1
|
Kumar A, Bhat RS, Mani RK. Terminal Extubation or Terminal Weaning: Is it Feasible in Indian Intensive Care Units? Indian J Crit Care Med 2024; 28:103-105. [PMID: 38323253 PMCID: PMC10839942 DOI: 10.5005/jp-journals-10071-24631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 12/15/2023] [Indexed: 02/08/2024] Open
Abstract
Terminal extubation (TE) and weaning have long been suggested as a modality of intervention when the continuation of mechanical ventilation is not expected to achieve its therapeutic aim and is merely prolonging the dying process. The decision, however, is complex considering limited evidence regarding the best practices and is often defied due to inherent ethical, legal, and medical dilemmas. The article attempts a brief overview of available literature on this subject and discusses its feasibility in Indian intensive care units (ICUs). How to cite this article Kumar A, Bhat RS, Mani RK. Terminal Extubation or Terminal Weaning: Is it Feasible in Indian Intensive Care Units? Indian J Crit Care Med 2024;28(2):103-105.
Collapse
Affiliation(s)
- Arun Kumar
- Department of Critical Care, Palliation, and Intensive Care Rehabilitation, Fortis Hospital, Mohali, Punjab, India
| | - Rajani S Bhat
- Department of Interventional Pulmonology, Sparsh Hospitals, Bengaluru, Karnataka, India
| | - Raj K Mani
- Department of Pulmonology and Critical Care, Yashoda Super Specialty Hospitals, Kaushambi, Ghaziabad, Uttar Pradesh, India
| |
Collapse
|
2
|
Dilemas bioéticos experimentados por el cuidador respiratorio durante el retiro de la ventilación mecánica en adultos al final de la vida. MOVIMIENTO CIENTÍFICO 2022. [DOI: 10.33881/2011-7191.mct.15205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Introducción: sobre el retiro de la ventilación mecánica al final de la vida, la literatura ha documentado brechas conceptuales en los cuidadores respiratorios y los consecuentes dilemas bioéticos a los que se enfrentan estos profesionales. Objetivo: analizar los dilemas bioéticos que experimentan los cuidadores respiratorios durante el retiro de la ventilación mecánica en adultos al final de la vida a partir de una revisión integradora de la literatura publicada entre 2010 y 2021. Metodología: revisión integrativa de la literatura siguiendo los lineamientos de Whittemore & Knafl (2005) y Guirao Goris (2015). Para el análisis de la información se realizó una evaluación crítica de la literatura acopiada para identificar patrones de comportamiento de los cuidadores respiratorios. Resultados: las enfermedades no transmisibles y crónicas fueron identificadas como las principales condiciones clínicas que determinan la toma de decisiones del cuidador respiratorio en el retiro de la ventilación mecánica paliativa; prolongar la vida de forma artificial a pacientes en estado terminal fue el dilema bioético más frecuente. Conclusiones: los profesionales del cuidado respiratorio enfrentan dilemas éticos en el retiro de la ventilación mecánica al final de la vida de pacientes con afecciones oncológicas y no oncológica; la toma de decisiones se realiza principalmente con base en los principios bioéticos clásicos de Respeto por la autonomía, Beneficencia, No maleficencia y Justicia. Se evidencia la carencia de estudios sobre bioética en diálogo con lineamientos de la Declaración Universal sobre Bioética y Derechos humanos.
Collapse
|
3
|
Orr S, Efstathiou N, Baernholdt M, Vanderspank-Wright B. ICU Clinicians' Experiences of Terminal Weaning and Extubation. J Pain Symptom Manage 2022; 63:e521-e528. [PMID: 35093503 DOI: 10.1016/j.jpainsymman.2022.01.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/17/2022] [Accepted: 01/21/2022] [Indexed: 11/21/2022]
Abstract
CONTEXT Aside from spontaneous death, a majority of ICU deaths occur after a decision to either withhold or withdraw life-sustaining measures, including withdrawal of ventilatory support. While terminal weaning or terminal extubation are both used, the lack of evidence on the superiority of one method over the other can create challenges for ICU clinicians. There is a need to explore clinicians' experiences related to terminal weaning/extubation to understand their decision-making processes as well as the context and mechanisms that guide this process. OBJECTIVES This study aimed to explore ICU clinicians'experiences of Terminal Weaning of Mechanical Ventilation (TWMV) in order to better understand the process, and clinicians' feelings about the process. METHODS This study used an exploratory descriptive qualitative design. Data were collected via semi-structured, face-to-face interviews with 20 ICU clinicians. An inductive, data driven thematic analysis approach was used for data analysis. RESULTS Analysis of the data resulted in four themes: Fine-tuning the Process of TWMV; Focusing on the Family; Ensuring Patient-Centered Care; and Impact on Health care Clinicians and Support Needs. CONCLUSION The identified themes provide insight into the complexity of the withdrawal of mechanical ventilation within the context of end-of-life care in the ICU. The themes highlight the need for clear communication of a TWMV plan between clinicians to avoid conflict during the process, ensuring medication is in place for potential distressing symptoms, incorporating patient and family wishes in planning, supporting the family during the process, and training and support for clinicians.
Collapse
Affiliation(s)
- Shelly Orr
- Research Operations Program Director (S.O.), Virginia Commonwealth University Health System, Richmond, Virginia, USA; Lecturer (N.E.), University of Birmingham, Birmingham, England, UK; Associate Dean for Global Initiatives and Professor (M.B.), University of North Carolina, Chapel Hill, North Carolina, USA; Associate Professor (B.V.W), University of Ottawa, Ottawa, Ontario, Canada.
| | - Nikolaos Efstathiou
- Research Operations Program Director (S.O.), Virginia Commonwealth University Health System, Richmond, Virginia, USA; Lecturer (N.E.), University of Birmingham, Birmingham, England, UK; Associate Dean for Global Initiatives and Professor (M.B.), University of North Carolina, Chapel Hill, North Carolina, USA; Associate Professor (B.V.W), University of Ottawa, Ottawa, Ontario, Canada
| | - Marianne Baernholdt
- Research Operations Program Director (S.O.), Virginia Commonwealth University Health System, Richmond, Virginia, USA; Lecturer (N.E.), University of Birmingham, Birmingham, England, UK; Associate Dean for Global Initiatives and Professor (M.B.), University of North Carolina, Chapel Hill, North Carolina, USA; Associate Professor (B.V.W), University of Ottawa, Ottawa, Ontario, Canada
| | - Brandi Vanderspank-Wright
- Research Operations Program Director (S.O.), Virginia Commonwealth University Health System, Richmond, Virginia, USA; Lecturer (N.E.), University of Birmingham, Birmingham, England, UK; Associate Dean for Global Initiatives and Professor (M.B.), University of North Carolina, Chapel Hill, North Carolina, USA; Associate Professor (B.V.W), University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
4
|
Romdhani M, Kohler S, Koskas P, Drunat O. Ethical dilemma for healthcare professionals facing elderly dementia patients during the COVID-19 pandemic. Encephale 2021; 48:595-598. [PMID: 34916078 PMCID: PMC8542442 DOI: 10.1016/j.encep.2021.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 08/30/2021] [Accepted: 09/13/2021] [Indexed: 01/20/2023]
Abstract
The management of elderly patients with dementia and COVID-19 infections without access to an intensive care unit gives rise to serious ethical conflicts. Therapeutic decisions have been made in psychogeriatric units, leaving a heavy moral burden on staff. They had to deal with the most difficult patients without the support of appropriate guidelines. The gap between established rules and hospital reality led to psychological distress and burnout. Managing uncertainty in medical decisions is a skill that doctors and staff learn through experience. However, with the COVID-19 pandemic, uncertainty about patient outcomes seems no longer acceptable. Geriatric triage has challenged professional conscience, emotions and values. The principle of distributive justice, which consists of giving each person in society what is rightfully his or hers, is not being respected during this pandemic. Charity has been reduced to patient survival. Staffs need to make decisions together, and it is important to allow all carers access to a space for reflection. In our unit, the involvement of nurses and care assistants in the decision-making process for patient care is crucial especially for refusal of care. Their view of the patient's condition is different from that of the doctors, as they provide daily care to the patient and stay in the wards for several hours with them. By including as many people as possible in the reflection, we could avoid moral or personal prejudices related to these difficult decisions. The current pandemic can give new meaning to team thinking, giving everyone a voice without hierarchical barriers. With these new waves of COVID-19, we need to rethink our therapeutic conduct for elderly patients with dementia to avoid ethical failure.
Collapse
Affiliation(s)
- M Romdhani
- Hôpital Bretonneau (AP-HP.7), 23, rue Joseph-de-Maistre, 75018 Paris, France.
| | - S Kohler
- Hôpital Bretonneau (AP-HP.7), 23, rue Joseph-de-Maistre, 75018 Paris, France
| | - P Koskas
- Hôpital Bretonneau (AP-HP.7), 23, rue Joseph-de-Maistre, 75018 Paris, France
| | - O Drunat
- Hôpital Bretonneau (AP-HP.7), 23, rue Joseph-de-Maistre, 75018 Paris, France
| |
Collapse
|
5
|
Efstathiou N, Vanderspank-Wright B, Vandyk A, Al-Janabi M, Daham Z, Sarti A, Delaney JW, Downar J. Terminal withdrawal of mechanical ventilation in adult intensive care units: A systematic review and narrative synthesis of perceptions, experiences and practices. Palliat Med 2020; 34:1140-1164. [PMID: 32597309 DOI: 10.1177/0269216320935002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND During the terminal withdrawal of life-sustaining measures for intensive care patients, the removal of respiratory support remains an ambiguous practice. Globally, perceptions and experiences of best practice vary due to the limited evidence in this area. AIM To identify, appraise and synthesise the latest evidence around terminal withdrawal of mechanical ventilation in adult intensive care units specific to perceptions, experiences and practices. DESIGN Mixed methods systematic review and narrative synthesis. A review protocol was registered on PROSPERO (CRD42018086495). DATA SOURCES Four electronic databases were systematically searched (Medline, Embase, CENTRAL and CINAHL). Obtained articles published between January 2008 and January 2020 were screened for eligibility. All included papers were appraised using relevant appraisal tools. RESULTS Twenty-five papers were included in the review. Findings from the included papers were synthesised into four themes: 'clinicians' perceptions and practices'; 'time to death and predictors'; 'analgesia and sedation practices'; 'physiological and psychological impact'. CONCLUSIONS Perceptions, experiences and practices of terminal withdrawal of mechanical ventilation vary significantly across the globe. Current knowledge highlights that the time to death after withdrawal of mechanical ventilation is very short. Predictors for shorter duration could be considered by clinicians and guide the choice of pharmacological interventions to address distressing symptoms that patients may experience. Clinicians ought to prepare patients, families and relatives for the withdrawal process and the expected progression and provide them with immediate and long-term support following withdrawal. Further research is needed to improve current evidence and better inform practice guidelines.
Collapse
Affiliation(s)
- Nikolaos Efstathiou
- College of Medical and Dental Sciences, Institute of Clinical Sciences, School of Nursing, University of Birmingham, Birmingham, UK
| | | | - Amanda Vandyk
- Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, ON, Canada
| | - Mustafa Al-Janabi
- Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, ON, Canada
| | - Zeinab Daham
- Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa, ON, Canada
| | - Aimee Sarti
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - James Downar
- Divisions of Critical Care and Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| |
Collapse
|
6
|
Fehnel CR, Armengol de la Hoz M, Celi LA, Campbell ML, Hanafy K, Nozari A, White DB, Mitchell SL. Incidence and Risk Model Development for Severe Tachypnea Following Terminal Extubation. Chest 2020; 158:1456-1463. [PMID: 32360728 DOI: 10.1016/j.chest.2020.04.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 04/03/2020] [Accepted: 04/20/2020] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Palliative ventilator withdrawal (PVW) in the ICU is a common occurrence. RESEARCH QUESTION The goal of this study was to measure the rate of severe tachypnea as a proxy for dyspnea and to identify characteristics associated with episodes of tachypnea. STUDY DESIGN AND METHODS This study assessed a retrospective cohort of ICU patients from 2008 to 2012 mechanically ventilated at a single academic medical center who underwent PVW. The primary outcome of at least one episode of severe tachypnea (respiratory rate > 30 breaths/min) within 6 h after PVW was measured by using detailed physiologic and medical record data. Multivariable logistic regression was used to examine the association between patient and treatment characteristics with the occurrence of a severe episode of tachypnea post extubation. RESULTS Among 822 patients undergoing PVW, 19% and 30% had an episode of severe tachypnea during the 1-h and 6-h postextubation period, respectively. Within 1 h postextubation, patients with the following characteristics were more likely to experience tachypnea: no pre-extubation opiates (adjusted OR [aOR], 2.08; 95% CI, 1.03-4.19), lung injury (aOR, 3.33; 95% CI, 2.19-5.04), Glasgow Coma Scale score > 8 (aOR, 2.21; 95% CI, 1.30-3.77), and no postextubation opiates (aOR, 1.90; 95% CI, 1.19-3.00). INTERPRETATION Up to one-third of ICU patients undergoing PVW experience severe tachypnea. Administration of pre-extubation opiates (anticipatory dosing) represents a key modifiable factor that may reduce poor symptom control.
Collapse
Affiliation(s)
- Corey R Fehnel
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, MA; Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA.
| | - Miguel Armengol de la Hoz
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA; Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA; Biomedical Engineering and Telemedicine Group, Biomedical Technology Centre CTB, ETSI Telecomunicación, Universidad Politécnica de Madrid, Madrid, Spain
| | - Leo A Celi
- Department of Medicine, Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts Institute of Technology, Cambridge, MA
| | | | - Khalid Hanafy
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Ala Nozari
- Department of Medicine, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Douglas B White
- Department of Critical Care, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Susan L Mitchell
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, MA; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| |
Collapse
|
7
|
Update and recommendations in decision making referred to limitation of advanced life support treatment. Med Intensiva 2019; 44:101-112. [PMID: 31472947 DOI: 10.1016/j.medin.2019.07.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 06/16/2019] [Accepted: 07/14/2019] [Indexed: 12/18/2022]
Abstract
The Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) Bioethics Working Group has developed recommendations on the Limitation of Advanced Life Support Treatment (LLST) decisions, with the aim of reducing variability in clinical practice and of improving end of life care in critically ill patients. The conceptual framework of LLST and futility are explained. Recommendations referred to new forms of LLST encompassing also the adequacy of other treatments and diagnostic methods are developed. In addition, planning of the possible clinical courses following the decision of LLST is commented. The importance of advanced care planning in decision-making is emphasized, and intensive care oriented towards organ donation at end of life in the critically ill patient is described. The integration of palliative care in the critical patient treatment is promoted in end of life stages in the Intensive Care Unit.
Collapse
|
8
|
Schwartz Y, Jarjoui A, Yinnon AM. Mechanical ventilation in medical departments: a necessary evil, or a blessing in bad disguise? Isr J Health Policy Res 2019; 8:48. [PMID: 31159870 PMCID: PMC6545679 DOI: 10.1186/s13584-019-0322-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 05/27/2019] [Indexed: 11/30/2022] Open
Abstract
In most countries there is a mismatch between demand for intensive care unit (ICU) beds and ICU bed availability. Because of a policy of low ICU-bed reimbursement this mismatch is much more profound in Israel, which arguably has the lowest number of ICU beds/1000 population of OECD countries. Increasing demand for mechanical ventilation has led to an ever-rising presence of ventilated patients in medical departments, which may reach up to 15% or more of medical beds, especially during winter months, posing serious challenges such as: delivery of adequate treatment, guaranteeing patient safety, nosocomial infections, emergence and spread of resistant organisms, dissatisfaction among family members and medical and nursing staff, as well as enormous direct and indirect expenses. This paper assumes that no change in ICU reimbursement will occur in the near future. We, therefore, describe a number of policy issues that should ideally be addressed together in order to cope realistically with the increase in mechanically ventilated patients in medical departments. First, all medical departments should operate a 5-bed augmented care room with one dedicated nurse per shift. Medical residents should receive a mandatory 3-month ICU rotation in their first year of residency, and attending physicians should receive adequate training in mechanical ventilation and vasopressor support, point-of-care ultrasound and central venous catheterization. Second, family physicians should be required to discuss and fill relevant forms with advance directives for elderly and/or chronically ill patients. Third, rules for terminal extubation should be established, even if only applied infrequently. Finally, co-payment should be considered for families of patients demanding all possible medical treatment in spite of contrary medical advice, considering these patients’ terminal status. Implementation of these recommendations will require policy decision making in the Ministry of Health, Scientific Council of the Israeli Medical Association, the professional societies (for internal medicine and family practice) and finally by the leadership of individual hospitals.
Collapse
Affiliation(s)
- Yuval Schwartz
- Infectious Disease Unit, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel.,Division of Internal Medicine, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, P.O. Box 3235, 91031, Jerusalem, Israel
| | - Amir Jarjoui
- Lung Institute, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel.,Division of Internal Medicine, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, P.O. Box 3235, 91031, Jerusalem, Israel
| | - Amos M Yinnon
- Infectious Disease Unit, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel. .,Division of Internal Medicine, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, P.O. Box 3235, 91031, Jerusalem, Israel.
| |
Collapse
|
9
|
Robert R, Reignier J. Reply: Discussion on Terminal weaning or immediate extubation for withdrawing mechanical ventilation in critically ill patients (the ARREVE observational study). Intensive Care Med 2017; 44:275-276. [PMID: 29481014 DOI: 10.1007/s00134-017-5037-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2017] [Indexed: 11/27/2022]
Affiliation(s)
- René Robert
- Inserm CIC 1402, Axe Alive, Poitiers, France
- Université de Poitiers, Poitiers, France
- CHU Poitiers, Service de Réanimation Médicale, Poitiers, France
| | - Jean Reignier
- Service de Réanimation Médicale, Centre Hospitalier Universitaire Hotel-Dieu, 30 Bd. Jean Monnet, 44093, Nantes Cedex 1, France
| |
Collapse
|
10
|
Quenot JP, Ecarnot F, Meunier-Beillard N, Dargent A, Large A, Andreu P, Rigaud JP. What are the ethical aspects surrounding the collegial decisional process in limiting and withdrawing treatment in intensive care? ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:S43. [PMID: 29302599 DOI: 10.21037/atm.2017.04.15] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The decision to limit or withdraw life-support treatment is an integral part of the job of a physician working in the intensive care unit, and of the approach to care. However, this decision is influenced by a number of factors. It is widely accepted that a medical decision that will ultimate lead to end-of-life in the intensive care unit (ICU) must be shared between all those involved in the care process, and should give precedence to the patient's wishes (either directly expressed by the patient or in written form, such as advance directives), and taking into account the opinion of the patient's family, including the surrogate if the patient is no longer capable of expressing themselves. A number of questions still remain unanswered regarding how decisions to limit or withdraw treatment are taken in daily practice, especially when this decision can be anticipated. We discuss here the collegial procedure for decision-making, in particular in the context of recent French legislation on end-of-life issues. We describe how collegial decision-making procedures should be carried out, and what points are covered in shared discussions regarding decisions to limit or withdraw life-sustaining therapies.
Collapse
Affiliation(s)
- Jean-Pierre Quenot
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France.,Lipness Team, INSERM Research Center LNC-UMR1231 and LabEx LipSTIC, University of Burgundy, Dijon, France.,INSERM Besancon, CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
| | - Fiona Ecarnot
- EA3920, Department of Cardiology, University Hospital Besancon, Besancon, France
| | - Nicolas Meunier-Beillard
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France.,Department of Sociology, Centre Georges Chevrier UMR 7366 CNRSUniversity of Burgundy, Dijon, France
| | - Auguste Dargent
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France.,Lipness Team, INSERM Research Center LNC-UMR1231 and LabEx LipSTIC, University of Burgundy, Dijon, France
| | - Audrey Large
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
| | - Pascal Andreu
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
| | | |
Collapse
|
11
|
Lesieur O, Genteuil L, Leloup M. A few realistic questions raised by organ retrieval in the intensive care unit. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:S44. [PMID: 29302600 DOI: 10.21037/atm.2017.05.08] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Organ transplantation saves the lives of many persons who would otherwise die from end-stage organ disease. The increasing demand for donated organs has led to a renewed interest in donation after circulatory determination of death (CDD). In many countries (including France), terminally ill patients who die of circulatory arrest after a planned withdrawal of life support may be considered as organ donors under certain conditions. While having equal responsibility towards the potential donor and the persons awaiting a transplant, caregivers may experience an ethical dilemma between the responsibility to deliver the best care to the dying, and the need to retrieve the organs. Once it has been established that the patient wishes to be a donor, we assume that end-of-life care and organ donation may have convergent goals when they contribute to transforming a comfortable death into a chance of life for others in need.
Collapse
Affiliation(s)
- Olivier Lesieur
- Intensive Care Unit, Saint Louis Hospital, La Rochelle, France
| | - Liliane Genteuil
- Organ Procurement Organization, Bicêtre Hospital, Le Kremlin Bicêtre, France
| | - Maxime Leloup
- Intensive Care Unit, Saint Louis Hospital, La Rochelle, France
| |
Collapse
|
12
|
Terminal weaning or immediate extubation for withdrawing mechanical ventilation in critically ill patients (the ARREVE observational study). Intensive Care Med 2017; 43:1793-1807. [PMID: 28936597 DOI: 10.1007/s00134-017-4891-0] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 07/18/2017] [Indexed: 12/20/2022]
Abstract
PURPOSE The relative merits of immediate extubation versus terminal weaning for mechanical ventilation withdrawal are controversial, particularly regarding the experience of patients and relatives. METHODS This prospective observational multicentre study (ARREVE) was done in 43 French ICUs to compare terminal weaning and immediate extubation, as chosen by the ICU team. Terminal weaning was a gradual decrease in the amount of ventilatory assistance and immediate extubation was extubation without any previous decrease in ventilatory assistance. The primary outcome was posttraumatic stress symptoms (Impact of Event Scale Revised, IES-R) in relatives 3 months after the death. Secondary outcomes were complicated grief, anxiety, and depression symptoms in relatives; comfort of patients during the dying process; and job strain in staff. RESULTS We enrolled 212 (85.5%) relatives of 248 patients with terminal weaning and 190 relatives (90.5%) of 210 patients with immediate extubation. Immediate extubation was associated with airway obstruction and a higher mean Behavioural Pain Scale score compared to terminal weaning. In relatives, IES-R scores after 3 months were not significantly different between groups (31.9 ± 18.1 versus 30.5 ± 16.2, respectively; adjusted difference, -1.9; 95% confidence interval, -5.9 to 2.1; p = 0.36); neither were there any differences in complicated grief, anxiety, or depression scores. Assistant nurses had lower job strain scores in the immediate extubation group. CONCLUSIONS Compared to terminal weaning, immediate extubation was not associated with differences in psychological welfare of relatives when each method constituted standard practice in the ICU where it was applied. Patients had more airway obstruction and gasps with immediate extubation. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01818895.
Collapse
|
13
|
Brown CE, Benoit DD, Curtis JR. Focus on palliative care in the ICU. Intensive Care Med 2017; 43:1898-1900. [PMID: 28932878 DOI: 10.1007/s00134-017-4938-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 09/13/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Crystal E Brown
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, University of Washington, Box 359762, Seattle, WA, 98104, USA
| | - Dominique D Benoit
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA.
- Division of Pulmonary, Critical Care, and Sleep Medicine, Harborview Medical Center, University of Washington, Box 359762, Seattle, WA, 98104, USA.
| |
Collapse
|