Medical futility

Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit

End-of-life care (EOLC) exemplifies the joint mission of intensive and palliative care (PC) in their human-centeredness. The explosion of technological advances in medicine must be balanced with the culture of holistic care. Inevitably, it brings together the science and the art of medicine in their full expression. High-quality EOLC in the ICU is grounded in evidence, ethical principles, and professionalism within the framework of the Law. Expert professional statements over the last two decades in India were developed while the law was evolving. Recent landmark Supreme Court judgments have necessitated a review of the clinical pathway for EOLC outlined in the previous statements. Much empirical and interventional evidence has accumulated since the position statement in 2014. This iteration of the joint Indian Society of Critical Care Medicine-Indian Association of Palliative Care (ISCCM-IAPC) Position Statement for EOLC combines contemporary evidence, ethics, and law for decision support by the bedside in Indian ICUs.

How to cite this article

Mani RK, Bhatnagar S, Butola S, Gursahani R, Mehta D, Simha S, et al. Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit. Indian J Crit Care Med 2024;28(3):200-250.

Predictors of Early Readmission in Hospitalized Patients with Inflammatory Bowel Disease

BACKGROUND

Readmissions are being increasingly used as an indicator of quality of care. We sought to identify risk factors for 30-day readmission in hospitalized patients with inflammatory bowel disease.

METHODS

Patients with inflammatory bowel disease hospitalized between 2004 and 2013 at the University of Maryland were identified. Demographic and clinical information were extracted from the medical record for each admission. Multivariate logistic regression was performed to determine the association between these variables and readmission.

RESULTS

One thousand two hundred thirteen admissions were identified in 498 patients; 232 (19.1%) index admissions were followed by a 30-day readmission. Mean age was 39.4 ± 14.5 years. Approximately 70% of the population was white, 60% were women, and 67.5% had Crohn's disease. Concurrent congestive heart failure and chronic obstructive pulmonary disease, history of steroid use, diverting ileostomy, subtotal colectomy, or a thromboembolic event during index admission, and IV antibiotics or restricted diet at discharge were associated with readmission. After adjustment, patients with congestive heart failure or chronic obstructive pulmonary disease were more likely to be readmitted (aOR 4.06 and 2.86, respectively). Underweight or obese patients were nearly twice as likely to be readmitted (aOR 1.81 and 1.72, respectively). Those with past steroid use, new ileostomy, or those who were discharged on hyperalimentation were twice as likely to be readmitted (aOR 1.90, 2.04, and aOR 1.97, respectively).

CONCLUSIONS

Nineteen percentage of patients with inflammatory bowel disease treated at a referral center are readmitted within 30 days. Our results suggest that patients with comorbid medical conditions, malnutrition or obesity, a new ileostomy, past steroid use, or those discharged on hyperalimentation are at increased risk for readmission. Research is needed to determine if targeted interventions for high-risk patients decreases readmissions.

Medical futility and its challenges: a review study

Concerns over limited medical equipment and resources, particularly in intensive care units (ICUs), have raised the issue of medical futility. Medical futility draws a contrast between physician's authority and patients' autonomy and it is one of the major issues of end-of-life ethical decision-making. The aim of this study was to review medical futility and its challenges. In this systematized review study, a comprehensive search of the existing literature was performed using an internet search with broad keywords to access related articles in both Persian and English databases. Finally, 89 articles were selected and surveyed. Medical futility is a complex, ambiguous, subjective, situation-specific, value-laden, and goal-dependent concept which is almost always surrounded by some degrees of uncertainty; hence, there is no objective and valid criterion for its determination. This concept is affected by many different factors such as physicians' and patients' value systems, medical goals, and sociocultural and religious context, and individuals' emotions and personal characteristics. It is difficult to achieve a clear consensus over the concept of medical futility; hence, it should be defined and determined at an individual level and based on the unique condition of each patient.

Reasons behind providing futile medical treatments in Iran

Background:

Despite their negative consequences, evidence shows that futile medical treatments are still being provided, particularly to terminally ill patients. Uncovering the reasons behind providing such treatments in different religious and sociocultural contexts can create a better understanding of medical futility and help manage it effectively.

Research objectives:

This study was undertaken to explore Iranian nurses’ and physicians’ perceptions of the reasons behind providing futile medical treatments.

Research design:

This was a qualitative exploratory study. Study data were gathered through conducting in-depth semi-structured personal interviews and analyzed using the conventional content analysis method.

Participants and research context:

Twenty-one nurses and nine medical specialists were recruited purposively from four teaching hospitals affiliated to Tehran University of Medical Sciences.

Ethical considerations:

This study was approved by the Nursing and Midwifery Research Center and the Research Ethics Committee of Tehran University of Medical Sciences. All participants gave informed consent for the research and that their anonymity was preserved.

Findings:

The main theme of the study was “having an obligation to provide medical treatments despite knowing their futility.” This theme consisted of three main categories including patients’ and family members’ request for continuing life-sustaining treatments, healthcare professionals’ personal motives, and organizational atmosphere and structure.

Discussion and conclusion:

Different personal and organizational factors contribute to providing futile medical treatments. Promoting the structure and the function of hospital ethics committees, establishing and developing home care facilities, increasing the number of palliative care centers and hospices, and educating healthcare professionals, patients, and family members about the services and the benefits of such centers can facilitate making wise decisions about continuing or discontinuing treatments which have been labeled as futile.

Nurses' Perceptions of Futile Care: A Qualitative Study

Health care professionals believe that futile care must not be provided; however, there is no clear agreement over the definition and the manifestations of futile care. The aim of this study was to explore Iranian nurses' perceptions of futile care. In this qualitative exploratory study, the conventional content analysis approach was used for collecting and analyzing the study data. Three main themes were extracted from the data: nonfutility of care: care tantamount with outcome; sense of burnout; and subjectivity and relativity of medical futility concept.

Do-not-attempt-cardiopulmonary-resuscitation decisions: an evidence synthesis

Background

Cardiac arrest is the final common step in the dying process. In the right context, resuscitation can reverse the dying process, yet success rates are low. However, cardiopulmonary resuscitation (CPR) is a highly invasive medical treatment, which, if applied in the wrong setting, can deprive the patient of dignified death. Do-not-attempt-cardiopulmonary-resuscitation (DNACPR) decisions provide a mechanism to withhold CPR. Recent scientific and lay press reports suggest that the implementation of DNACPR decisions in NHS practice is problematic.

Aims and objectives

This project sought to identify reasons why conflict and complaints arise, identify inconsistencies in NHS trusts’ implementation of national guidelines, understand health professionals’ experience in relation to DNACPR, its process and ethical challenges, and explore the literature for evidence to improve DNACPR policy and practice.

Methods

A systematic review synthesised evidence of processes, barriers and facilitators related to DNACPR decision-making and implementation. Reports from NHS trusts, the National Reporting and Learning System, the Parliamentary and Health Service Ombudsman, the Office of the Chief Coroner, trust resuscitation policies and telephone calls to a patient information line were reviewed. Multiple focus groups explored service-provider perspectives on DNACPR decisions. A stakeholder group discussed the research findings and identified priorities for future research.

Results

The literature review found evidence that structured discussions at admission to hospital or following deterioration improved patient involvement and decision-making. Linking DNACPR to overall treatment plans improved clarity about goals of care, aided communication and reduced harms. Standardised documentation improved the frequency and quality of recording decisions. Approximately 1500 DNACPR incidents are reported annually. One-third of these report harms, including some instances of death. Problems with communication and variation in trusts’ implementation of national guidelines were common. Members of the public were concerned that their wishes with regard to resuscitation would not be respected. Clinicians felt that DNACPR decisions should be considered within the overall care of individual patients. Some clinicians avoid raising discussions about CPR for fear of conflict or complaint. A key theme across all focus groups, and reinforced by the literature review, was the negative impact on overall patient care of having a DNACPR decision and the conflation of ‘do not resuscitate’ with ‘do not provide active treatment’.

Limitations

The variable quality of some data sources allows potential overstatement or understatement of findings. However, data source triangulation identified common issues.

Conclusion

There is evidence of variation and suboptimal practice in relation to DNACPR decisions across health-care settings. There were deficiencies in considering, discussing and implementing the decision, as well as unintended consequences of DNACPR decisions being made on other aspects of patient care.

Future work

Recommendations supported by the stakeholder group are standardising NHS policies and forms, ensuring cross-boundary recognition of DNACPR decisions, integrating decisions with overall treatment plans and developing tools and training strategies to support clinician and patient decision-making, including improving communication.

Study registration

This study is registered as PROSPERO CRD42012002669.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Clinical effectiveness, access to, and satisfaction with care using a telehomecare substitution intervention: a randomized controlled trial

Background. Hospitalization accounts for 70% of heart failure (HF) costs; readmission rates at 30 days are 24% and rise to 50% by 90 days. Agencies anticipate that telehomecare will provide the close monitoring necessary to prevent HF readmissions. Methods and Results. Randomized controlled trial to compare a telehomecare intervention for patients 55 and older following hospital discharge for HF to usual skilled home care. Primary endpoints were 30- and 60-day all-cause and HF readmission, hospital days, and time to readmission or death. Secondary outcomes were access to care, emergency department (ED) use, and satisfaction with care. All-cause readmissions at 30 days (16% versus 19%) and over six months (46% versus 52%) were lower in the telehomecare group but were not statistically significant. Access to care and satisfaction were significantly higher for the telehomecare patients, including the number of in-person visits and days in home care. Conclusions. Patient acceptance of the technology and current home care policies and processes of care were barriers to gaining clinical effectiveness and efficiency.

Physicians' view of primary care-based case management for patients with heart failure: a qualitative study

BACKGROUND

As part of a trial aiming to improve care for patients with chronic (systolic) heart failure, a standardized, multifaceted case management approach was evaluated in German general practices. It consisted of regular telephone monitoring, home visits, health counselling, diagnostic screening and booklets for patients. Practice-based doctors' assistants (equivalent to a nursing role) adopted these new tasks and reported regularly to the employing general practitioner (GP).

OBJECTIVE

To explore GPs' perceptions of case management, subsequent changes in relationships within the practice team and the potential future role.

METHOD

Twenty-four GPs participated in five moderated, semi-structured, audio-taped focus groups. Full transcription and thematic content analysis was undertaken.

RESULTS

GPs rated all elements and instruments of case management conducted by doctors' assistants feasible, except for the geriatric assessment as patients had not been at risk. GPs perceived difficulties in their own role in delivering health behaviour counselling. Relationships between doctors' assistants and patients and between GPs and patients or doctors' assistants remained stable or improved. All GPs perceived a variety of role changes in doctors' assistants including more in-depth medical knowledge and higher responsibilities yielding more recognition by patients and GPs. Some GPs suggested transferring the case management programme to other chronic conditions and that it should form part of a further education curriculum for doctors' assistants.

CONCLUSION

This primary care-based case management model characterized by the orchestrated delegation of tasks to doctors' assistants offers a promising strategy of enhanced chronic illness care, but it needs further adaptation and evaluation.

Therapeutic and diagnostic role of electrical devices in acute heart failure

Electrical devices, Cardiac Resynchronization Therapy (CRT) pacemakers, the Implantable Cardiac Defibrillator (ICD) and a combination of both, constitute an important line of treatment in the therapy of moderate to severe chronic heart failure. The effectiveness of these devices in the treatment of acute decompensated heart failure has yet to be systematically evaluated. However, the beneficial clinical effects of CRT translate into a marked reduction of heart failure-related hospitalization. Devices also offer unique diagnostic applications by continuous measurement of clinically useful physiological parameters over time. Of particular interest, monitoring of intrathoracic impedance and right ventricular pressures allows to detect changes in volume load in an early stage prior to the development of clinical symptoms. This information could be helpful to stop further progression to acute cardiac decompensation and to avoid hospitalization and acute clinical events. Using modern telecommunication technology, patients can also be remotely monitored in their daily living environment. In consequence, the incorporation of device technology into heart failure management programs calls for a close cooperation between heart failure specialists and electrophysiologists. This review addresses therapeutic and diagnostic aspects of device therapies in the context of acute heart failure.

Case studies in medical futility

Technology has provided means to sustain life and provide care regardless of whether the treatment is appropriate and compassionate given the condition of the patient. This study presents two case histories, compiled from historical patient charts, staff notes and observations, that illustrate the variety of ethical issues involved and the role culture plays in the decision making process related to possible futile medical treatment. Ethical and cultural issues related to the cases are discussed and processes are presented that can help hospitals to avoid, or decrease the level of, medically futile care, and improve the cultural appropriateness of medical care and relationships with patients.

Ventricular Structure and Surgical History

The Reviews report will establish guidelines that underlie why the "restoration concept" may develop a paradigm shift in thinking, by addressing the geometric underpinnings of heart failure and their evolution. This presentation will (a) show that the underlying structure of the failing dilated heart involves a cardiac architectural change from the normal elliptical shape toward a dilated spherical form, (b) define the anatomic framework of this shape change, (c) convey the functional characteristics of heart function that result from this architectural underpinning, (d) describe the pattern of CHF development, (e) indicate imaging measurement guidelines to follow as heart form adversely changes from ellipse to sphere, (f) identify how such architectural changes alter prognosis, and (g) develop a historical evolution of surgical approaches to alter form to improve function to create the background for subsequent RESTORE team reports of current restoration to treat CHF and its complications.

Long-Term Healthcare and Cost Outcomes of Disease Management in a Large, Randomized, Community-Based Population With Heart Failure

Background— Because of the prevalence and expense of congestive heart failure (CHF), significant efforts have been made to develop disease management (DM) programs that will improve clinical and financial outcomes. The effectiveness of such programs in a large, heterogeneous population of CHF patients remains unknown.

Methods and Results— We randomized 1069 patients (aged 70.9±10.3 years) with systolic (ejection fraction 35±9%) or echocardiographically confirmed diastolic heart failure (HF) to assess telephonic DM over an 18-month period. Data were collected at baseline and at 6-month intervals. Survival analysis was performed by Kaplan-Meier and Cox regression methods. Healthcare utilization was defined after extensive record review, with an attempt to account for all inpatient and outpatient visits, medications, and diagnostic tests. We obtained data on 92% of the patients, from nearly 53 000 health-related encounters. Total cost per patient was defined by adding estimated costs for the observed encounters, excluding the cost of the DM. Kaplan-Meier analysis showed that DM patients had a reduced mortality rate ( P =0.037), with DM patients surviving an average of 76 days longer than controls. Subgroup analysis showed that DM had beneficial outcomes in patients with systolic HF (hazard ratio 0.62; P =0.040), which was more pronounced in NYHA classes III and IV. Although improvements in NYHA class were more likely with DM ( P <0.001), 6-minute walk data from 217 patients in whom data were available at each visit showed no significant benefit from DM ( P =0.08). Total and CHF-related healthcare utilization, including medications, office or emergency department visits, procedures, or hospitalizations, was not decreased by DM. Repeated-measures ANOVA for cost by group showed no significant differences, even in the higher NYHA class groups.

Conclusions— Participation in DM resulted in a significant survival benefit, most notably in symptomatic systolic HF patients. Although DM was associated with improved NYHA class, 6-minute walk test results did not improve. Healthcare utilization was not reduced by DM, and it conferred no cost savings. DM in HF results in improved life expectancy but does not improve objective measures of functional capacity and does not reduce cost.

Effect of epicardial or biventricular pacing to prolong QT interval and increase transmural dispersion of repolarization: does resynchronization therapy pose a risk for patients predisposed to long QT or torsade de pointes?

BACKGROUND

The present study examined pacing site-dependent changes in QT interval and transmural dispersion of repolarization (TDR) and their potential role in the development of torsade de pointes (TdP).

METHODS AND RESULTS

In humans, the QT interval, JT interval, and TDR were measured in 29 patients with heart failure during right ventricular endocardial pacing (RVEndoP), biventricular pacing (BiVP), and left ventricular epicardial pacing (LVEpiP). In animal experiments, pacing site--dependent changes in ventricular repolarization were examined with a rabbit left ventricular wedge preparation in which action potentials from endocardium and epicardium could be simultaneously recorded with a transmural ECG. In humans, LVEpiP and BiVP led to significant QT and JT prolongation. LVEpiP also enhanced TDR. Frequent R-on-T extrasystoles generated by BiVP and LVEpiP but completely inhibited by RVEndoP occurred in 4 patients, of whom 1 developed multiple episodes of nonsustained polymorphic ventricular tachycardia and another suffered incessant TdP. In rabbit experiments, switching from endocardial to epicardial pacing produced a net increase in QT interval and TDR by 17+/-5 and 22+/-5 ms, respectively (n=6, P<0.01), without parallel increases in ventricular transmembrane action potential durations. Epicardial pacing facilitated transmural propagation of early afterdepolarization, leading to the development of R-on-T extrasystoles and TdP in the presence of action potential duration-prolonging agents.

CONCLUSIONS

LVEpiP and BiVP increase QT, JT, and TDR by altering the transmural sequence of activation of the intrinsically heterogeneous ventricular myocardium. Our data suggest that the resultant exaggeration of arrhythmic substrates can lead to the development of TdP in a subset of patients.

Nesiritide: review of clinical pharmacology and role in heart failure management

Nesiritide mimics the actions of endogenous B-type natriuretic peptides. Clinical studies on patients who had acute decompensated heart failure demonstrated rapid-onset dose-related vasodilatory effects. Nesiritide reduces pulmonary capillary wedge pressure and improves dypsnea. These effects compared favorably to standard treatments. It decreases preload and afterload and suppresses the renin-angiotensin-aldosterone axis and the release of norepinephrine. Nesiritide also promotes diuresis and has no proarrhythmic effects. Nesiritide is a valuable therapeutic option in the treatment of patients hospitalized for decompensated heart failure. On-going studies target the examination of its long-term effects on mortality and morbidity and its pharmacoeconomic benefits to the healthcare system.

Motivating factors in futile clinical interventions

With modern medical technology, it is now possible to sustain life for prolonged periods in critically ill patients, even when there is no reasonable hope of improvement or achieving the goals of therapy. Such futile and medically inappropriate interventions may violate both the ethical and medical precepts generally accepted by patients, families, and physicians. In this study, we sought to determine who was primarily responsible for such interventions, the nature of their motivation, and the role of a timely bioethical consultation. In a retrospective review, we identified 100 patients of 331 bioethical consultations who had futile or medically inappropriate therapy. The average age of patients was 73.5 +/- 32 years (mean +/- 2 SD) with 57% being male. Fifty-seven percent of the patients were admitted to the hospital with a degenerative disorder, 21% with an inflammatory disorder, and 16% with a neoplastic disorder. The family was responsible for futile treatment in 62% of cases, the physician in 37% of cases, and a conservator in one case. Unreasonable expectation for improvement was the most common underlying factor. Family dissent was involved in 7 of 62 cases motivated by family, but never when physicians were primarily responsible. Liability issues motivated physicians in 12 of 37 cases where they were responsible but in only 1 of 62 cases when the family was (chi(2) 5 degrees of freedom = 26.7, p < 0.001). When the bioethics consultation resulted in cessation of the therapy, patients died in a median of 2 days as opposed to 16 days if therapy continued (p < 0.001).

Biomedical ethics and the withdrawal of advanced life support

It is common for health care providers to deal with the complex and difficult issue of withdrawing advanced life support. The patient is always the key source of authority in these decisions. The most important ingredient in end-of-life decision making is effective communication. It is important to try to ascertain what the patient thought about quality-of-life values before surrogate decisions can be made on the patient's behalf. The concepts of beneficence, nonmaleficence, autonomy, and justice are the foundation of ethical decision making. Numerous legal precedents have laid the groundwork for end-of-life decision making. Most state courts have supported withholding and withdrawing life support from patients who will not regain a reasonable quality of life. The recent Patient Self-Determination Act encourages patients to fill out advance directives that state their desires. When continued intensive care is futile, advanced life support should be withdrawn. However, a narrow definition of futility in this situation is the key, since the concept of futility could lead to inappropriate decisions. It is best to consider a situation futile when the patient is terminally ill, the condition is irreversible, and death is imminent. During the withdrawal of advanced life support, terminal or rapid weaning is preferable to extubation. Combinations of opiates, benzodiazepines, and other agents help provide comfort to patients who are suffering.

In vivo acceleration of heart relaxation performance by parvalbumin gene delivery

Defective cardiac muscle relaxation plays a causal role in heart failure. Shown here is the new in vivo application of parvalbumin, a calcium-binding protein that facilitates ultrafast relaxation of specialized skeletal muscles. Parvalbumin is not naturally expressed in the heart. We show that parvalbumin gene transfer to the heart in vivo produces levels of parvalbumin characteristic of fast skeletal muscles, causes a physiologically relevant acceleration of heart relaxation performance in normal hearts, and enhances relaxation performance in an animal model of slowed cardiac muscle relaxation. Parvalbumin may offer the unique potential to correct defective relaxation in energetically compromised failing hearts because the relaxation-enhancement effect of parvalbumin arises from an ATP-independent mechanism. Additionally, parvalbumin gene transfer may provide a new therapeutic approach to correct cellular disturbances in calcium signaling pathways that cause abnormal growth or damage in the heart or other organs.

Evolution and pathophysiology of chronic systolic heart failure

Understanding of the pathophysiology of chronic systolic heart failure evolved from a purely mechanical model to one in which a cascade of neurohormones and biologically active molecules are thought to be critical in the development, maintenance, and progression of the disease. Two important neurohormonal systems are the sympathetic nervous and renin-angiotensin-aldosterone systems. Initially, increases in norepinephrine concentrations from the sympathetic nervous system and in angiotensin II and aldosterone are beneficial in the short term to maintain cardiac output after an insult to the myocardium. However, long-term exposure to these neurohormones causes alterations of myocytes and interstitial make-up of the heart. These alterations in myocardium lead to progression of heart failure and, eventually, death.