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Feldman C, Joynt GM, Mentzelopoulos SD, Sprung CL, Avidan A, Richards GA. Limitations of life-sustaining therapies in South Africa. J Crit Care 2024; 82:154797. [PMID: 38554544 DOI: 10.1016/j.jcrc.2024.154797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/18/2024] [Accepted: 03/19/2024] [Indexed: 04/01/2024]
Abstract
PURPOSE Limitations of life sustaining therapies (LLST) are frequent in intensive care units (ICUs), but no previous studies have examined end-of-life (EOL) care and LLST in South Africa (SA). MATERIALS AND METHODS This study evaluated LLST in SA from the data of a prospective, international, multicentre, observational study (Ethicus-2) and compared practices with countries in the rest of the world. RESULTS LLST was relatively common in SA, and withholding was more frequent than withdrawing therapy. However, withdrawing and withholding therapy were less common, while failed CPR was more common, than in many other countries. No patients had an advance directive. Primary reasons for LLST in SA were poor quality of life, multisystem organ failure and patients' unresponsiveness to maximal therapy. Primary considerations for EOL decision-making were good medical practice and patients' best-interest, with the need for an ICU bed only rarely considered. CONCLUSIONS Withholding was more common than withdrawing treatment both in SA and worldwide, although both were significantly less frequent in SA compared with the world average.
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Affiliation(s)
- Charles Feldman
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Gavin M Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, China
| | - Spyros D Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelsimos General Hospital, Athens, Greece
| | - Charles L Sprung
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Alexander Avidan
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Guy A Richards
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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2
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Mani RK, Bhatnagar S, Butola S, Gursahani R, Mehta D, Simha S, Divatia JV, Kumar A, Iyer SK, Deodhar J, Bhat RS, Salins N, Thota RS, Mathur R, Iyer RK, Gupta S, Kulkarni P, Murugan S, Nasa P, Myatra SN. 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; 28:200-250. [PMID: 38477011 PMCID: PMC10926026 DOI: 10.5005/jp-journals-10071-24661] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 02/28/2024] [Indexed: 03/14/2024] Open
Abstract
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.
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Affiliation(s)
- Raj K Mani
- Department of Critical Care and Pulmonology, Yashoda Super Specialty Hospital, Ghaziabad, Kaushambi, Uttar Pradesh, India
| | - Sushma Bhatnagar
- Department of Onco-Anaesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Savita Butola
- Department of Palliative Care, Border Security Force Sector Hospital, Panisagar, Tripura, India
| | - Roop Gursahani
- Department of Neurology, P. D. Hinduja National Hospital & Medical Research Centre, Mumbai, Maharashtra, India
| | - Dhvani Mehta
- Division of Health, Vidhi Centre for Legal Policy, New Delhi, India
| | - Srinagesh Simha
- Department of Palliative Care, Karunashraya, Bengaluru, Karnataka, India
| | - Jigeeshu V Divatia
- Department of Anaesthesia, Critical Care, and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Arun Kumar
- Department of Intensive Care, Medical Intensive Care Unit, Fortis Healthcare Ltd, Mohali, Punjab, India
| | - Shiva K Iyer
- Department of Critical Care, Bharati Vidyapeeth (Deemed to be University) Medical College, Pune, Maharashtra, India
| | - Jayita Deodhar
- Department Palliative Care, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Rajani S Bhat
- Department of Interventional Pulmonology and Palliative Medicine, SPARSH Hospitals, Bengaluru, Karnataka, India
| | - Naveen Salins
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Raghu S Thota
- Department Palliative Care, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Roli Mathur
- Department of Bioethics, Indian Council of Medical Research, Bengaluru, Karnataka, India
| | - Rajam K Iyer
- Department of Palliative Care, Bhatia Hospital; P. D. Hinduja National Hospital & Medical Research Centre, Mumbai, Maharashtra, India
| | - Sudeep Gupta
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | | | - Sangeetha Murugan
- Department of Education and Research, Karunashraya, Bengaluru, Karnataka, India
| | - Prashant Nasa
- Department of Critical Care Medicine, NMC Specialty Hospital, Dubai, United Arab Emirates
| | - Sheila N Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
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3
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Wolff G, Wernly B, Flaatten H, Fjølner J, Bruno RR, Artigas A, Pinto BB, Schefold JC, Kelm M, Binneboessel S, Baldia P, Beil M, Sivri S, van Heerden PV, Szczeklik W, Elhadi M, Joannidis M, Oeyen S, Flamm M, Zafeiridis T, Marsh B, Andersen FH, Moreno R, Boumendil A, De Lange DW, Guidet B, Leaver S, Jung C. Sex-specific treatment characteristics and 30-day mortality outcomes of critically ill COVID-19 patients over 70 years of age-results from the prospective COVIP study. Can J Anaesth 2022; 69:1390-1398. [PMID: 35945477 PMCID: PMC9363137 DOI: 10.1007/s12630-022-02304-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 05/06/2022] [Accepted: 05/06/2022] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Older critically ill patients with COVID-19 have been the most vulnerable during the ongoing pandemic, with men being more prone to hospitalization and severe disease than women. We aimed to explore sex-specific differences in treatment and outcome after intensive care unit (ICU) admission in this cohort. METHODS We performed a sex-specific analysis in critically ill patients ≥ 70 yr of age with COVID-19 who were included in the international prospective multicenter COVIP study. All patients were analyzed for ICU admission and treatment characteristics. We performed a multilevel adjusted regression analysis to elucidate associations of sex with 30-day mortality. RESULTS A total of 3,159 patients (69.8% male, 30.2% female; median age, 75 yr) were included. Male patients were significantly fitter than female patients as determined by the Clinical Frailty Scale (fit, 67% vs 54%; vulnerable, 14% vs 19%; frail, 19% vs 27%; P < 0.001). Male patients more often underwent tracheostomy (20% vs 14%; odds ratio [OR], 1.57; P < 0.001), vasopressor therapy (69% vs 62%; OR, 1.25; P = 0.02), and renal replacement therapy (17% vs 11%; OR, 1.96; P < 0.001). There was no difference in mechanical ventilation, life-sustaining treatment limitations, and crude 30-day mortality (50% male vs 49% female; OR, 1.11; P = 0.19), which remained true after adjustment for disease severity, frailty, age and treatment limitations (OR, 1.17; 95% confidence interval, 0.94 to 1.45; P = 0.16). CONCLUSION In this analysis of sex-specific treatment characteristics and 30-day mortality outcomes of critically ill patients with COVID-19 ≥ 70 yr of age, we found more tracheostomy and renal replacement therapy in male vs female patients, but no significant association of patient sex with 30-day mortality. STUDY REGISTRATION www. CLINICALTRIALS gov (NCT04321265); registered 25 March 2020).
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Affiliation(s)
- Georg Wolff
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - Bernhard Wernly
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Hans Flaatten
- Department of Clinical Medicine, Department of Anaesthesia and Intensive Care, Haukeland University Hospital, University of Bergen, Bergen, Norway
| | - Jesper Fjølner
- Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Raphael Romano Bruno
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - Antonio Artigas
- Department of Intensive Care Medicine, CIBER Enfermedades Respiratorias, Corporacion Sanitaria Universitaria Parc Tauli, Autonomous University of Barcelona, Sabadell, Spain
| | | | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, Universitätsspital, University of Bern, Bern, Switzerland
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - Stephan Binneboessel
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - Philipp Baldia
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - Michael Beil
- Department of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sigal Sivri
- Department of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Peter Vernon van Heerden
- Department of Anesthesia, Intensive Care and Pain Medicine, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Wojciech Szczeklik
- Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Kraków, Poland
| | | | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Sandra Oeyen
- Department of Intensive Care 1K12IC, Ghent University Hospital, Ghent, Belgium
| | - Maria Flamm
- Institute of General Practice, Family Medicine and Preventive Medicine, Paracelsus Medical University, Salzburg, Austria
| | | | - Brian Marsh
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - Finn H Andersen
- Department of Anesthesia and Intensive Care, Ålesund Hospital, Ålesund, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Rui Moreno
- Unidade de Cuidados Intensivos Neurocríticos e Trauma, Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Faculdade de Ciências Médicas de Lisboa, Nova Médical School, Lisbon, Portugal
| | - Ariane Boumendil
- Sorbonne Universités, UPMC Univ Paris, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Equipe: épidémiologie hospitalière qualité et organisation des soins, Paris, France, Assistance Publique - Hôpitaux de Paris, Hôpital Saint-Antoine, Service de Réanimation Médicale, Paris, France
| | - Dylan W De Lange
- Department of Intensive Care Medicine, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Bertrand Guidet
- Sorbonne Universités, UPMC Univ Paris, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Equipe: épidémiologie hospitalière qualité et organisation des soins, Paris, France, Assistance Publique - Hôpitaux de Paris, Hôpital Saint-Antoine, Service de Réanimation Médicale, Paris, France
| | - Susannah Leaver
- General Intensive care, St George´s University Hospitals NHS Foundation Trust, London, UK
| | - Christian Jung
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Düsseldorf, Medical Faculty, Düsseldorf, Germany.
- Division of Cardiology, Department of Internal Medicine, Pulmonology and Vascular Medicine, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany.
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Kim S, Lee I, Hong SW, Koh SJ. Psychometric properties of the end-of-life care decision inventory (EOL-CDI): a mixed-methods study. Health Qual Life Outcomes 2022; 20:48. [PMID: 35331255 PMCID: PMC8944124 DOI: 10.1186/s12955-022-01952-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 02/21/2022] [Indexed: 11/25/2022] Open
Abstract
Background End-of-life care decision-making has become important to support dignity and quality of life for patients who are facing death in Korea, along with the enactment of the Life-Sustaining Treatment Act in 2018. However, it seems that the concepts and policies related to the law are not yet familiar to health care providers or the general public. This unfamiliarity can hinder efficient end-of-life care discussions. Therefore, the purpose of this study was to propose a valid and reliable tool to explore the level of understanding of concepts and attributes related to end-of-life care decisions.
Methods This is a mixed-methods study design. A relevant law and literature analysis, expert consultation, cognitive interviews of 10 adults, and cross-sectional survey for psychometric tests using data from 238 clinical nurses were performed to update a tool developed before the life-sustaining treatment Act was enacted in Korea. Results 29 items of the draft version were polished in terms of literacy, total length, and scoring method via cognitive interviews and finalized into 21 items through psychometric tests and expert consultations. The 21 items conformed to the Rasch unidimensional paramenters. Conclusion A tool to identify the level of understanding of concepts related to end-of-life care decisions was proposed through a rather rigorous process to ensure feasibility and validity/reliability. We recommend the proposed tool to apply to the adult population and nurses for evaluation and educational purposes.
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Affiliation(s)
- Shinmi Kim
- Department of Nursing, Changwon National University, C.P.O. Box 51140, Changwon, Korea
| | - Insook Lee
- Department of Nursing, Changwon National University, C.P.O. Box 51140, Changwon, Korea.
| | - Sun-Woo Hong
- Department of Emergency Medical Services, Daejeon University, Daejeon, Korea
| | - Su-Jin Koh
- Division of Haematology and Oncology, Department of Internal Medicine, Ulsan University Hospital, Ulsan University College of Medicine, Ulsan, Korea
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5
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Guidet B, Jung C, Flaatten H, Fjølner J, Artigas A, Pinto BB, Schefold JC, Beil M, Sigal S, van Heerden PV, Szczeklik W, Joannidis M, Oeyen S, Kondili E, Marsh B, Andersen FH, Moreno R, Cecconi M, Leaver S, De Lange DW, Boumendil A. Increased 30-day mortality in very old ICU patients with COVID-19 compared to patients with respiratory failure without COVID-19. Intensive Care Med 2022; 48:435-447. [PMID: 35218366 PMCID: PMC8881896 DOI: 10.1007/s00134-022-06642-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 02/05/2022] [Indexed: 12/26/2022]
Abstract
Purpose The number of patients ≥ 80 years admitted into critical care is increasing. Coronavirus disease 2019 (COVID-19) added another challenge for clinical decisions for both admission and limitation of life-sustaining treatments (LLST). We aimed to compare the characteristics and mortality of very old critically ill patients with or without COVID-19 with a focus on LLST. Methods Patients 80 years or older with acute respiratory failure were recruited from the VIP2 and COVIP studies. Baseline patient characteristics, interventions in intensive care unit (ICU) and outcomes (30-day survival) were recorded. COVID patients were matched to non-COVID patients based on the following factors: age (± 2 years), Sequential Organ Failure Assessment (SOFA) score (± 2 points), clinical frailty scale (± 1 point), gender and region on a 1:2 ratio. Specific ICU procedures and LLST were compared between the cohorts by means of cumulative incidence curves taking into account the competing risk of discharge and death. Results 693 COVID patients were compared to 1393 non-COVID patients. COVID patients were younger, less frail, less severely ill with lower SOFA score, but were treated more often with invasive mechanical ventilation (MV) and had a lower 30-day survival. 404 COVID patients could be matched to 666 non-COVID patients. For COVID patients, withholding and withdrawing of LST were more frequent than for non-COVID and the 30-day survival was almost half compared to non-COVID patients. Conclusion Very old COVID patients have a different trajectory than non-COVID patients. Whether this finding is due to a decision policy with more active treatment limitation or to an inherent higher risk of death due to COVID-19 is unclear. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-022-06642-z.
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Affiliation(s)
- Bertrand Guidet
- UPMC Univ Paris 06, INSERM, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Equipe: épidémiologie hospitalière qualité et organisation des soins, Medical Intensive Care, Sorbonne Universités, 184 rue du Faubourg Saint Antoine, 75012, Paris, France. .,Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, service de réanimation médicale, 75012, Paris, France.
| | - Christian Jung
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - Hans Flaatten
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Anaestesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Jesper Fjølner
- Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Antonio Artigas
- Department of Intensive Care Medicine, CIBER Enfermedades Respiratorias, Corporacion Sanitaria Universitaria Parc Tauli, Autonomous University of Barcelona, Sabadell, Spain
| | | | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, Universitätsspital, University of Bern, Bern, Switzerland
| | - Michael Beil
- Medical Intensive Care, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sviri Sigal
- Medical Intensive Care, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Peter Vernon van Heerden
- General Intensive Care, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Sandra Oeyen
- Department of Intensive Care 1K12IC, Ghent University Hospital, Ghent, Belgium
| | - Eumorfia Kondili
- Intensive Care Unit, University Hospital of Heraklion, Medical School University of Crete, Giofirakia, Greece
| | - Brian Marsh
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - Finn H Andersen
- Department of Anaesthesia and Intensive Care, Ålesund Hospital, Alesund, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Rui Moreno
- Centro Hospitalar Universitário de Lisboa Central, Faculdade de Ciências Médicas de Lisboa, Nova Médical School, Unidade de Cuidados Intensivos Neurocríticos e Trauma. Hospital de São José, Lisbon, Portugal
| | - Maurizio Cecconi
- Department of Anaesthesia IRCCS, Instituto Clínico Humanitas, Humanitas University, Milan, Italy
| | - Susannah Leaver
- General Intensive Care, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Dylan W De Lange
- Department of Intensive Care Medicine, University Medical Center, University Utrecht, Utrecht, the Netherlands
| | - Ariane Boumendil
- UPMC Univ Paris 06, INSERM, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Equipe: épidémiologie hospitalière qualité et organisation des soins, Medical Intensive Care, Sorbonne Universités, 184 rue du Faubourg Saint Antoine, 75012, Paris, France.,Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, service de réanimation médicale, 75012, Paris, France
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6
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Jung C, Fjølner J, Bruno RR, Wernly B, Artigas A, Bollen Pinto B, Schefold JC, Wolff G, Kelm M, Beil M, Sviri S, van Heerden PV, Szczeklik W, Czuczwar M, Joannidis M, Oeyen S, Zafeiridis T, Andersen FH, Moreno R, Leaver S, Boumendil A, De Lange DW, Guidet B, Flaatten H. Differences in mortality in critically ill elderly patients during the second COVID-19 surge in Europe. Crit Care 2021; 25:344. [PMID: 34556171 PMCID: PMC8459701 DOI: 10.1186/s13054-021-03739-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 08/19/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The primary aim of this study was to assess the outcome of elderly intensive care unit (ICU) patients treated during the spring and autumn COVID-19 surges in Europe. METHODS This was a prospective European observational study (the COVIP study) in ICU patients aged 70 years and older admitted with COVID-19 disease from March to December 2020 to 159 ICUs in 14 European countries. An electronic database was used to register a number of parameters including: SOFA score, Clinical Frailty Scale, co-morbidities, usual ICU procedures and survival at 90 days. The study was registered at ClinicalTrials.gov (NCT04321265). RESULTS In total, 2625 patients were included, 1327 from the first and 1298 from the second surge. Median age was 74 and 75 years in surge 1 and 2, respectively. SOFA score was higher in the first surge (median 6 versus 5, p < 0.0001). The PaO2/FiO2 ratio at admission was higher during surge 1, and more patients received invasive mechanical ventilation (78% versus 68%, p < 0.0001). During the first 15 days of treatment, survival was similar during the first and the second surge. Survival was lower in the second surge after day 15 and differed after 30 days (57% vs 50%) as well as after 90 days (51% vs 40%). CONCLUSION An unexpected, but significant, decrease in 30-day and 90-day survival was observed during the second surge in our cohort of elderly ICU patients. The reason for this is unclear. Our main concern is whether the widespread changes in practice and treatment of COVID-19 between the two surges have contributed to this increased mortality in elderly patients. Further studies are urgently warranted to provide more evidence for current practice in elderly patients. TRIAL REGISTRATION NUMBER NCT04321265 , registered March 19th, 2020.
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Affiliation(s)
- Christian Jung
- Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany.
| | - Jesper Fjølner
- Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Raphael Romano Bruno
- Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany
| | - Bernhard Wernly
- Department of Cardiology, Paracelsus Medical University, Salzburg, Austria
| | - Antonio Artigas
- Department of Intensive Care Medicine, CIBER Enfermedades Respiratorias, Corporacion Sanitaria Universitaria Parc Tauli, Autonomous University of Barcelona, Sabadell, Spain
| | | | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, Universitätsspital, University of Bern, Bern, Switzerland
| | - Georg Wolff
- Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany
| | - Malte Kelm
- Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany
| | - Michael Beil
- Department of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sigal Sviri
- Department of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Miroslaw Czuczwar
- 2nd Department of Anesthesiology and Intensive Care, Medical University of Lublin, Staszica 16, 20-081, Lublin, Poland
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Sandra Oeyen
- Department of Intensive Care 1K12IC, Ghent University Hospital, Ghent, Belgium
| | | | - Finn H Andersen
- Department of Anaesthesia and Intensive Care, Ålesund Hospital, Ålesund, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Rui Moreno
- Unidade de Cuidados Intensivos Neurocríticos E Trauma. Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Faculdade de Ciências Médicas de Lisboa, Nova Médical School, Lisbon, Portugal
| | - Susannah Leaver
- General Intensive Care, St George's University Hospital NHS Foundation Trust, London, UK
| | - Ariane Boumendil
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Equipe: épidémiologie hospitalière qualité et organisation des soins, 75012, Paris, France
- Assistance Publique - Hôpitaux de Paris, Hôpital Saint-Antoine, service de réanimation médicale, 75012, Paris, France
| | - Dylan W De Lange
- Department of Intensive Care Medicine, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Bertrand Guidet
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Equipe: épidémiologie hospitalière qualité et organisation des soins, 75012, Paris, France
- Assistance Publique - Hôpitaux de Paris, Hôpital Saint-Antoine, service de réanimation médicale, 75012, Paris, France
| | - Hans Flaatten
- Department of Clinical Medicine, University of Bergen, Department of Anaestesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
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Occurrence and timing of withdrawal of life-sustaining measures in traumatic brain injury patients: a CENTER-TBI study. Intensive Care Med 2021; 47:1115-1129. [PMID: 34351445 PMCID: PMC8486724 DOI: 10.1007/s00134-021-06484-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 07/14/2021] [Indexed: 12/16/2022]
Abstract
Background In patients with severe brain injury, withdrawal of life-sustaining measures (WLSM) is common in intensive care units (ICU). WLSM constitutes a dilemma: instituting WLSM too early could result in death despite the possibility of an acceptable functional outcome, whereas delaying WLSM could unnecessarily burden patients, families, clinicians, and hospital resources. We aimed to describe the occurrence and timing of WLSM, and factors associated with timing of WLSM in European ICUs in patients with traumatic brain injury (TBI). Methods The CENTER-TBI Study is a prospective multi-center cohort study. For the current study, patients with traumatic brain injury (TBI) admitted to the ICU and aged 16 or older were included. Occurrence and timing of WLSM were documented. For the analyses, we dichotomized timing of WLSM in early (< 72 h after injury) versus later (≥ 72 h after injury) based on recent guideline recommendations. We assessed factors associated with initiating WLSM early versus later, including geographic region, center, patient, injury, and treatment characteristics with univariable and multivariable (mixed effects) logistic regression. Results A total of 2022 patients aged 16 or older were admitted to the ICU. ICU mortality was 13% (n = 267). Of these, 229 (86%) patients died after WLSM, and were included in the analyses. The occurrence of WLSM varied between regions ranging from 0% in Eastern Europe to 96% in Northern Europe. In 51% of the patients, WLSM was early. Patients in the early WLSM group had a lower maximum therapy intensity level (TIL) score than patients in the later WLSM group (median of 5 versus 10) The strongest independent variables associated with early WLSM were one unreactive pupil (odds ratio (OR) 4.0, 95% confidence interval (CI) 1.3–12.4) or two unreactive pupils (OR 5.8, CI 2.6–13.1) compared to two reactive pupils, and an Injury Severity Score (ISS) if over 41 (OR per point above 41 = 1.1, CI 1.0–1.1). Timing of WLSM was not significantly associated with region or center. Conclusion WLSM occurs early in half of the patients, mostly in patients with severe TBI affecting brainstem reflexes who were severely injured. We found no regional or center influences in timing of WLSM. Whether WLSM is always appropriate or may contribute to a self-fulfilling prophecy requires further research and argues for reluctance to institute WLSM early in case of any doubt on prognosis. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06484-1.
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8
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Jung C, Flaatten H, Fjølner J, Bruno RR, Wernly B, Artigas A, Bollen Pinto B, Schefold JC, Wolff G, Kelm M, Beil M, Sviri S, van Heerden PV, Szczeklik W, Czuczwar M, Elhadi M, Joannidis M, Oeyen S, Zafeiridis T, Marsh B, Andersen FH, Moreno R, Cecconi M, Leaver S, Boumendil A, De Lange DW, Guidet B. The impact of frailty on survival in elderly intensive care patients with COVID-19: the COVIP study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:149. [PMID: 33874987 PMCID: PMC8054503 DOI: 10.1186/s13054-021-03551-3] [Citation(s) in RCA: 96] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 03/25/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND The COVID-19 pandemic has led highly developed healthcare systems to the brink of collapse due to the large numbers of patients being admitted into hospitals. One of the potential prognostic indicators in patients with COVID-19 is frailty. The degree of frailty could be used to assist both the triage into intensive care, and decisions regarding treatment limitations. Our study sought to determine the interaction of frailty and age in elderly COVID-19 ICU patients. METHODS A prospective multicentre study of COVID-19 patients ≥ 70 years admitted to intensive care in 138 ICUs from 28 countries was conducted. The primary endpoint was 30-day mortality. Frailty was assessed using the clinical frailty scale. Additionally, comorbidities, management strategies and treatment limitations were recorded. RESULTS The study included 1346 patients (28% female) with a median age of 75 years (IQR 72-78, range 70-96), 16.3% were older than 80 years, and 21% of the patients were frail. The overall survival at 30 days was 59% (95% CI 56-62), with 66% (63-69) in fit, 53% (47-61) in vulnerable and 41% (35-47) in frail patients (p < 0.001). In frail patients, there was no difference in 30-day survival between different age categories. Frailty was linked to an increased use of treatment limitations and less use of mechanical ventilation. In a model controlling for age, disease severity, sex, treatment limitations and comorbidities, frailty was independently associated with lower survival. CONCLUSION Frailty provides relevant prognostic information in elderly COVID-19 patients in addition to age and comorbidities. Trial registration Clinicaltrials.gov: NCT04321265 , registered 19 March 2020.
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Affiliation(s)
- Christian Jung
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany.
| | - Hans Flaatten
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.,Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Jesper Fjølner
- Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Raphael Romano Bruno
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany
| | - Bernhard Wernly
- Department of Cardiology, Paracelsus Medical University, Salzburg, Austria
| | - Antonio Artigas
- Department of Intensive Care Medicine, CIBER Enfermedades Respiratorias, Corporacion Sanitaria Universitaria Parc Tauli, Autonomous University of Barcelona, Sabadell, Spain
| | | | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, Universitätsspital, University of Bern, Bern, Switzerland
| | - Georg Wolff
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225, Duesseldorf, Germany
| | - Michael Beil
- Department of Medical Intensive Care, Hadassah University Medical Center, Jerusalem, Israel
| | - Sigal Sviri
- Department of Medical Intensive Care, Hadassah University Medical Center, Jerusalem, Israel
| | | | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Miroslaw Czuczwar
- 2nd Department of Anesthesiology and Intensive Care, Medical University of Lublin, Staszica 16, 20-081, Lublin, Poland
| | | | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Sandra Oeyen
- Department of Intensive Care 1K12IC, Ghent University Hospital, Ghent, Belgium
| | | | - Brian Marsh
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - Finn H Andersen
- Department of Anaesthesia and Intensive Care, Ålesund Hospital, Ålesund, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Rui Moreno
- Unidade de Cuidados Intensivos Neurocríticos e Trauma, Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Faculdade de Ciências Médicas de Lisboa, Nova Médical School, Lisbon, Portugal
| | - Maurizio Cecconi
- Department of Anaesthesia, IRCCS Instituto Clínico Humanitas, Humanitas University, Milan, Italy
| | - Susannah Leaver
- General Intensive Care, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Ariane Boumendil
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Equipe: épidémiologie hospitalière qualité et organisation des soins, 75012, Paris, France.,Assistance Publique - Hôpitaux de Paris, Hôpital Saint-Antoine, service de réanimation médicale, 75012, Paris, France
| | - Dylan W De Lange
- Department of Intensive Care Medicine, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Bertrand Guidet
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Equipe: épidémiologie hospitalière qualité et organisation des soins, 75012, Paris, France.,Assistance Publique - Hôpitaux de Paris, Hôpital Saint-Antoine, service de réanimation médicale, 75012, Paris, France
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9
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Smirdec M, Jourdain M, Guastella V, Lambert C, Richard JC, Argaud L, Jaber S, Klouche K, Medard A, Reignier J, Rigaud JP, Doise JM, Chabanne R, Souweine B, Bourenne J, Delmas J, Bertrand PM, Verdier P, Quenot JP, Aubron C, Eisenmann N, Asfar P, Fratani A, Dellamonica J, Terzi N, Constantin JM, Van Lander A, Guerin R, Pereira B, Lautrette A. Impact of advance directives on the variability between intensivists in the decisions to forgo life-sustaining treatment. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:672. [PMID: 33267904 PMCID: PMC7709386 DOI: 10.1186/s13054-020-03402-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 11/20/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND There is wide variability between intensivists in the decisions to forgo life-sustaining treatment (DFLST). Advance directives (ADs) allow patients to communicate their end-of-life wishes to physicians. We assessed whether ADs reduced variability in DFLSTs between intensivists. METHODS We conducted a multicenter, prospective, simulation study. Eight patients expressed their wishes in ADs after being informed about DFLSTs by an intensivist-investigator. The participating intensivists answered ten questions about the DFLSTs of each patient in two scenarios, referring to patients' characteristics without ADs (round 1) and then with (round 2). DFLST score ranged from 0 (no-DFLST) to 10 (DFLST for all questions). The main outcome was variability in DFLSTs between intensivists, expressed as relative standard deviation (RSD). RESULTS A total of 19,680 decisions made by 123 intensivists from 27 ICUs were analyzed. The DFLST score was higher with ADs than without (6.02 95% CI [5.85; 6.19] vs 4.92 95% CI [4.75; 5.10], p < 0.001). High inter-intensivist variability did not change with ADs (RSD: 0.56 (round 1) vs 0.46 (round 2), p = 0.84). Inter-intensivist agreement on DFLSTs was weak with ADs (intra-class correlation coefficient: 0.28). No factor associated with DFLSTs was identified. A qualitative analysis of ADs showed focus on end-of-life wills, unwanted things and fear of pain. CONCLUSIONS ADs increased the DFLST rate but did not reduce variability between the intensivists. In the decision-making process using ADs, the intensivist's decision took priority. Further research is needed to improve the matching of the physicians' decision with the patient's wishes. Trial registration ClinicalTrials.gov Identifier: NCT03013530. Registered 6 January 2017; https://clinicaltrials.gov/ct2/show/NCT03013530 .
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Affiliation(s)
- Margot Smirdec
- Department of Anaesthesiology and Critical Care Medicine, Estaing Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Mercé Jourdain
- INSERM U1190, CHU Lille, Department of Critical Care Medicine, Roger Salengro Hospital, Univ. Lille, 59000, Lille, France
| | - Virginie Guastella
- Palliative Care Unit, Louise Michel Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Céline Lambert
- Biostatistics Unit (DRCI), University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Jean-Christophe Richard
- Medical Intensive Care Unit, La Croix Rousse Hospital, University Hospital of Lyon, Lyon, France
| | - Laurent Argaud
- Medical Intensive Care Unit, Edouard Herriot Hospital, University Hospital of Lyon, Lyon, France
| | - Samir Jaber
- Department of Anaesthesiology and Critical Care Medicine, Saint Eloi Hospital, University Hospital of Montpellier, Montpellier, France
| | - Kada Klouche
- Medical Intensive Care Unit, Lapeyronnie Hospital, University Hospital of Montpellier, Montpellier, France
| | - Anne Medard
- Cardiac Surgery Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, Montpied Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Jean Reignier
- Medical Intensive Care Unit, Hotel-Dieu Hospital, University Hospital of Nantes, Nantes, France
| | | | - Jean-Marc Doise
- Intensive Care Unit, Morey Hospital, Hospital of Chalon-Sur-Saône, Chalon-sur-Saône, France
| | - Russell Chabanne
- Neurocritical Care Unit, Department of Anaesthesiology and Critical Care Medicine, Montpied Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Bertrand Souweine
- Medical Intensive Care Unit, Montpied Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Jeremy Bourenne
- Emergency Intensive Care Unit, La Timone Hospital, University Hospital of Marseille, Marseille, France
| | - Julie Delmas
- Intensive Care Unit, Puel Hospital, Hospital of Rodez, Rodez, France
| | | | | | - Jean-Pierre Quenot
- Medical Intensive Care Unit, Mitterrand Hospital, University Hospital of Dijon, Dijon, France
| | - Cecile Aubron
- Medical Intensive Care Unit, Centre Hospitalier Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | - Nathanael Eisenmann
- Intensive Care Unit, Centre Jean Perrin, 54 Rue Montalembert, BP69, 63003, Clermont-Ferrand, Cedex 1, France
| | - Pierre Asfar
- Medical Intensive Care Unit, Larrey Hospital, University Hospital of Angers, Angers, France
| | - Alexandre Fratani
- Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, Saint-Louis Hospital, Assistance Publique Hopitaux de Paris, Paris, France
| | - Jean Dellamonica
- Medical Intensive Care Unit, l'Archet Hospital, University Hospital of Nice, Nice, France
| | - Nicolas Terzi
- Medical Intensive Care Unit, Michallon Hospital, University Hospital of Grenoble, Grenoble, France
| | - Jean-Michel Constantin
- GRC 29, AP-HP, DMU DREAM, Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Axelle Van Lander
- UPU ACCePPt, Université Clermont Auvergne, Clermont-Ferrand, France.,EA-481, Laboratoire de Neurosciences, UBFC, Besançon, France
| | - Renaud Guerin
- Intensive Care Unit, Department of Anaesthesiology and Critical Care Medicine, Estaing Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics Unit (DRCI), University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Alexandre Lautrette
- Intensive Care Unit, Centre Jean Perrin, 54 Rue Montalembert, BP69, 63003, Clermont-Ferrand, Cedex 1, France. .,LMGE «Laboratoire Micro-Organismes: Génome Et Environnement», UMR CNRS 6023, Clermont-Auvergne University, Clermont-Ferrand, France. .,Intensive Care Medicine, Montpied Teaching Hospital, 54 Rue Montalembert, BP69, 63003, Clermont-Ferrand, Cedex 1, France.
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10
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Long term outcomes for elderly patients after emergency intensive care admission: A cohort study. PLoS One 2020; 15:e0241244. [PMID: 33119649 PMCID: PMC7595304 DOI: 10.1371/journal.pone.0241244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 10/11/2020] [Indexed: 11/19/2022] Open
Abstract
Background Elderly patients (≥ 80 years of age) surviving an episode of critical illness suffer long-term morbidity and risk of mortality. Identifying high risk groups could assist in informing discussions with patients and families. Aim To determine factors associated with long-term survival following ICU admission. Design A cohort study of patients aged ≥ 80 years of age admitted to the ICU as an emergency. Methods Patients admitted from January 2010 to December 2018 were included in the study. Primary outcome was five year survival. Mortality was assessed using a multivariable flexible parametric survival analysis adjusted for demographics, and clinically relevant covariates. Results There were 828 patients. Mean age was 84 years (SD 3.2) and 419 (51%) were male. Patients were categorised into medical (423 (51%)) and surgical (405 (49%)) admissions. Adjusted hazard ratios (aHR) for mortality were highest for serum lactate (>8 mmol/l aHR 2.56 (C.I. 1.79–3.67)), lowest systolic blood pressure (< 70 mmHg aHR 2.04 (C.I. 1.36–3.05)) and pH (< 7.05 aHR 4.70 (C.I 2.67–8.21)). There were no survivors beyond one year with severe abnormalities of pH and lactate (< 7.05 and > 8 mmol/l respectively). Relative survival for medical patients was below that expected for the general population for the duration of the study. Conclusion Overall five-year survival was 27%. For medical and surgical patients it was 19% and 35% respectively. Survival at 30 days and one year was 61% and 46%. The presence of features of circulatory shock predicted poor short and long term survival.
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11
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Abstract
Critical care clinicians strive to reverse the disease process and are frequently faced with difficult end-of-life (EoL) situations, which include transitions from curative to palliative care, avoidance of disproportionate care, withholding or withdrawing therapy, responding to advance treatment directives, as well as requests for assistance in dying. This article presents a summary of the most common issues encountered by intensivists caring for patients around the end of their life. Topics explored are the practices around limitations of life-sustaining treatment, with specific mention to the thorny subject of assisted dying and euthanasia, as well as the difficulties encountered regarding the adoption of advance care directives in clinical practice and the importance of integrating palliative care in the everyday practice of critical-care physicians. The aim of this article is to enhance understanding around the complexity of EoL decisions, highlight the intricate cultural, religious, and social dimensions around death and dying, and identify areas of potential improvement for individual practice.
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Affiliation(s)
- Victoria Metaxa
- Critical Care Department, King's College Hospital NHS Foundation Trust, London, United Kingdom
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12
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Flaatten H, Beil M, Guidet B. Elderly Patients in the Intensive Care Unit. Semin Respir Crit Care Med 2020; 42:10-19. [PMID: 32772353 DOI: 10.1055/s-0040-1710571] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Very old intensive care unit (ICU) patients, aged ≥ 80 years, are by no mean newcomers, but during the last decades their impact on ICU admissions has grown in parallel with the increase in the number of elderly persons in the community. Hence, from being a "rarity," they have now become common and constitute one of the largest subgroups within intensive care, and may easily be the largest group in 20 years and make up 30 to 40% of all ICU admissions. Obviously, they are not admitted because they are old but because they are with various diseases and problems like any other ICU patient. However, their age and the presence of common geriatric syndromes such as frailty, cognitive decline, reduced activity of daily life, and several comorbid conditions makes this group particularly challenging, with a high mortality rate. In this review, we will highlight aspects of current and future epidemiology and current knowledge on outcomes, and describe the effects of the aforementioned geriatric syndromes. The major challenge for the coming decades will be the question of whom to treat and the quest for better triage criteria not based on age alone. Challenges with the level of care during the ICU stay will also be discussed. A stronger relationship with geriatricians should be promoted to create a better and more holistic care and aftercare for survivors.
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Affiliation(s)
- Hans Flaatten
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen Norway
| | - Michael Beil
- Institute of Health Sciences, Philosophisch-Theologische Hochschule Vallendar, Vallendar, Germany
| | - Bertrand Guidet
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, Paris, France
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13
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van Veen E, van der Jagt M, Citerio G, Stocchetti N, Epker JL, Gommers D, Burdorf L, Menon DK, Maas AIR, Lingsma HF, Kompanje EJO. End-of-life practices in traumatic brain injury patients: Report of a questionnaire from the CENTER-TBI study. J Crit Care 2020; 58:78-88. [PMID: 32387842 DOI: 10.1016/j.jcrc.2020.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 03/30/2020] [Accepted: 04/06/2020] [Indexed: 11/17/2022]
Abstract
PURPOSE We aimed to study variation regarding specific end-of-life (EoL) practices in the intensive care unit (ICU) in traumatic brain injury (TBI) patients. MATERIALS AND METHODS Respondents from 67 hospitals participating in The Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study completed several questionnaires on management of TBI patients. RESULTS In 60% of the centers, ≤50% of all patients with severe neurological damage dying in the ICU, die after withdrawal of life-sustaining measures (LSM). The decision to withhold/withdraw LSM was made following multidisciplinary consensus in every center. Legal representatives/relatives played a role in the decision-making process in 81% of the centers. In 82% of the centers, age played a role in the decision to withhold/withdraw LSM. Furthermore, palliative therapy was initiated in 79% of the centers after the decision to withdraw LSM was made. Last, withholding/withdrawing LSM was, generally, more often considered after more time had passed, in a patient with TBI, who remained in a very poor prognostic condition. CONCLUSION We found variation regarding EoL practices in TBI patients. These results provide insight into variability regarding important issues pertaining to EoL practices in TBI, which can be useful to stimulate discussions on EoL practices, comparative effectiveness research, and, ultimately, development of recommendations.
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Affiliation(s)
- Ernest van Veen
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Medical Ethics and Philosophy of Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy; San Gerardo Hospital, ASST-Monza, Italy.
| | - Nino Stocchetti
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy; Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milano, Milan, Italy.
| | - Jelle L Epker
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Diederik Gommers
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Lex Burdorf
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - David K Menon
- Department of Anaesthesia, University of Cambridge, Cambridge, United Kingdom.
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium.
| | - Hester F Lingsma
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Erwin J O Kompanje
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Medical Ethics and Philosophy of Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands.
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14
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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.
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Abstract
PURPOSE OF REVIEW Published data and practice recommendations on end-of-life (EOL) generally reflect Western practice frameworks. Understanding worldwide practices is important because improving economic conditions are promoting rapid expansion of intensive care services in many previously disadvantaged regions, and increasing migration has promoted a new cultural diversity previously predominantly unicultural societies. This review explores current knowledge of similarities and differences in EOL practice between regions and possible causes and implications of these differences. RECENT FINDINGS Recent observational and survey data shows a marked variability in the practice of withholding and withdrawing life sustaining therapy worldwide. Some evidence supports the view that culture, religion, and socioeconomic factors influence EOL practice, and individually or together account for differences observed. There are also likely to be commonly desired values and expectations for EOL practice, and recent attempts at establishing where worldwide consensus may lie have improved our understanding of shared values and practices. SUMMARY Awareness of differences, understanding their likely complex causes, and using this knowledge to inform individualized care at EOL is likely to improve the quality of care for patients. Further research should clarify the causes of EOL practice variability, monitor trends, and objectively evaluate the quality of EOL practice worldwide.
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16
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Guidet B, Flaatten H, Boumendil A, Morandi A, Andersen FH, Artigas A, Bertolini G, Cecconi M, Christensen S, Faraldi L, Fjølner J, Jung C, Marsh B, Moreno R, Oeyen S, Öhman CA, Pinto BB, Soliman IW, Szczeklik W, Valentin A, Watson X, Zafeiridis T, De Lange DW. Withholding or withdrawing of life-sustaining therapy in older adults (≥ 80 years) admitted to the intensive care unit. Intensive Care Med 2018; 44:1027-1038. [DOI: 10.1007/s00134-018-5196-7] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 04/25/2018] [Indexed: 01/18/2023]
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17
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Guidet B, de Lange DW, Flaatten H. Should this elderly patient be admitted to the ICU? Intensive Care Med 2018; 44:1926-1928. [PMID: 29356853 DOI: 10.1007/s00134-018-5054-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 01/09/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Bertrand Guidet
- Service de Réanimation Médicale, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Saint-Antoine, Paris, 75012, France. .,Sorbonne Universités, Université Pierre et Marie Curie, Paris 06, France. .,UMR_S 1136, Institut Pierre Louis d'Épidémiologie et de Santé Publique, Institut National de la Santé et de la Recherche Médicale (INSERM), Paris, 75013, France.
| | - Dylan W de Lange
- Department of Intensive Care, University Medical Center Utrecht, University Utrecht, Utrecht, The Netherlands
| | - Hans Flaatten
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Flaatten H, De Lange DW, Morandi A, Andersen FH, Artigas A, Bertolini G, Boumendil A, Cecconi M, Christensen S, Faraldi L, Fjølner J, Jung C, Marsh B, Moreno R, Oeyen S, Öhman CA, Pinto BB, Soliman IW, Szczeklik W, Valentin A, Watson X, Zaferidis T, Guidet B. The impact of frailty on ICU and 30-day mortality and the level of care in very elderly patients (≥ 80 years). Intensive Care Med 2017; 43:1820-1828. [DOI: 10.1007/s00134-017-4940-8] [Citation(s) in RCA: 176] [Impact Index Per Article: 25.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 09/14/2017] [Indexed: 10/18/2022]
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Lee SH, Lee TW, Ju S, Yoo JW, Lee SJ, Cho YJ, Jeong YY, Lee JD, Kim HC. Outcomes of very elderly (≥ 80 years) critical-ill patients in a medical intensive care unit of a tertiary hospital in Korea. Korean J Intern Med 2017. [PMID: 28651311 PMCID: PMC5511932 DOI: 10.3904/kjim.2015.331] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS This study evaluated clinical characteristics and outcomes in very elderly (≥ 80 years of age) critical-ill patients admitted to a medical intensive care unit (MICU) in a regional single tertiary hospital. METHODS We retrospectively evaluated prospectively collected data in the MICU for the period of December 2011 to May 2014. Patients were divided into ≥ 80 and < 80 years of age and clinical characteristics and outcomes were compared among these patients. RESULTS A total of 468 patients were evaluated and 102 patients (21.7%) were ≥ 80 years of age. Overall mortality was 38.5% in the intensive care unit (ICU) and 44.7% in the hospital. There was no significant difference in ICU and in-hospital mortalities between those ≥ 80 years and those < 80 years (34.9% vs. 39.5% for ICU mortality; 40.6% vs. 45.9% for in-hospital mortality). Lengths of ICU and hospital stays were significantly longer in patients < 80 years compared to patients ≥ 80 years (10.57 ± 19.96 days vs. 8.19 ± 8.78 days for ICU stay; 27.95 ± 39.62 days vs. 18.17 ± 15.44 days for hospital stay). The rate of withholding intensive care in hospital stay over 48 hours was significantly higher in patients ≥ 80 years compared to patients < 80 years (22.9% vs. 11.8%). In multivariate analysis, weaning failure and withdrawal or withholding of intensive care in ICU was significantly related to death in patients with age ≥ 80. CONCLUSIONS Clinical outcomes were not significantly different for very elderly critical-ill patients compared to those of their younger counterparts in the MICU in this study.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Ho Cheol Kim
- Correspondence to Ho Cheol Kim, M.D. Department of Internal Medicine, Gyeongsang National University School of Medicine, 15 Jinju-daero 816beon-gil, Jinju 52727, Korea Tel: +82-55-750-8684 Fax: +82-55-750-8618 E-mail:
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Darmon M, Ducos G, Coquet I, Resche-Rigon M, Pochard F, Paries M, Kentish-Barnes N, Chaize M, Schlemmer B, Azoulay E. Formal Academic Training on Ethics May Address Junior Physicians' Needs. Chest 2017; 150:180-7. [PMID: 26927524 DOI: 10.1016/j.chest.2016.02.651] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 01/29/2016] [Accepted: 02/02/2016] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Surveys have highlighted perceived deficiencies among ICU residents in end-of-life care, symptom control, and confidence in dealing with dying patients. Lack of formal training may contribute to the failure to meet the needs of dying patients and their families. The objective of this study was to evaluate junior intensivists' perceptions of triage and of the quality of the dying process before and after formal academic training. METHODS Formal training on ethics was implemented as a part of resident training between 2007 and 2012. A cross-sectional survey was performed before (2007) and after (2012) this implementation. This study included 430 junior intensivists who were interviewed during these periods. RESULTS More responders attended a dedicated training course on ethics and palliative care during 2012 (38.5%) than during 2007 (17.4%; P < .0001). During 2012, respondents reported less discomfort and fewer uncertainties regarding decisions about limiting life-sustaining treatment (17.7% vs 39.1% in 2007; P < .0001) or the triage process (48.5% vs 69.4% in 2007; P < .0001). Factors independently associated with positive perceptions of the dying process were physician's age (OR, 1.19 per year; 95% CI, 1.09-1.25) and male sex (OR, 1.61; 95% CI, 1.05-2.47). Conversely, anxiety about family members' reactions (OR, 0.58; 95% CI, 0.0.37-0.87) and lack of training (OR, 0.29; 95% CI, 0.17-0.50) were associated with negative perceptions of this process. CONCLUSIONS Formal training dedicated to ethics and palliative care was associated with a more comfortable perception of the dying process. This training may decrease the uncertainty and discomfort of junior intensivists in these situations.
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Affiliation(s)
- Michael Darmon
- Medical-Surgical Intensive Care Unit, Saint-Etienne University Hospital, Saint-Etienne, France.
| | - Guillaume Ducos
- Medical Intensive Care Unit and FAMIREA Study Group, Saint-Louis University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Isaline Coquet
- Medical Intensive Care Unit and FAMIREA Study Group, Saint-Louis University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Matthieu Resche-Rigon
- Biostatistic Department, Saint-Louis University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Frederic Pochard
- Medical Intensive Care Unit and FAMIREA Study Group, Saint-Louis University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marie Paries
- Medical Intensive Care Unit and FAMIREA Study Group, Saint-Louis University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Nancy Kentish-Barnes
- Medical Intensive Care Unit and FAMIREA Study Group, Saint-Louis University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marine Chaize
- Medical Intensive Care Unit and FAMIREA Study Group, Saint-Louis University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Benoit Schlemmer
- Medical Intensive Care Unit and FAMIREA Study Group, Saint-Louis University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Faculté de Médecine, Université Paris-Diderot, Sorbonne-Paris-Cité, Paris, France
| | - Elie Azoulay
- Medical Intensive Care Unit and FAMIREA Study Group, Saint-Louis University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Faculté de Médecine, Université Paris-Diderot, Sorbonne-Paris-Cité, Paris, France
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Myburgh J, Abillama F, Chiumello D, Dobb G, Jacobe S, Kleinpell R, Koh Y, Martin C, Michalsen A, Pelosi P, Torra LB, Vincent JL, Yeager S, Zimmerman J. End-of-life care in the intensive care unit: Report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine. J Crit Care 2016; 34:125-30. [DOI: 10.1016/j.jcrc.2016.04.017] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 04/08/2016] [Indexed: 11/30/2022]
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Boumendil A, Woimant M, Quenot JP, Rooryck FX, Makhlouf F, Yordanov Y, Delerme S, Takun K, Ray P, Kouka MC, Poly C, Garrouste-Orgeas M, Thomas C, Simon T, Azerad S, Leblanc G, Pateron D, Guidet B. Designing and conducting a cluster-randomized trial of ICU admission for the elderly patients: the ICE-CUB 2 study. Ann Intensive Care 2016; 6:74. [PMID: 27473119 PMCID: PMC4967062 DOI: 10.1186/s13613-016-0161-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 06/21/2016] [Indexed: 11/15/2022] Open
Abstract
Background
The benefit of ICU admission for elderly patients remains controversial. This report highlights the methodology, the feasibility of and the ethical and logistical constraints in designing and conducting a cluster-randomized trial of intensive care unit (ICU) admission for critically ill elderly patients. Methods
We designed an interventional open-label cluster-randomized controlled trial in 24 centres in France. Clusters were healthcare centres with at least one emergency department (ED) and one ICU. Healthcare centres were randomly assigned either to recommend a systematic ICU admission (intervention group) or to follow standard practices regarding ICU admission (control group). Clusters were stratified by the number of ED annual visits (<44,616 or >44,616 visits), the presence or absence of a geriatric ward and the geographical area (Paris area vs other regions in France). All elderly patients (≥75 years of age) who got to the ED were assessed for eligibility. Patients were included if they had one of the pre-established critical conditions, a preserved functional status as assessed by an ADL scale ≥4 (0 = very dependent, 6 = independent), a preserved nutritional status (subjectively assessed by physicians) and without active cancer. Exclusion criteria were an ED stay >24 h, a secondary referral to the ED and refusal to participate. The primary outcome was the mortality at 6 months calculated at the individual patient level. Secondary outcomes were ICU and hospital mortality, as well as ADL scale and quality of life (as assessed by the SF-12 Health Survey) at 6 months. Results
Between January 2012 and April 2015, 3036 patients were included in the trial, 1518 patients in 11 clusters allocated to intervention group and 1518 patients in 13 clusters allocated to standard care. There were 51 protocol violations. Conclusions The ICE-CUB 2 trial was deemed feasible and ethically acceptable. The ICE-CUB 2 trial will be the first cluster-randomized trial to assess the benefits of ICU admission for selected elderly patients on long-term mortality. Trial registration Clinical trials.gov identifier: NCT01508819 Electronic supplementary material The online version of this article (doi:10.1186/s13613-016-0161-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ariane Boumendil
- Hôpital Saint-Antoine, Service de Réanimation Médicale (Intensive Care Unit - ICU), Assistance Publique - Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75012, Paris, France
| | - Maguy Woimant
- Hôpital Avicenne, Service d'Accueil des Urgences (SAU, Emergency Department), AP-HP, 93009, Bobigny, France
| | | | | | | | | | - Samuel Delerme
- Hôpital Pitié Salpétrière, SAU, AP-HP, 75013, Paris, France
| | - Khalil Takun
- Hôpital Cochin, SAU, AP-HP, 75014, Paris, France
| | - Patrick Ray
- Hôpital Tenon, SAU, AP-HP, 75020, Paris, France
| | | | - Claire Poly
- SAU, Hôpital Robert Ballanger, 93602, Aulnay-Sous-Bois, France
| | | | - Caroline Thomas
- Hôpital Saint-Antoine, Acute Geriatric Ward, AP-HP, 75012, Paris, France
| | - Tabasome Simon
- Hôpital Saint-Antoine, URC Est, AP-HP, 75012, Paris, France
| | - Sylvie Azerad
- Hôpital Ambroise Paré, URC Ouest, AP-HP, 92104, Boulogne-Billancourt, Paris, France
| | - Guillaume Leblanc
- Department of Anesthesiology and Critical Care, Université Laval, Québec, QC, Canada
| | - Dominique Pateron
- Hôpital Saint-Antoine, SAU, AP-HP, 75012, Paris, France.,UPMC Univ Paris 06, Sorbonne Universités, Paris, France
| | - Bertrand Guidet
- Hôpital Saint-Antoine, Service de Réanimation Médicale (Intensive Care Unit - ICU), Assistance Publique - Hôpitaux de Paris (AP-HP), 184 rue du Faubourg Saint-Antoine, 75012, Paris, France. .,UPMC Univ Paris 06, Sorbonne Universités, Paris, France. .,UMR_S 1136, Institut Pierre Louis d'Épidémiologie et de Santé Publique, INSERM, 75013, Paris, France.
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