relatives had symptoms of post-traumatic stress disorder, anxiety or depression, respectively. Predictors for depression and post-traumatic stress disorder were patient age and relatives' gender. Relatives' satisfaction with medical care and communication predicted less anxiety (p = 0.025). CONCLUSION Communication should be improved within the intensive care unit caregiver team to strengthen the involvement of nurses in end-of-life care. Improved communication between caregivers and the family might lessen relatives' long-term anxiety.
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Affiliation(s)
- Christiane S Hartog
- Integrated Research and Treatment Center, Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Daniel Schwarzkopf
- Integrated Research and Treatment Center, Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany
| | - Niels C Riedemann
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Ruediger Pfeifer
- Department of Internal Medicine I, Jena University Hospital, Jena, Germany
| | | | - Kati Egerland
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Charles L Sprung
- Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Heike Hoyer
- Institute of Medical Statistics, Information Sciences and Documentation, Jena University Hospital, Jena, Germany
| | - Jochen Gensichen
- Integrated Research and Treatment Center, Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany Department of General Medicine, Jena University Hospital, Jena, Germany
| | - Konrad Reinhart
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
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12
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A comparison of the willingness of resident and attending physicians to comply with the requests of patients at the end of life. J Gen Intern Med 2014; 29:1048-54. [PMID: 24647724 PMCID: PMC4061369 DOI: 10.1007/s11606-014-2830-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2013] [Revised: 11/07/2013] [Accepted: 03/02/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Little is known about the differences between physicians in training and post training in their willingness to comply with patient requests at the end of life. OBJECTIVE To compare the attitudes of attendings and residents regarding a range of patient requests at the end of life DESIGN Written, cross-sectional survey PARTICIPANTS The cohort included 191 attendings randomly selected across the state of Connecticut and 240 residents from 2 university-affiliated Internal Medicine programs. MAIN MEASURES We surveyed attendings and residents about their willingness to honor the requests of the same decisionally capable elderly patient in five scenarios involving different requests regarding end-of-life treatment. RESULTS While a large majority of both attendings and residents were willing to comply with each of the requests to withhold intubation (100 % and 94 %, respectively), to extubate (92 % and 77 %), and to give increasingly higher doses of narcotics (94 % and 71 %), a significantly larger proportion of attendings versus residents was willing to comply with each of these requests. Small proportions of attendings and residents were willing to prescribe a lethal amount of sleeping pills (3 % and 5 %, respectively) and to give a lethal injection in its current illegal state (1 % and 4 %). A significantly larger proportion of residents (32 %) compared to attendings (19 %) was willing to give a lethal injection if legal. Adjusting for sociodemographic factors, attending status was independently associated with willingness to extubate [adjusted odds ratio (AOR) = 3.0, 95 % CI = 1.6-5.7] and to give a lethal injection if legal (AOR = 0.5, 95 % CI = 0.3-0.8). The proportion of physicians willing to extubate increased across years since graduation, with the greatest differences occurring across the residency years (69 % to 86 %). CONCLUSIONS AND RELEVANCE Clinical experience was an important determinant of physicians' willingness to perform multiple patient requests at the end of life, with substantial changes in attitudes occurring during residency training. More research is needed to determine whether dedicated clinical exposure for physicians in training influences attitudes.
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13
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Holloway RG, Arnold RM, Creutzfeldt CJ, Lewis EF, Lutz BJ, McCann RM, Rabinstein AA, Saposnik G, Sheth KN, Zahuranec DB, Zipfel GJ, Zorowitz RD. Palliative and End-of-Life Care in Stroke. Stroke 2014; 45:1887-916. [DOI: 10.1161/str.0000000000000015] [Citation(s) in RCA: 179] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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14
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Quill CM, Quill TE. Palliative use of noninvasive ventilation: navigating murky waters. J Palliat Med 2014; 17:657-61. [PMID: 24824625 DOI: 10.1089/jpm.2014.0010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The use of noninvasive positive pressure ventilation (NPPV) as a palliative treatment for respiratory failure and dyspnea has become increasingly common. NPPV has a well-established, evidence-based role in the management of respiratory failure due to acute exacerbations of congestive heart failure and chronic obstructive pulmonary disease, both for patients with and without restrictions on endotracheal intubation. There are emerging uses of NPPV in patients clearly nearing the end-of-life, but the evidence to support these applications is limited. Alongside these emerging applications of NPPV are new ethical dilemmas that should be considered in medical decision-making regarding these therapies. DISCUSSION Herein, we describe the use of NPPV in four patients with advanced disease and preexisting treatment-limiting directives. We discuss some of the ethical dilemmas and unintended consequences that may accompany the use of NPPV in such circumstances, and we review the benefits and burdens of palliative NPPV. CONCLUSION Finally, we conclude with a summary of principles that can be used as a guide to decision making regarding palliative NPPV.
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Affiliation(s)
- Caroline M Quill
- 1 Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center , Rochester, New York
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15
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Bruce CR, Allen NG, Fahy BN, Gordon HL, Suarez EE, Bruckner BA. Challenges in deactivating a total artificial heart for a patient with capacity. Chest 2014; 145:625-631. [PMID: 24590023 DOI: 10.1378/chest.13-1103] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
The use of mechanical circulatory support (MCS) devices has increased sixfold since 2006. Although there is an established legal and ethical consensus that patients have the right to withdraw and withhold life-sustaining interventions when burdens exceed benefits, this consensus arose prior to the widespread use of MCS technology and is not uniformly accepted in these cases. There are unique ethical and clinical considerations regarding MCS deactivation. Our center recently encountered the challenge of an awake and functionally improving patient with a total artificial heart (TAH) who requested its deactivation. We present a narrative description of this case with discussion of the following questions: (1) Is it ethically permissible to deactivate this particular device, the TAH? (2) Are there any particular factors in this case that are ethical contraindications to proceeding with deactivation? (3) What are the specific processes necessary to ensure a compassionate and respectful deactivation? (4) What proactive practices could have been implemented to lessen the intensity of this case's challenges? We close with a list of recommendations for managing similar cases.
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Affiliation(s)
- Courtenay R Bruce
- Center for Medical Ethics & Health Policy, Department of Medicine, Baylor College of Medicine, St. Luke's Episcopal Hospital, Houston, TX; Methodist Hospital System, The Methodist Hospital System Ethics Program, St. Luke's Episcopal Hospital, Houston, TX.
| | - Nathan G Allen
- Center for Medical Ethics & Health Policy, Department of Medicine, Baylor College of Medicine, St. Luke's Episcopal Hospital, Houston, TX; Section of Emergency Medicine, Department of Medicine, Baylor College of Medicine, St. Luke's Episcopal Hospital, Houston, TX; Methodist Hospital System, The Methodist Hospital System Ethics Program, St. Luke's Episcopal Hospital, Houston, TX
| | - Bridget N Fahy
- Center for Medical Ethics & Health Policy, Department of Medicine, Baylor College of Medicine, St. Luke's Episcopal Hospital, Houston, TX; Methodist Hospital System, The Methodist Hospital System Ethics Program, St. Luke's Episcopal Hospital, Houston, TX; Department of Surgery, Weill Cornell Medical College, Methodist Hospital, St. Luke's Episcopal Hospital, Houston, TX; Division of Palliative Medicine, The Methodist Hospital, St. Luke's Episcopal Hospital, Houston, TX
| | - Harvey L Gordon
- Center for Medical Ethics & Health Policy, Department of Medicine, Baylor College of Medicine, St. Luke's Episcopal Hospital, Houston, TX; Methodist Hospital System, The Methodist Hospital System Ethics Program, St. Luke's Episcopal Hospital, Houston, TX
| | - Erik E Suarez
- Center for Medical Ethics & Health Policy, Department of Medicine, Baylor College of Medicine, St. Luke's Episcopal Hospital, Houston, TX; Methodist DeBakey Heart and Vascular Center and JC Walter Jr Transplant Center, St. Luke's Episcopal Hospital, Houston, TX
| | - Brian A Bruckner
- Center for Medical Ethics & Health Policy, Department of Medicine, Baylor College of Medicine, St. Luke's Episcopal Hospital, Houston, TX; Texas Heart Institute, St. Luke's Episcopal Hospital, Houston, TX
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Abstract
OBJECTIVE Substantial variability exists in the timing of limitations in life support for critically ill patients. Our objective was to investigate how the timing of limitations in life support varies with changes in organ failure status and time since acute lung injury onset. DESIGN, SETTING, AND PATIENTS This evaluation was performed as part of a prospective cohort study evaluating 490 consecutive acute lung injury patients recruited from 11 ICUs at three teaching hospitals in Baltimore, MD. INTERVENTIONS None. MEASUREMENTS The primary exposure was proportion of days without improvement in Sequential Organ Failure Assessment score, evaluated as a daily time-varying exposure. The outcome of interest was a documented limitation in life support defined as any of the following: 1) no cardiopulmonary resuscitation, 2) do not reintubate, 3) no vasopressors, 4) no hemodialysis, 5) do not escalate care, or 6) other limitations (e.g., "comfort care only"). MAIN RESULTS For medical ICU patients without improvement in daily Sequential Organ Failure Assessment score, the rate of limitation in life support tripled in the first 3 days after acute lung injury onset, increased again after day 5, and peaked at day 19. Compared with medical ICU patients, surgical ICU patients had a rate of limitations that was significantly lower during the first 5 days after acute lung injury onset. In all patients, more days without improvement in Sequential Organ Failure Assessment scores was associated with limitations in life support, independent of the absolute magnitude of the Sequential Organ Failure Assessment score. CONCLUSIONS Persistent organ failure is associated with an increase in the rate of limitations in life support independent of the absolute magnitude of Sequential Organ Failure Assessment score, and this association strengthens during the first weeks of treatment. During the first 5 days after acute lung injury onset, limitations were significantly more common in medical ICUs than surgical ICUs.
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Development of a post-intensive care unit storytelling intervention for surrogates involved in decisions to limit life-sustaining treatment. Palliat Support Care 2014; 13:451-63. [PMID: 24524736 DOI: 10.1017/s1478951513001211] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Surrogates involved in decisions to limit life-sustaining treatment for a loved one in the intensive care unit (ICU) are at increased risk for adverse psychological outcomes that can last for months to years after the ICU experience. Post-ICU interventions to reduce surrogate distress have not yet been developed. We sought to (1) describe a conceptual framework underlying the beneficial mental health effects of storytelling, and (2) present formative work developing a storytelling intervention to reduce distress for recently bereaved surrogates. METHOD An interdisciplinary team conceived the idea for a storytelling intervention based on evidence from narrative theory that storytelling reduces distress from traumatic events through emotional disclosure, cognitive processing, and social connection. We developed an initial storytelling guide based on this theory and the clinical perspectives of team members. We then conducted a case series with recently bereaved surrogates to iteratively test and modify the guide. RESULTS The storytelling guide covered three key domains of the surrogate's experience of the patient's illness and death: antecedents, ICU experience, and aftermath. The facilitator focused on the parts of a story that appeared to generate strong emotions and used nonjudgmental statements to attend to these emotions. Between September 2012 and May 2013, we identified 28 eligible surrogates from a medical ICU and consented 20 for medical record review and recontact; 10 became eligible, of whom 6 consented and completed the storytelling intervention. The single-session storytelling intervention lasted from 40 to 92 minutes. All storytelling participants endorsed the intervention as acceptable, and five of six reported it as helpful. SIGNIFICANCE OF RESULTS Surrogate storytelling is an innovative and acceptable post-ICU intervention for recently bereaved surrogates and should be evaluated further.
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El Sayed MF, Chan M, McAllister M, Hellmann J. End-of-life care in Toronto neonatal intensive care units: challenges for physician trainees. Arch Dis Child Fetal Neonatal Ed 2013; 98:F528-33. [PMID: 23899436 DOI: 10.1136/archdischild-2012-303000] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Physician trainees in neonatology can find it extremely challenging to care for patients from diverse linguistic and multicultural backgrounds. This challenge is particularly highlighted when difficult and ethically challenging end-of-life (EOL) decision-making with parents is required. While these interactions are an opportunity for growth and learning, they also have the potential to lead to misunderstanding and uncertainty and can add to trainees' insecurity, unpreparedness and stress when participating in such interactions. OBJECTIVES To explore the challenges for trainees when EOL decisions are undertaken and to encourage them to reflect on how they might influence such decision-making. DESIGN AND INTERVIEW An in-depth, semi-structured interview guide was developed: the interview questions address trainees' beliefs, attitudes, preferences and expectations regarding discussions of EOL neonatal care. Twelve interviews were completed and the audio records transcribed verbatim, after removal of identifying personal information. RESULTS Participants identified six domains of challenge in EOL care: withdrawal of life-sustaining treatment based on poor outcome, explaining 'no resuscitation options' to parents, clarifying 'do not resuscitate (DNR)' orders, empowering families with knowledge and shared decision-making, dealing with different cultures and managing personal internal conflict. Participants experienced the most difficulty during the initial stages of training and eventually reported good knowledge of the EOL care process. They had a sense of security and confidence working within a multidisciplinary care team, which includes experienced nursing staff as well as bereavement and palliative care coordinator within the neonatal intensive care unit. CONCLUSIONS The challenges experienced by physician trainees when providing EOL care can serve as focal points for improving EOL educational programmes for neonatal fellowship training.
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Affiliation(s)
- Manal F El Sayed
- Division of Neonatology, Department of Paediatrics, The Hospital for Sick Children, , Toronto, Ontario, Canada
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19
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Abstract
PURPOSE OF REVIEW Conflicts occur frequently in the ICU. Research on ICU conflicts is an emerging field, with only few recent studies being available on intrateam and team-family conflicts. Research on communication in the ICU is developing at a faster pace. RECENT FINDINGS Recent findings come from one multinational epidemiological survey on intrateam conflicts and one qualitative study on the causes and consequences of conflicts. Advances in research on communication with families in the ICU have improved our understanding of team-family and intrateam conflicts, thus suggesting targets for improvement. SUMMARY Data about ICU conflicts depend on conflict definition, study designs (qualitative versus quantitative), patient case-mix, and detection bias. Conflicts perceived by caregivers are frequent and consist mainly in intrateam conflicts. The two main sources of conflicts in the ICU are end-of-life decisions and communication issues. Conflicts negatively impact patient safety, patient/family-centered care, and team welfare and cohesion. They generate staff burnout and increase healthcare costs. Further qualitative studies rooted in social-science theories about workplace conflicts are needed to better understand the typology of ICU conflicts (sources and consequences) and to address complex ICU conflicts that involve systems as opposed to people. Conflict prevention and resolution are complex issues requiring multimodal interventions. Clinical research in this field is insufficiently developed, and no guidelines are available so far. Prevention strategies need to be developed along two axes: improved understanding of family experience, preferences, and values, as well as evidence-based communication may reduce team-family conflicts and organizational measures including restoring leadership, multidisciplinary teamwork, and improved communication within the team may prevent intrateam conflicts in the ICU.
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Gerritsen RT, Hofhuis JGM, Koopmans M, van der Woude M, Bormans L, Hovingh A, Spronk PE. Perception by family members and ICU staff of the quality of dying and death in the ICU: a prospective multicenter study in The Netherlands. Chest 2013; 143:357-363. [PMID: 22878897 DOI: 10.1378/chest.12-0569] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE Admission to the ICU is a major event in a patient’s life and also for family members. We tried to elucidate how family members and ICU caregivers experience the dying process of their patients. METHODS The prospective study took place in three Dutch ICUs. Patients who had stayed . 48 h and died in the ICU were eligible. The Quality of Dying and Death (QODD) questionnaire was used, with addition of items pertaining to the patient’s autonomy. Values indicate median and interquartile range. RESULTS We included 100 consecutive patients. ICU stay before death was 8 (3-16) days. APACHE (Acute Physiology and Chronic Health Evaluation) II score at admission was 24 (19-31). Family response rate was 89%. Families were satisfied with overall QODD (score, 8 [7-9]) and felt supported by the ICU caregivers (8 [7-9]). Pain control was scored lower by family members (8 [5.75- 8.25]) than by nurses and physicians (9 [8-10], P 5 .024) Almost always, physicians discussed the patient’s end-of-life wishes with family members, although families rated the quality of the discussion lower (7 [5.5-8.5]) than physicians (9 [6.5-10]) ( P 5 .045). The majority of the families (89%) felt included in the decision-making process. More than one-half of the family members (57%) believed that the physician made the fi nal decision alone after giving information, whereas 36.8% believed they had participated in making the decision. Family members rated the QODD questionnaire as difficult (6 [5-8]), and several items were not answered by a majority of family members. CONCLUSIONS Quality of dying and death is generally perceived to be good by family members and caregivers of patients who die in Dutch ICUs. There is a need for modification of the QODD questionnaire for the European ICU population.
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Affiliation(s)
- Rik T Gerritsen
- Department of Intensive Care, Medical Center Leeuwarden, Leeuwarden, The Netherlands.
| | - José G M Hofhuis
- Department of Intensive Care, Gelre Hospitals, Apeldoorn, The Netherlands
| | - Matty Koopmans
- Department of Intensive Care, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Meta van der Woude
- Department of Intensive Care, Heerlen Medical Center, Heerlen, The Netherlands
| | - Laura Bormans
- Department of Intensive Care, Heerlen Medical Center, Heerlen, The Netherlands
| | - Aly Hovingh
- Department of Intensive Care, Gelre Hospitals, Apeldoorn, The Netherlands
| | - Peter E Spronk
- Department of Intensive Care, Gelre Hospitals, Apeldoorn, The Netherlands; HERMES Critical Care Group, Amsterdam, The Netherlands
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Thongrong C, Kasemsiri P, Hofmann JP, Bergese SD, Papadimos TJ, Gracias VH, Adolph MD, Stawicki SPA. Amniotic fluid embolism. Int J Crit Illn Inj Sci 2013; 3:51-7. [PMID: 23724386 PMCID: PMC3665120 DOI: 10.4103/2229-5151.109422] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Amniotic fluid embolism (AFE) is an unpredictable and as-of-yet unpreventable complication of maternity. With its low incidence it is unlikely that any given practitioner will be confronted with a case of AFE. However, this rare occurrence carries a high probability of serious sequelae including cardiac arrest, ARDS, coagulopathy with massive hemorrhage, encephalopathy, seizures, and both maternal and infant mortality. In this review the current state of medical knowledge about AFE is outlined including its incidence, risk factors, diagnosis, pathophysiology, and clinical manifestations. Special attention is paid to the modern aggressive supportive care that resulted in an overall reduction in the still alarmingly high mortality rate of this devastating entity. The key factors for successful management and resolution of this disease process continue to be sharp vigilance, a high level of clinical suspicion, and rapid all-out resuscitative efforts on the part of all clinicians involved in the medical care of the parturient.
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Affiliation(s)
- Cattleya Thongrong
- Department of Anesthesiology, Division of Trauma, Critical Care and Burn, The Ohio State University College of Medicine, Columbus, USA ; Department of Anesthesiology, Srinagarind Hospital, Faculty of Medicine at the Khon Kaen University, Khon Kaen, Thailand
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Manalo MFC. End-of-Life Decisions about Withholding or Withdrawing Therapy: Medical, Ethical, and Religio-Cultural Considerations. Palliat Care 2013; 7:1-5. [PMID: 25278756 PMCID: PMC4147759 DOI: 10.4137/pcrt.s10796] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Towards the end of life, physicians face dilemmas of discontinuing life-sustaining treatments or interventions. In some circumstances, these treatments are no longer of benefit, while in others the patient or family no longer want them. The physician plays an essential role in clarifying the goals of medical treatment, defining the care plan, initiating discussions about life-sustaining therapy, educating patients and families, helping them deliberate, making recommendations, and implementing the treatment plan. Communication is key. It should be clarified that when inevitable death is imminent, it is legitimate to refuse or limit forms of treatment that would only secure a precarious and burdensome prolongation of life, for as long as basic humane, compassionate care is not interrupted. Agreement to DNR status does not preclude supportive measures that keep patients free from pain and suffering as possible. Acceptable clinical practice on withdrawing or withholding treatment is based on an understanding of the medical, ethical, cultural, and religious issues. There is a need to individualize care option discussions to illness status, and patient and family preferences, beliefs, values, and cultures. The process of shared decision making between the patient, the family, and the clinicians should continue as goals evolve and change over time.
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Affiliation(s)
- Maria Fidelis C Manalo
- Palliative Care Unit, Cancer Center, The Medical City, Ortigas, Pasig City, Philippines; Supportive and Palliative Care Service, Department of Community and Family Medicine, Far Eastern University-Dr. Nicanor Reyes Medical Foundation, Fairview, Quezon City, Philippines
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Abstract
Ethically charged situations are common in pediatric critical care. Most situations can be managed with minimal controversy within the medical team or between the team and patients/families. Familiarity with institutional resources, such as hospital ethics committees, and national guidelines, such as publications from the American Academy of Pediatrics, American Medical Association, or Society of Critical Care Medicine, are an essential part of the toolkit of any intensivist. Open discussion with colleagues and within the multidisciplinary team can also ensure that when difficult situations arise, they are addressed in a proactive, evidence-based, and collegial manner.
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Affiliation(s)
- Alberto Orioles
- Departments of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
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Tellett L, Pyle L, Coombs M. End of life in intensive care: Is transfer home an alternative? Intensive Crit Care Nurs 2012; 28:234-41. [DOI: 10.1016/j.iccn.2012.01.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Revised: 01/10/2012] [Accepted: 01/20/2012] [Indexed: 11/17/2022]
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Experiences and Needs of Families Regarding Prognostic Communication in an Intensive Care Unit. Crit Care Nurs Q 2012; 35:299-313. [DOI: 10.1097/cnq.0b013e318255ee0d] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Meisel A, Meisel C, Harms H, Hartmann O, Ulm L. Predicting Post-Stroke Infections and Outcome with Blood-Based Immune and Stress Markers. Cerebrovasc Dis 2012; 33:580-8. [DOI: 10.1159/000338080] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Accepted: 03/16/2012] [Indexed: 12/16/2022] Open
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The need for safeguards in advance care planning. J Gen Intern Med 2012; 27:595-600. [PMID: 22237664 PMCID: PMC3326115 DOI: 10.1007/s11606-011-1976-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Revised: 12/15/2011] [Accepted: 12/19/2011] [Indexed: 10/14/2022]
Abstract
The recent uproar about Medicare "death panels" draws attention to public and professional concerns that advance care planning might restrict access to desired life-sustaining care. The primary goal of advance care planning is to promote the autonomy of a decisionally incapacitated patient when choices about life-sustaining treatments are encountered, but the safety of this procedure has not received deserved scrutiny. Patients often do not understand their decisions or they may change their mind without changing their advance care directives. Likewise, concordance between patients' wishes and the understanding of the physicians and surrogate decision makers who need to represent these wishes is disappointingly poor. A few recent reports show encouraging outcomes from advance care planning, but most studies indicate that the procedure is ineffective in protecting patients from unwanted treatments and may even undermine autonomy by leading to choices that do not reflect patient values, goals, and preferences. Safeguards for advance care planning should be put in place, such as encouraging physicians to err on the side of preserving life when advance care directives are unclear, requiring a trained advisor to review non-emergent patient choices to limit life-sustaining treatment, training of clinicians in conducting such conversations, and structured discussion formats that first address values and goals rather than particular life-sustaining procedures. Key targets for research include: how to improve completion rates for person wanting advance care directives, especially among minorities; more effective and standardized approaches to advance care planning discussions, including how best to present prognostic information to patients; methods for training clinicians and others to assist patients in this process; and systems for assuring that directives are available and up-to-date.
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Reticker AL, Nici L, ZuWallack R. Pulmonary rehabilitation and palliative care in COPD: Two sides of the same coin? Chron Respir Dis 2012; 9:107-16. [DOI: 10.1177/1479972312441379] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Pulmonary rehabilitation and palliative care are two important components of the integrated care of the patient with chronic respiratory disease such as chronic obstructive pulmonary disease (COPD). These two interventions are remarkably similar in many respects. Both utilize a multidisciplinary team that focuses on the specific needs of the individual patient. Care in both is goal defined and includes relief of symptoms and improvements in functional status and quality of life. Pulmonary rehabilitation is commonly given in a specific setting, such as a hospital-based outpatient setting, while palliative care is often hospital based, with its services extending into the home setting in the form of hospice. Components of pulmonary rehabilitation and palliative care should be administered as part of good medical care. Both pulmonary rehabilitation and palliative care are currently underutilized in the respiratory patient, and often provided relatively late in the patient’s clinical course. The case provided illustrates the often-overwhelming symptom burden of advanced COPD and demonstrates opportunities for the application of these twin interventions.
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Affiliation(s)
| | - Linda Nici
- Providence Veterans Affairs Medical Center, The Alpert Medical School of Brown University, Providence, RI, USA
| | - Richard ZuWallack
- Section of Pulmonary and Critical Care, St. Francis Hospital & Medical Center, Hartford, CT, UK
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Lamba S, Nagurka R, Murano T, Zalenski RJ, Compton S. Early Identification of Dying Trajectories in Emergency Department Patients: Potential Impact on Hospital Care. J Palliat Med 2012; 15:392-5. [DOI: 10.1089/jpm.2011.0358] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Sangeeta Lamba
- University of Medicine and Dentistry of New Jersey, New Jersey Medical School, University Hospital, Newark, New Jersey
| | - Roxanne Nagurka
- University of Medicine and Dentistry of New Jersey, New Jersey Medical School, University Hospital, Newark, New Jersey
| | - Tiffany Murano
- University of Medicine and Dentistry of New Jersey, New Jersey Medical School, University Hospital, Newark, New Jersey
| | | | - Scott Compton
- University of Medicine and Dentistry of New Jersey, New Jersey Medical School, University Hospital, Newark, New Jersey
- Wayne State University, School of Medicine, Detroit, Michigan
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Providing a "good death" for oncology patients during the final hours of life in the intensive care unit. AACN Adv Crit Care 2012; 22:379-96. [PMID: 22064586 DOI: 10.1097/nci.0b013e31823100dc] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Cancer is a leading cause of death in the United States. Aggressiveness of cancer care continues to rise in parallel with scientific discoveries in the treatment of a variety of malignancies. As a result, patients with cancer often require care in intensive care units (ICUs). Although growth in hospice and palliative care programs has occurred nationwide, access to these programs varies by geographic region and hospital type. Thus, critical care nurses may be caring for patients with cancer during the final hours of life in the ICU without the support of palliative care experts. This article provides an overview of the meaning of the final hours of life for cancer patients and uses principles of a "good death" and the tenets of hospice care to organize recommendations for critical care nurses for providing high quality end-of-life care to patients with cancer in the ICU.
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Increased nonbeneficial care in patients spending their birthday in the ICU. Intensive Care Med 2012; 38:1169-76. [PMID: 22323081 DOI: 10.1007/s00134-012-2510-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Accepted: 01/23/2012] [Indexed: 10/14/2022]
Abstract
OBJECTIVE End-of-life decisions are based on objective and subjective criteria. Previous studies identified substantial subjective biases during end-of-life decision-making. We evaluated whether in-ICU patient's birthday influenced management decisions. DESIGN We used a case-control design in which patients spending their birthday in the ICU (cases) were matched to controls on center, gender, age, severity, type of admission, and length of ICU stay before birthday. SETTING 12 ICUs in French hospitals. PATIENTS The cases and controls were patients with ICU admissions >48 h over a 10-year period. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Compared with the 1,042 controls, the 223 cases were more often trauma patients and received a larger number and longer durations of life-sustaining interventions. This increased intensity of life support occurred after, but not before, the birthday. The cases had longer ICU stay lengths. ICU and hospital mortality were not different between the two groups. End-of-life decisions were made in 22% and 24% of cases and controls, respectively. However, these decisions were made later in the cases than in the controls (18 [5-33] versus 9 [3-19] days). CONCLUSIONS Our finding that patients who spent their birthday in the ICU received a higher intensity of life-sustaining care and had longer ICU stays but did not have significantly different mortality rates compared with the controls suggests the use of nonbeneficial interventions. Staff members caring for patients whose birthdays fall during the ICU stay should be aware that this feature can bias end-of-life decisions, leading to an inappropriate level of care.
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Billings JA. The end-of-life family meeting in intensive care part II: Family-centered decision making. J Palliat Med 2012; 14:1051-7. [PMID: 21910612 DOI: 10.1089/jpm.2011.0038-b] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- J Andrew Billings
- Harvard Medical School Center for Palliative Care, Boston, Massachusetts, USA
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35
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Jeong SY, McMillan M, Higgins I. Gerotranscendence: The Phenomenon of Advance Care Planning. JOURNAL OF RELIGION SPIRITUALITY & AGING 2012. [DOI: 10.1080/15528030.2012.632712] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Abstract
OBJECTIVES Relatives often lack important information about intensive care unit patients. High-quality information is crucial to help relatives overcome the often considerable situational stress and to acquire the ability to participate in the decision-making process, most notably regarding the appropriate level of care. We aimed to develop a list of questions important for relatives of patients in the intensive care unit. DESIGN, SETTING, AND PARTICIPANTS This was a multicenter study. Questions asked by relatives of intensive care unit patients were collected from five different sources (literature, panel of 28 intensive care unit nurses and physicians, 1-wk survey of nurses and 1-wk survey of physicians in 14 intensive care units, and in-depth interviews with 14 families). After a qualitative analysis (framework approach and thematic analysis), questions were rated by 22 relatives and 14 intensive care unit physicians, and the ratings were analyzed using principal component analysis and hierarchical clustering. RESULTS The five sources produced 2,135 questions. Removal of duplicates and redundancies left 443 questions, which were distributed among nine predefined domains using a framework approach ("diagnosis," "treatment," "prognosis," "comfort," "interaction," "communication," "family," "end of life," and "postintensive care unit management"). Thematic analysis in each domain led to the identification of 46 themes, which were reworded as 46 different questions. Ratings by relatives and physicians showed that 21 of these questions were particularly important for relatives of intensive care unit patients. CONCLUSION This study increases knowledge about the informational needs of relatives of intensive care unit patients. This list of questions may prove valuable for both relatives and intensive care unit physicians as a tool for improving communication in the intensive care unit.
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Beckstrand RL, Rawle NL, Callister L, Mandleco BL. Pediatric nurses' perceptions of obstacles and supportive behaviors in end-of-life care. Am J Crit Care 2010; 19:543-52. [PMID: 20026650 DOI: 10.4037/ajcc2009497] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Each year 55 000 children die in the United States, and most of these deaths occur in hospitals. The barriers and supportive behaviors in providing end-of-life care to children should be determined. OBJECTIVE To determine pediatric intensive care unit nurses' perceptions of sizes, frequencies, and magnitudes of selected obstacles and helpful behaviors in providing end-of-life care to children. METHOD A national sample of 1047 pediatric intensive care unit nurses who were members of the American Association of Critical-Care Nurses were surveyed. A 76-item questionnaire adapted from 3 similar surveys with critical care, emergency, and oncology nurses was mailed to possible participants. Nurses who did not respond to the first mailing were sent a second mailing. Nurses were asked to rate the size and frequency of listed obstacles and supportive behaviors in caring for children at the end of life. RESULTS A total of 474 usable questionnaires were received from 985 eligible respondents (return rate, 48%). The 2 items with the highest perceived obstacle magnitude scores for size and frequency means were language barriers and parental discomfort in withholding and/or withdrawing mechanical ventilation. The highest supportive behavior item was allowing time alone with the child when he or she has died. CONCLUSIONS Pediatric intensive care unit nurses play a vital role in caring for dying children and the children's families. Overcoming language and communication barriers with children's families and between interdisciplinary team members could greatly improve the end-of-life experience for dying children.
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Affiliation(s)
- Renea L. Beckstrand
- Renea L. Beckstrand is an associate professor, Nicole L. Rawle is working in pediatrics, and Lynn Callister and Barbara L. Mandleco are professors in the College of Nursing, Brigham Young University, Provo, Utah
| | - Nicole L. Rawle
- Renea L. Beckstrand is an associate professor, Nicole L. Rawle is working in pediatrics, and Lynn Callister and Barbara L. Mandleco are professors in the College of Nursing, Brigham Young University, Provo, Utah
| | - Lynn Callister
- Renea L. Beckstrand is an associate professor, Nicole L. Rawle is working in pediatrics, and Lynn Callister and Barbara L. Mandleco are professors in the College of Nursing, Brigham Young University, Provo, Utah
| | - Barbara L. Mandleco
- Renea L. Beckstrand is an associate professor, Nicole L. Rawle is working in pediatrics, and Lynn Callister and Barbara L. Mandleco are professors in the College of Nursing, Brigham Young University, Provo, Utah
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Levin TT, Moreno B, Silvester W, Kissane DW. End-of-life communication in the intensive care unit. Gen Hosp Psychiatry 2010; 32:433-42. [PMID: 20633749 DOI: 10.1016/j.genhosppsych.2010.04.007] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Revised: 04/21/2010] [Accepted: 04/22/2010] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Because one in five Americans die in the intensive care unit (ICU), the potential role of palliative care is considerable. End-of-life (EOL) communication is essential for the implementation of ICU palliative care. The objective of this review was to summarize current research and recommendations for ICU EOL communication. DESIGN For this qualitative, critical review, we searched PubMed, Embase, Cochrane, Ovid Medline, Cinahl and Psychinfo databases for ICU EOL communication clinical trials, systematic reviews, consensus statements and expert opinions. We also hand searched pertinent bibliographies and cross-referenced known EOL ICU communication researchers. RESULTS Family-centered communication is a key component of implementing EOL ICU palliative care. The main forum for this is the family meeting, which is an essential platform for implementing shared decision making, e.g., transitioning from curative to EOL palliative goals of care. Better communication can improve patient outcomes such as reducing psychological trauma symptoms, depression and anxiety; shortening ICU length of stay; and improving the quality of death and dying. Communication strategies for EOL discussions focus on addressing family emotions empathically and discussing death and dying in an open and meaningful way. Central to this is viewing ICU EOL palliative care and withdrawal of life-extending treatment as predictable and not an unexpected emergency. CONCLUSIONS Because the ICU is now a well-established site for death, ICU physicians should be trained with EOL communication skills so as to facilitate palliative care more hospitably in this challenging setting. Patient/family outcomes are important ways of measuring the quality of ICU palliative care and EOL communication.
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Affiliation(s)
- Tomer T Levin
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
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How I conduct the family meeting to discuss the limitation of life-sustaining interventions: a recipe for success. Blood 2010; 116:1648-54. [PMID: 20442362 DOI: 10.1182/blood-2010-03-277343] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The meeting with the family of a hospitalized patient dying with advanced cancer or hematologic disease in which the limitation of life-sustaining interventions is discussed can be a challenge, particularly for junior physicians. A successful conclusion to this discussion involves an outcome in which the family, without coercion or manipulation, comes to accept that the appropriate care has been provided to their loved one, while the caregivers are enabled to provide care that is goal-directed and patient-centered. This type of result can be achieved through an approach in which patient-focused recommendations are offered in the context of diligent efforts to establish and sustain trust, thoughtful preparation, and respectful discussions with the family.
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Falcó-Pegueroles A. [The nursing profession regarding limitation of life support treatment in the intensive care units. Technical and practical features]. ENFERMERIA INTENSIVA 2010; 20:104-9. [PMID: 19775567 DOI: 10.1016/s1130-2399(09)72590-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The scientific and technical developments in medicine in the recent decades have greatly helped to increase life expectancy and quality of life of many patients. In hospitals, this technological scenario has clearly influenced patient care, for example, in the Intensive Medicine Departments, leading to new clinical perspectives and has made the growing complexity of giving treatment and making decisions more evident. In some cases, it is difficult to predict how beneficial intensive medical care can be when there is no reasonable prospect of improving the patient's health, prolonging their life in situations with poor prognosis or dramatically reducing their quality of life. The clinical diagnosis of irreversibility, through indicators of severity and principles of beneficence, autonomy and justice in the professional conduct are the elements that give rise to the consideration of withholding and withdrawing treatment in the critical patient. However, there are other factors that need to be taken into consideration and that are analyzed by professional ethics and bioethics. It is from this approach that any decision involving withholding and withdrawing treatment should be taken so that these decisions can be considered estimable form an ethical point of view. The nursing professional in intensive care units is expected to actively participate in decision making by contributing with their humanizing vision and care ethics. They should be aware of their contribution in the medical team behaving, representing and encouraging the requirements of bioethics.
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Affiliation(s)
- A Falcó-Pegueroles
- Departamento de Enfermería Fundamental y Médico-quirúrgica, Escuela de Enfermería, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, España.
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Varelas PN, Hacein-Bey L, Schultz L, Conti M, Spanaki MV, Gennarelli TA. Withdrawal of life support in critically ill neurosurgical patients and in-hospital death after discharge from the neurosurgical intensive care unit. Clinical article. J Neurosurg 2009; 111:396-404. [PMID: 19374492 DOI: 10.3171/2009.3.jns08493] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The aim of this study was to examine the variables influencing the mode and location of death in patients admitted to a neurosurgical intensive care unit (NICU), including the participation of a newly appointed neurointensivist (NI). METHODS Data from all patients admitted to a university hospital NICU were prospectively collected and compared between 2 consecutive 19-month periods before and after the appointment of an NI. RESULTS One thousand eighty-seven patients were admitted before and 1279 after the NI's appointment. The withdrawal of life support (WOLS) occurred in 52% of all cases of death. Death following WOLS compared with survival was independently associated with an older patient age (OR 1.04/year, 95% CI 1.03-1.05), a higher University Hospitals Consortium (UHC) expected mortality rate (OR 1.05/%, 95% CI 1.04-1.07), transfer from another hospital (OR 3.7, 95% CI 1.6-8.4) or admission through the emergency department (OR 5.3, 95% CI 2.4-12), admission to the neurosurgery service (OR 7.5, 95% CI 3.2-17.6), and diagnosis of an ischemic stroke (OR 5.4, 95% CI 1.4-20.8) or intracerebral hemorrhage (OR 5.7, 95% CI 1.9-16.7). On discharge from the NICU, 54 patients died on the hospital ward (2.7% mortality rate). A younger patient age (OR 0.94/year, 95% CI 0.92-0.96), higher UHC-expected mortality rate (OR 1.01/%, 95% CI 1-1.03), and admission to the neurosurgery service (OR 9.35, 95% CI 1.83-47.7) were associated with death in the NICU rather than the ward. There was no association between the participation of an NI and WOLS or ward mortality rate. CONCLUSIONS The mode and location of death in NICU-admitted patients did not change after the appointment of an NI. Factors other than the participation of an NI-including patient age and the severity and type of neurological injury-play a significant role in the decision to withdraw life support in the NICU or dying in-hospital after discharge from the NICU.
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Affiliation(s)
- Panayiotis N Varelas
- Department of Neurology, Henry Ford Hospital, K-11, 2799 West Grand Boulevard, Detroit, Michigan 48202, USA.
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Leung KKH, Fung COY, Au CC, Chan DMK, Leung GKK. Knowledge and attitudes toward brain stem death among university undergraduates. Transplant Proc 2009; 41:1469-72. [PMID: 19545658 DOI: 10.1016/j.transproceed.2008.10.096] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2008] [Accepted: 10/06/2008] [Indexed: 11/20/2022]
Abstract
BACKGROUND Withdrawal of life support and organ procurement for transplantation are the main implications of a diagnosis of brain stem death (BSD). Various factors may impact this important decision-making process. The present study sought to investigate the knowledge and attitudes about BSD among university undergraduates as a "well-informed" subgroup of our local population. METHODS A cross-sectional questionnaire survey was administered to a sample of nonmedical university undergraduate students in Hong Kong. RESULTS The subjects' overall knowledge of BSD was unsatisfactory. Only 24% of subjects knew that BSD was the equivalent of legal death in Hong Kong. Among subjects who agreed to withdraw life support treatment from themselves upon the diagnosis of BSD, 30% and 24% refused to do so for their family members or a stranger, respectively. Subjects who agreed to withdraw life support showed significantly better knowledge about BSD than did those who did not agree. Concerns about doctors' inclination to diagnose BSD to save resources and extract organs for transplantation were not observed to negatively affect subjects' decisions about life support withdrawal. CONCLUSION The level of knowledge is an important factor affecting an individual's decision concerning withdrawal of life support therapy upon the diagnosis of BSD. Adequate explanation and counseling are important to facilitate family members in coping with this important end-of-life issue.
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Affiliation(s)
- K K H Leung
- Department of Community Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong.
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Azoulay E, Timsit JF, Sprung CL, Soares M, Rusinová K, Lafabrie A, Abizanda R, Svantesson M, Rubulotta F, Ricou B, Benoit D, Heyland D, Joynt G, Français A, Azeivedo-Maia P, Owczuk R, Benbenishty J, de Vita M, Valentin A, Ksomos A, Cohen S, Kompan L, Ho K, Abroug F, Kaarlola A, Gerlach H, Kyprianou T, Michalsen A, Chevret S, Schlemmer B. Prevalence and factors of intensive care unit conflicts: the conflicus study. Am J Respir Crit Care Med 2009; 180:853-60. [PMID: 19644049 DOI: 10.1164/rccm.200810-1614oc] [Citation(s) in RCA: 332] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Many sources of conflict exist in intensive care units (ICUs). Few studies recorded the prevalence, characteristics, and risk factors for conflicts in ICUs. OBJECTIVES To record the prevalence, characteristics, and risk factors for conflicts in ICUs. METHODS One-day cross-sectional survey of ICU clinicians. Data on perceived conflicts in the week before the survey day were obtained from 7,498 ICU staff members (323 ICUs in 24 countries). MEASUREMENTS AND MAIN RESULTS Conflicts were perceived by 5,268 (71.6%) respondents. Nurse-physician conflicts were the most common (32.6%), followed by conflicts among nurses (27.3%) and staff-relative conflicts (26.6%). The most common conflict-causing behaviors were personal animosity, mistrust, and communication gaps. During end-of-life care, the main sources of perceived conflict were lack of psychological support, absence of staff meetings, and problems with the decision-making process. Conflicts perceived as severe were reported by 3,974 (53%) respondents. Job strain was significantly associated with perceiving conflicts and with greater severity of perceived conflicts. Multivariate analysis identified 15 factors associated with perceived conflicts, of which 6 were potential targets for future intervention: staff working more than 40 h/wk, more than 15 ICU beds, caring for dying patients or providing pre- and postmortem care within the last week, symptom control not ensured jointly by physicians and nurses, and no routine unit-level meetings. CONCLUSIONS Over 70% of ICU workers reported perceived conflicts, which were often considered severe and were significantly associated with job strain. Workload, inadequate communication, and end-of-life care emerged as important potential targets for improvement.
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Affiliation(s)
- Elie Azoulay
- AP-HP, Hôpital Saint-Louis, Medical ICU, University Paris-7 Paris-Diderot, UFR de Médecine, 1 avenue Claude Vellefaux, 75010 Paris, France.
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Escarrabill J, Soler Cataluña JJ, Hernández C, Servera E. [Recommendations for end-of-life care in patients with chronic obstructive pulmonary disease]. Arch Bronconeumol 2009; 45:297-303. [PMID: 19442429 DOI: 10.1016/j.arbres.2008.11.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2008] [Accepted: 11/24/2008] [Indexed: 10/20/2022]
Affiliation(s)
- Joan Escarrabill
- Institut d'Estudis de la Salut, Departament de Salut, Barcelona, España.
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Almoosa KF, Goldenhar LM, Panos RJ. Characteristics of discussions on cardiopulmonary resuscitation between physicians and surrogates of critically ill patients. J Crit Care 2009; 24:280-7. [PMID: 19427765 DOI: 10.1016/j.jcrc.2009.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2008] [Revised: 01/30/2009] [Accepted: 03/08/2009] [Indexed: 11/26/2022]
Abstract
PURPOSE In the intensive care unit (ICU), critically ill patients are often unable to participate in discussions about cardiopulmonary resuscitation (CPR), and decisions on CPR are often made by surrogate decision makers. The objective of this study is to determine the prevalence, content, and perceptions of CPR discussions between critically ill patients' surrogates and ICU physicians and their effect on resuscitation decisions. MATERIALS AND METHODS Eligible patients' surrogates were interviewed using a structured questionnaire more than 24 hours after admission to the medical ICUs at 2 university-affiliated medical centers. Data from surrogates who did and did not participate in a CPR discussion were compared and correlated with patient characteristics and outcomes. RESULTS Of 84 surrogates interviewed, 54% participated in more than 1 CPR discussion. Although most (73%) recalled discussing endotracheal intubation, 49% and 44% recalled discussing chest compressions or electrical cardioversion, respectively, and 68% to 84% stated they understood these components. Mortality was higher in the discussion group compared to the no-discussion group (37% vs. 8%; P < .05), although changes in CPR decisions were similar in both groups (25% vs 18%, P = .5). CONCLUSIONS Only half of critically ill patients' surrogates participated in CPR discussions. For those who did participate, most reported good understanding of resuscitation techniques, but less than half recalled the core components of CPR.
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Affiliation(s)
- Khalid F Almoosa
- University of Cincinnati University Hospital, Cincinnati Veterans Affairs Medical Center, Cincinnati, OH, USA.
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Yun YH, Lee MK, Chang YJ, You CH, Kim S, Choi JS, Lim HY, Lee CG, Choi YS, Hong YS, Kim SY, Heo DS, Jeong HS. The life-sustaining treatments among cancer patients at end of life and the caregiver’s experience and perspectives. Support Care Cancer 2009; 18:189-96. [DOI: 10.1007/s00520-009-0644-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2009] [Accepted: 04/06/2009] [Indexed: 11/29/2022]
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Bach V, Ploeg J, Black M. Nursing Roles in End-of-Life Decision Making in Critical Care Settings. West J Nurs Res 2009; 31:496-512. [PMID: 19208850 DOI: 10.1177/0193945908331178] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study used a grounded theory approach to formulate a conceptual framework of the nursing role in end-of-life decision making in a critical care setting. Fourteen nurses from an intensive care unit and cardio-respiratory care unit were interviewed. The core concept, Supporting the Journey, became evident in four major themes: Being There, A Voice to Speak Up, Enable Coming to Terms, and Helping to Let Go. Nurses described being present with patients and families to validate feelings and give emotional support. Nursing work, while bridging the journey between life and death, imparted strength and resilience and helped overcome barriers to ensure that patients received holistic care. The conceptual framework challenges nurses to be present with patients and families at the end of life, clarify and interpret information, and help families come to terms with end-of-life decisions and release their loved ones.
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Abstract
PURPOSE To examine whether a relationship exists between a neonate's weight and the neonate's receipt of comfort medication between four hours prior to elective ventilator withdrawal and death. It was hypothesized that the greater the neonate's weight, the more likely the neonate was to receive comfort medication at end of life. DESIGN A retrospective chart review. SAMPLE One hundred seventy-one neonates in a midwestern Level III NICU who died after withdrawal of ventilatory support. RESULTS Of the 171 neonates in the sample, 27.5 percent (n = 47) did not receive comfort medication within the designated time frame; neonates who weighed < 800 g were significantly less likely to receive comfort medication than were their heavier cohorts. CONCLUSION In this sample, smaller neonates were given comfort medication less often while they were dying than were their larger counterparts.
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Chung K, Essex E, Samson LF. Ethnic variation in timing of hospice referral: does having no informal caregiver matter? J Palliat Med 2008; 11:484-91. [PMID: 18363492 DOI: 10.1089/jpm.2007.0149] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND The length of hospice stay, as an indicator of timing of hospice referral, is an important outcome to examine in end-of-life care because it is relevant to the quality and cost efficiency of end-of-life care that patients receive. Although the majority receives nonmedical care from informal caregivers, many elderly hospice users rely on paid caregivers or staff of residential facilities. OBJECTIVE This study examined whether availability of informal primary caregiver interact with ethnicity to affect length of hospice stay. DESIGN A retrospective cross-sectional study. SETTING/SUBJECTS Data on 3024 hospice patients aged 65 and older discharged between 1997 and 2000 was extracted from the National Center for Health Statistics' National Home and Hospice Care Survey (NHHCS). MEASUREMENTS Length of hospice stay prior to death or discharge. RESULTS Survival analysis revealed that among patients with formal caregivers, minority patients were likely to have significantly shorter hospice stays than non-Hispanic whites. There were no significant ethnic differences in length of stay among patients with informal caregivers. CONCLUSIONS Our findings suggest that ethnic differences in length of stay should be discussed in terms of type of caregiver, not just type of setting, since patients in residential facilities can have informal primary caregivers who are vigilant advocates for their dying relatives. We discuss possible reasons for the influence of having formal caregivers on length of stay of minority elders.
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Affiliation(s)
- Kyusuk Chung
- Department of Health Administration, Governors State University, University Park, Illinois 60466, USA.
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