Cardiopulmonary resuscitation directives on admission to intensive-care unit: an international observational study

Frequency of Withdrawal of Life-Sustaining Therapy for Perceived Poor Neurologic Prognosis

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OBJECTIVES:

To measure the frequency of withdrawal of life-sustaining therapy for perceived poor neurologic prognosis among decedents in hospitals of different sizes and teaching statuses.

DESIGN:

We performed a multicenter, retrospective cohort study.

SETTING:

Four large teaching hospitals, four affiliated small teaching hospitals, and nine affiliated nonteaching hospitals in the United States.

PATIENTS:

We included a sample of all adult inpatient decedents between August 2017 and August 2019.

MEASUREMENTS AND MAIN RESULTS:

We reviewed inpatient notes and categorized the immediately preceding circumstances as withdrawal of life-sustaining therapy for perceived poor neurologic prognosis, withdrawal of life-sustaining therapy for nonneurologic reasons, limitations or withholding of life support or resuscitation, cardiac death despite full treatment, or brain death. Of 2,100 patients, median age was 71 years (interquartile range, 60–81 yr), median hospital length of stay was 5 days (interquartile range, 2–11 d), and 1,326 (63%) were treated at four large teaching hospitals. Withdrawal of life-sustaining therapy for perceived poor neurologic prognosis occurred in 516 patients (25%) and was the sole contributing factor to death in 331 (15%). Withdrawal of life-sustaining therapy for perceived poor neurologic prognosis was common in all hospitals: 30% of deaths at large teaching hospitals, 19% of deaths in small teaching hospitals, and 15% of deaths at nonteaching hospitals. Withdrawal of life-sustaining therapy for perceived poor neurologic prognosis happened frequently across all hospital units. Withdrawal of life-sustaining therapy for perceived poor neurologic prognosis contributed to one in 12 deaths in patients without a primary neurologic diagnosis. After accounting for patient and hospital characteristics, significant between-hospital variability in the odds of withdrawal of life-sustaining therapy for perceived poor neurologic prognosis persisted.

CONCLUSIONS:

A quarter of inpatient deaths in this cohort occurred after withdrawal of life-sustaining therapy for perceived poor neurologic prognosis. The rate of withdrawal of life-sustaining therapy for perceived poor neurologic prognosis occurred commonly in all type of hospital settings. We observed significant unexplained variation in the odds of withdrawal of life-sustaining therapy for perceived poor neurologic prognosis across participating hospitals.

Overcoming Challenges to Surrogate Decision Making for Young Adults at the End of Life

Surrogate decision makers (SDMs) are challenged by difficult decisions at the end of life. This becomes more complex in young adult patients when parents are frequently the SDMs. This age group (18 to 39 years old) commonly lacks advanced directives to provide guidance which results in increased moral distress during end of life decisions. Multiple factors help guide medical decision making throughout a patient's disease course and at the end of life. These include personal patient factors and SDM factors. It has been identified that spiritual and community group support is a powerful, but inadequately used resource for these discussions. It can improve patient-SDM-provider communications, decrease psycho-social distress, and avoid unnecessary interventions at the end of life.

Differences in Characteristics, Hospital Care and Outcomes between Acute Critically Ill Emergency Department Patients with Early and Late Do-Not-Resuscitate Orders

Background: A do-not-resuscitate (DNR) order is associated with an increased risk of death among emergency department (ED) patients. Little is known about patient characteristics, hospital care, and outcomes associated with the timing of the DNR order. Aim: Determine patient characteristics, hospital care, survival, and resource utilization between patients with early DNR (EDNR: signed within 24 h of ED presentation) and late DNR orders. Design: Retrospective observational study. Setting/Participants: We enrolled consecutive, acute, critically ill patients admitted to the emergency intensive care unit (EICU) at Taipei Veterans General Hospital from 1 February 2018, to 31 January 2020. Results: Of the 1064 patients admitted to the EICU, 619 (58.2%) had EDNR and 445 (41.8%) LDNR. EDNR predictors were age >85 years (adjusted odd ratios (AOR) 1.700, 1.027–2.814), living in long-term care facilities (AOR 1.880, 1.066–3.319), having advanced cardiovascular diseases (AOR 2.128, 1.039–4.358), “medical staff would not be surprised if the patient died within 12 months” (AOR 1.725, 1.193–2.496), and patients’ family requesting palliative care (AOR 2.420, 1.187–4.935). EDNR patients underwent lesser endotracheal tube (ET) intubation (15.6% vs. 39.9%, p < 0.001) and had reduced epinephrine injection (19.9% vs. 30.3%, p = 0.009), ventilator support (16.7% vs. 37.9%, p < 0.001), and narcotic use (51.1% vs. 62.6%, p = 0.012). EDNR patients had significantly lower 7-day (p < 0.001), 30-day (p < 0.001), and 90-day (p = 0.023) survival. Conclusions: EDNR patients underwent decreased ET intubation and had reduced epinephrine injection, ventilator support, and narcotic use during EOL as well as decreased length of hospital stay, hospital expenditure, and survival compared to LDNR patients.

Dying in the Neurointensive Care Unit After Withdrawal of Life-Sustaining Therapy: Associations of Advance Directives and Health-Care Proxies With Timing and Treatment Intensity

BACKGROUND AND PURPOSE

Critically ill patients require a careful approach for prognosis and decision-making. The German health legislation aims to strengthen the role of advance directives (ADs) and health-care proxies (HCPs). Their impact within a dedicated neurocritical care setting is unknown. This study aimed to assess the practice of withdrawal or withholding of life-sustaining therapy (WOLST) in a German neurointensive care unit (NICU) focusing on whether AD or HCP is associated with timing and treatment intensity.

METHODS

Data on patients who died after WOLST at a dedicated NICU of a German university hospital, from 2010 to 2013, were retrospectively analyzed.

RESULTS

Of 400 deceased patients, 310 (77.5%) died after initiation of WOLST. Among them, 68 (21.9%) were identified to have AD or HCP or both (AD + HCP). WOLST patients with AD, HCP, or AD + HCP were older than those without (median age: 77 vs 72 years, P < .001) but did not show any other distinct baseline features. There was no difference in the specific neurocritical care measures between the groups. Poisson regression analysis showed no significant difference in the probability of time-dependent WOLST initiation between those with and without AD/HCP, after adjusting for age and sex (adjusted incidence rate ratio, 1.10; 95% confidence interval, 0.94-1.28; P = .244).

CONCLUSIONS

In this single-center study of mainly cerebrovascular NICU patients, AD or HCP was neither associated with an earlier WOLST nor associated with a difference in treatment intensity before WOLST. Further prospective studies should assess the emerging concept of advance care planning in neurocritical care.

Assessment of Variability in End-of-Life Care Delivery in Intensive Care Units in the United States

IMPORTANCE

Overall, 1 of 5 decedents in the United States is admitted to an intensive care unit (ICU) before death.

OBJECTIVE

To describe structures, processes, and variability of end-of-life care delivered in ICUs in the United States.

DESIGN, SETTING, AND PARTICIPANTS

This nationwide cohort study used data on 16 945 adults who were cared for in ICUs that participated in the 68-unit ICU Liberation Collaborative quality improvement project from January 2015 through April 2017. Data were analyzed between August 2018 and June 2019.

MAIN OUTCOMES AND MEASURES

Published quality measures and end-of-life events, organized by key domains of end-of-life care in the ICU.

RESULTS

Of 16 945 eligible patients in the collaborative, 1536 (9.1%) died during their initial ICU stay. Of decedents, 654 (42.6%) were women, 1037 (67.5%) were 60 years or older, and 1088 (70.8%) were identified as white individuals. Wide unit-level variation in end-of-life care delivery was found. For example, the median unit-stratified rate of cardiopulmonary resuscitation avoidance in the last hour of life was 89.5% (interquartile range, 83.3%-96.1%; range, 50.0%-100%). Median rates of patients who were pain free and delirium free in last 24 hours of life were 75.1% (interquartile range, 66.0%-85.7%; range, 0-100%) and 60.0% (interquartile range, 43.7%-85.2%; range, 9.1%-100%), respectively. Ascertainment of an advance directive was associated with lower odds of cardiopulmonary resuscitation in the last hour of life (odds ratio, 0.70; 95% CI, 0.49-0.99; P = .04), and a documented offer or delivery of spiritual support was associated with higher odds of family presence at the time of death (odds ratio, 1.95; 95% CI, 1.37-2.77; P < .001). Death in a unit with an open visitation policy was associated with higher odds of pain in the last 24 hours of life (odds ratio, 2.21; 95% CI, 1.15-4.27; P = .02). Unsupervised cluster analysis revealed 3 mutually exclusive unit-level patterns of end-of-life care delivery among 63 ICUs with complete data. Cluster 1 units (14 units [22.2%]) had the lowest rate of cardiopulmonary resuscitation avoidance but achieved the highest pain-free rate. Cluster 2 (25 units [39.7%]) had the lowest delirium-free rate but achieved high rates of all other end-of-life events. Cluster 3 (24 units [38.1%]) achieved high rates across all favorable end-of-life events.

CONCLUSIONS AND RELEVANCE

In this study, end-of-life care delivery varied substantially among ICUs in the United States, and the patterns of care observed suggest that units can be characterized as higher and lower performing. To achieve optimal care for patients who die in an ICU, future research should target unit-level variation and disseminate the successes of higher-performing units.

How to discuss about do-not-resuscitate in the intensive care unit?

The improvement in cardiopulmonary resuscitation quality has reduced the mortality of individuals treated for cardiac arrest. However, survivors have a high risk of severe brain damage in cases of return of spontaneous circulation. Data suggest that cases of cardiac arrest in critically ill patients with non-shockable rhythms have only a 6% chance of returning of spontaneous circulation, and of these, only one-third recover their autonomy. Should we, therefore, opt for a procedure in which the chance of survival is minimal and the risk of hospital death or severe and definitive brain damage is approximately 70%? Is it worth discussing patient resuscitation in cases of cardiac arrest? Would this discussion bring any benefit to the patients and their family members? Advanced discussions on do-not-resuscitate are based on the ethical principle of respect for patient autonomy, as the wishes of family members and physicians often do not match those of patients. In addition to the issue of autonomy, advanced discussions can help the medical and care team anticipate future problems and, thus, better plan patient care. Our opinion is that discussions regarding the resuscitation of critically ill patients should be performed for all patients within the first 24 to 48 hours after admission to the intensive care unit.

Inter-ICU transfer of patients with ventilator dependent respiratory failure: Qualitative analysis of family and physician perspectives

OBJECTIVES

Ventilator dependent respiratory failure (VDRF) patients are seriously ill and often transferred between ICUs. Our objective was to obtain multi-stakeholder insights into the experiences of families during inter-ICU transfer.

METHODS

We conducted a qualitative study using semi-structured interviews with family members of VDRF patients as well as clinicians that have received or transferred VDRF patients to our hospital. Interviews were transcribed and template analysis was used to identify themes within/across stakeholder groups.

RESULTS

Patient, family, clinician and systems-level factors were identified as key themes during inter-ICU transfer. The main findings highlight that family members were rarely engaged in the decision to transfer as well as a lack of standardized communication between clinicians during care transitions. Family members were reassured with the care after transfer in spite of practical and financial challenges. Clinicians acknowledged the lack of a systematic approach for meeting the needs of families and suggested various resources.

CONCLUSIONS

This is one of the first qualitative studies to gather a multi-stakeholder perspective and identify problems faced by families during inter-ICU transfer of VDRF patients.

PRACTICE IMPLICATIONS

Our results provide a starting point for the development of family-centered support interventions which will need to be tested in future studies.

Quantifying the Mortality Impact of Do-Not-Resuscitate Orders in the ICU

OBJECTIVES

We quantified the 28-day mortality effect of preexisting do-not-resuscitate orders in ICUs.

DESIGN

Longitudinal, retrospective study of patients admitted to five ICUs at a tertiary university medical center (Beth Israel Deaconess Medical Center, BIDMC, Boston, MA) between 2001 and 2008.

INTERVENTION

None.

PATIENTS

Two cohorts were defined: patients with do not resuscitate advance directives on day 1 of ICU admission and a control group comprising patients with no limitations of level of care on ICU day 1 (full code).

MEASUREMENTS AND MAIN RESULTS

The primary outcome was mortality at 28 days after ICU admission. Of 19,007 ICU patients, 1,239 patients (6.5%) had a do-not-resuscitate order on the first day of ICU admission and survived 48 hours in the ICU. We matched those do-not-resuscitate patients with 2,402 patients with full-code status. Twenty-eight day and 1-year mortality were both significantly higher in the do-not-resuscitate group (33.9% vs 18.4% and 60.7% vs 40.2%; p < 0.001, respectively).

CONCLUSION

Do-not-resuscitate status is an independent risk factor for ICU mortality. This may reflect severity of illness not captured by other clinical factors, but the perceptions of the treating team related to do-not-resuscitate status could also be causally responsible for increased mortality in patients with do-not-resuscitate status.

Coping as a Multifaceted Construct: Associations With Psychological Outcomes Among Family Members of Mechanical Ventilation Survivors

OBJECTIVES

To develop and evaluate a preliminary multifaceted model for coping among family members of patients who survive mechanical ventilation.

DESIGN AND SETTING

In this multicenter cross-sectional survey, we interviewed family members of mechanically ventilated patients at the time of transfer from the ICU to the hospital ward. We constructed a theoretic model of coping that included characteristics attributable to family members, family-clinician rapport, and patients. We then explored relationships between coping factors and symptoms of psychological distress (anxiety, depression, and posttraumatic stress).

SUBJECTS

Fifty-six family members of survivors of mechanical ventilation.

MEASUREMENTS AND MAIN RESULTS

Psychological distress measured by the Hospital Anxiety and Depression Scale and Posttraumatic Stress Scale. Optimism measured using the Life Orientation Test scale, resiliency by Conner-Davidson Resilience Scale, and social support using the Patient Reported Outcomes Measurement Information System inventory. Family members had moderate levels of psychological distress with median total Hospital Anxiety and Depression Scale equal to 14 (interquartile range, 5-20) and Posttraumatic Stress Scale equal to 22 (interquartile range, 15-31). Among family member characteristics, greater optimism (p = 0.001, Hospital Anxiety and Depression Scale; p = 0.010, Posttraumatic Stress Scale), resilience (p = 0.012, Hospital Anxiety and Depression Scale), and social support (p = 0.013, Hospital Anxiety and Depression Scale) were protective against psychological distress. On the contrary, characteristics of family-clinician rapport such as communication quality and presence of conflict did not have any associations with psychological distress.

CONCLUSION

To our knowledge, this is the first study to explore coping as a multifaceted construct and its relationship with family psychological outcomes among survivors of mechanical ventilation. We found certain family characteristics of coping such as optimism, resilience, and social support to be associated with less psychological distress. Further research is warranted to identify potentially modifiable aspects of coping that might guide future interventions.

Dimensions and Role-Specific Mediators of Surrogate Trust in the ICU

OBJECTIVE

In the ICU, discussions between clinicians and surrogate decision makers are often accompanied by conflict about a patient's prognosis or care plan. Trust plays a role in limiting conflict, but little is known about the determinants of trust in the ICU. We sought to identify the dimensions of trust and clinician behaviors conducive to trust formation in the ICU.

DESIGN

Prospective qualitative study.

SETTING

Medical ICU of a major urban university hospital.

SUBJECTS

Surrogate decision makers of intubated, mechanically ventilated patients in the medical ICU.

MEASUREMENTS AND MAIN RESULTS

Semistructured interviews focused on surrogates' general experiences in the ICU and on their trust in the clinicians caring for the patient. Interviews were audio-recorded, transcribed verbatim, and coded by two reviewers. Constant comparison was used to identify themes pertaining to trust. Thirty surrogate interviews revealed five dimensions of trust in ICU clinicians: technical competence, communication, honesty, benevolence, and interpersonal skills. Most surrogates emphasized the role of nurses in trust formation, frequently citing their technical competence. Trust in physicians was most commonly related to honesty and the quality of their communication with surrogates.

CONCLUSIONS

Interventions to improve trust in the ICU should be role-specific, since surrogate expectations are different for physicians and nurses with regard to behaviors relevant to trust. Further research is needed to confirm our findings and explore the impact of trust modification on clinician-family conflict.

Nurses’ and Physicians’ Opinions on Aggressiveness of Treatment for General Ward Patients

The aim of this study was to evaluate agreement between nurses’ and physicians’ opinions regarding aggressiveness of treatment and to investigate and compare the rationales on which their opinions were based. Structured interviews regarding 714 patients were performed on seven general wards of a university hospital. The data gathered were then subjected to qualitative and quantitative analyses. There was 86% agreement between nurses’ and physicians’ opinions regarding full or limited treatment when the answers given as ‘uncertain’ were excluded. Agreement was less (77%) for patients with a life expectancy of less than one year. Disagreements were not associated with professional status because the physicians considered limiting life-sustaining treatment as often as the nurses. A broad spectrum of rationales was given but the results focus mostly on those for full treatment. The nurses and the physicians had similar bases for their opinions. For the majority of the patients, medical rationales were used, but age and quality of life were also expressed as important determinants. When considering full treatment, nurses used quality-of-life rationales for significantly more patients than the physicians. Respect for patients’ wishes had a minor influence.

The Natural History of Changes in Preferences for Life-Sustaining Treatments and Implications for Inpatient Mortality in Younger and Older Hospitalized Adults

OBJECTIVES

To compare changes in preferences for life-sustaining treatments (LSTs) and subsequent mortality of younger and older inpatients.

DESIGN

Retrospective cohort study.

SETTING

Kaiser Permanente Northern California (KPNC).

PARTICIPANTS

Individuals hospitalized at 21 KPNC hospitals between 2008 and 2012 (N = 227,525).

MEASUREMENTS

Participants were divided according to age (<65, 65-84, ≥85). The effect of age on adding new and reversing prior LST limitations was evaluated. Survival to inpatient discharge was compared according to age group after adding new LST limitations.

RESULTS

At admission, 18,254 (54.2%) of those aged 85 and older, 18,349 (20.8%) of those aged 65 to 84, and 3,258 (3.1%) of those younger than 65 had requested that the use of LST be limited. Of the 187,664 participants who initially did not request limitations on the use of LST, 15,932 (8.5%) had new LST limitations added; of the 39,861 admitted with LST limitations, 3,017 (7.6%) had these reversed. New limitations were more likely to be seen in older participants (aged 65-84, odds ratio (OR) = 2.27, 95% confidence interval (CI) = 2.16-2.39; aged ≥85, OR = 6.43, 95% CI = 6.05-6.84), and reversals of prior limitations were less likely to be seen in older individuals (aged 65-84, OR = 0.73, 95% CI = 0.65-0.83; aged ≥85, OR = 0.46, 95% CI = 0.41-0.53) than in those younger than 65. Survival rates to inpatient discharge were 71.7% of subjects aged 85 and older who added new limitations, 57.2% of those aged 65 to 84, and 43.4% of those younger than 65 (P < .001).

CONCLUSION

Changes in preferences for LSTs were common in hospitalized individuals. Age was an important determinant of likelihood of adding new or reversing prior LST limitations. Of subjects who added LST limitations, those who were older were more likely than those who were younger to survive to hospital discharge.

[The suitability of therapeutic effort: An end-of-life strategy]

End-of-life treatment and attention to the needs of relatives are not adequate for several reasons: Society denies or hides the death; it is very difficult to predict it accurately; treatment is frequently fragmented between different specialists, and there is insufficient palliative medicine training, including communication skills. There are frequent conflicts with decisions made at the end of life, particularly the suitability of therapeutic effort. The attitude of professionals on the adequacy of therapeutic effort is not homogenous, and varies depending on the specialty, experience, and beliefs. Many doctors are still afraid of inconveniencing patients. Primary care is in a privileged position to approach the life and values of our patients and their families, and not just the disease, which makes it the right place to guide and advise the patient on the preparation and registration of living wills.

Withholding or withdrawal of treatment under French rules: a study performed in 43 intensive care units

Background

In France, decisions to limit treatment fall under the Leonetti law adopted in 2005. Leading figures from the French world of politics, science, and justice recently claimed for amendments to the law, considering it incomplete. This study, conducted before any legislative change, aimed to investigate the procedural aspects of withholding/withdrawing treatment in French ICUs and their adequacy with the existing law.

Methods

The characteristics of patients qualified for a withholding/withdrawal procedure were prospectively collected in 43 French ICUs. The study period (60 or 90 days under normal operating conditions) took place in the first half of 2013.

Results

During the study period, 777 (14 %) of 5589 admitted patients and 584 (52 %) of 1132 patients dying in the ICU had their treatment withheld or withdrawn. Whereas 344 patients had treatment(s) withheld (i.e., not started or not increased if already engaged), 433 had one or more treatment(s) withdrawn. Withdrawal of treatment was applied in 156 of 223 (70 %) brain-injured patients, compared to 277 of 554 (50 %) patients with other reasons for admission (p < 0.01). At the time of the decision-making, the patient’s wishes were known in 181 (23 %) of the 777 cases in one or more different way(s): 73 (9.4 %) from the patient, 10 (1.3 %) by advance directives, 10 (1.3 %) through a designated trusted person, and 108 (13.9 %) reported by the family or close relatives. An external consultant was involved in less than half of all decisions (356 of 777, 46 %). Of the 777 patients qualified for a withholding/withdrawal procedure, 133 (17 %) were discharged alive from the hospital (126 after withholding, 7 after withdrawal).

Conclusions

More than half of deaths in the study population occurred after a decision to withhold or withdraw treatment. Among patients under withholding/withdrawal procedures, brain-injured subjects were more likely to undergo a withdrawal procedure. The prevalence of advance directives and designated trusted persons was low. Because patients’ preferences were unknown in more than three quarters of cases, decisions remained primarily based on medical judgment. Limitations, especially withholding of treatment, did not preclude survival and hospital discharge.

Predictors of early care withdrawal following out-of-hospital cardiac arrest

AIMS

To identify factors that associated with early care withdrawal in out-of-hospital cardiac arrest patients.

METHODS

Data was collected from 189 survivors to hospital admission. Patients were classified by survival status upon hospital discharge, and those who died were categorized into withdrawal vs. no withdrawal of care. Those who had care withdrawn were further subdivided into early care withdrawal i.e. ≤72 h vs. late withdrawal >72 h. Multivariable adjusted odds ratios were used to assess factors associated with early care withdrawal.

RESULTS

Of 189 patients with cardiac arrest, only 36 had advanced directives (19%) and 99 (52%) had care withdrawn. Most patients whose care was withdrawn died in hospital (94/99, 95%), and the remainder died in hospice. Care was withdrawn early ≤72 h in the majority of patients (59/94, 63%). Median time to early care withdrawal was 2 days IQR (1-3). Factors associated with early care withdrawal were age ≥75 years, poor initial neurologic exam, multiple co morbidities, multi-organ failure, lactic acid ≥10 mmolL(-1), Caucasian race and absence of bystander CPR. Advance directives did not appear to determine early care withdrawal.

CONCLUSIONS

Although most cardiac arrest patients do not have advance directives, care is often withdrawn in more than 50% and in many before the accepted time for neurological awakening (72h). The decision to withdraw care is influenced by older age, race, preexisting co morbidities, multi-organ failure, and a poor initial neurological exam. Further studies are needed to better understand this phenomenon and other sociological factors that guide such decisions.

Uncertainty in end-of-life care

PURPOSE OF REVIEW

Uncertainty surrounding medical decision-making is particularly important during end-of-life decision-making. Doubts about the patient's best interests and prognostic accuracy may lead to conflict.

RECENT FINDINGS

Many authors have suggested recently that medical attitudes to uncertainty need review. It is inappropriate to avoid discussion of uncertainty during end-of-life care and American literature suggests that patients and families accept uncertainty in end-of-life discussions. Recently, authors have advocated the concept of 'Practical Certainty' accepting that absolute certainty is rarely possible in end-of-life decision-making and openly acknowledging that the physicians are as certain as they can be in the circumstances. Allowing time to provide acceptance of a palliative care pathway and using the collective wisdom of colleagues improves the accuracy of prediction and reduces conflict at the end of life.

SUMMARY

The implications of this review are that doctors should not avoid discussing uncertainty in end-of-life conversations and the article provides some recommendations for minimizing conflict arising from end-of-life discussion.

Age and decisions to limit life support for patients with acute lung injury: a prospective cohort study

Introduction

The proportion of elderly Americans admitted to the intensive care unit (ICU) in the last month of life is rising. Hence, challenging decisions regarding the appropriate use of life support are increasingly common. The objective of this study was to estimate the association between patient age and the rate of new limitations in the use of life support, independent of daily organ dysfunction status, following acute lung injury (ALI) onset.

Methods

This was a prospective cohort study of 490 consecutive patients without any limitations in life support at the onset of ALI. Patients were recruited from 11 ICUs at three teaching hospitals in Baltimore, Maryland, USA, and monitored for the incidence of six pre-defined limitations in life support, with adjustment for baseline comorbidity and functional status, duration of hospitalization before ALI onset, ICU severity of illness, and daily ICU organ dysfunction score.

Results

The median patient age was 52 (range: 18 to 96), with 192 (39%) having a new limitation in life support in the ICU. Of patients with a new limitation, 113 (59%) had life support withdrawn and died, 53 (28%) died without resuscitation, and 26 (14%) survived to ICU discharge. Each ten-year increase in patient age was independently associated with a 24% increase in the rate of limitations in life support (Relative Hazard 1.24; 95% CI 1.11 to 1.40) after adjusting for daily ICU organ dysfunction score and all other covariates.

Conclusions

Older critically ill patients are more likely to have new limitations in life support independent of their baseline status, ICU-related severity of illness, and daily organ dysfunction status. Future studies are required to determine whether this association is a result of differences in patient preferences by age, or differences in the treatment options discussed with the families of older versus younger patients.

DNR directives are established early in mechanically ventilated intensive care unit patients

PURPOSE

Setting treatment goals in the intensive care unit (ICU) often involves resuscitation decisions. Our objective was to study the rate of establishing do-not-resuscitate (DNR) directives, determinants, and outcomes of those directives for mechanically ventilated patients.

METHODS

In a multicentre observational study, we included consecutive adults with no DNR directives within 24 hr of ICU admission who were mechanically ventilated for at least 48 hr. We identified the rate with which DNR directives were established, and factors associated with these directives.

RESULTS

Among 765 patients, DNR directives were established for 231 (30.2%) patients; 143 (62.1%) of these were established within the first week. Factors independently associated with a DNR directive were: patient age [> or = 75 yr (hazard ratio [HR] 2.3, 95% confidence interval 1.5-3.4], 65 to 74 yr (HR 1.8, 1.2-2.7), 50 to 64 yr (HR 1.4, 1.0-2.2) relative to < 50 yr); medical rather than surgical diagnosis (HR 1.8, 1.3-2.5); multiple organ dysfunction score (HR 1.7 for each five-point increment, 1.4-2.0); physician prediction of ICU survival [< 10% (HR 15.0, 6.7-33.6)], 10 to 40% [(HR 5.0, 2.3-11.2), 41 to 60% (HR 4.0, 1.8-9.0) relative to > 90%]; and physician perception of patient preference to limit life support (no advanced life support [(HR 5.8, 3.6-9.4) or partial advanced life support (HR 3.2, 2.2-4.6) compared to full measures].

CONCLUSION

One third of mechanically ventilated patients had DNR directives established early during their ICU stay after the first 24 hr of admission. The strongest predictors of DNR directives were physician prediction of low probability of survival, physician perception of patient preference to limit life support, organ dysfunction, medical diagnosis and age.

Clinical review: International comparisons in critical care - lessons learned

Critical care medicine is a global specialty and epidemiologic research among countries provides important data on availability of critical care resources, best practices, and alternative options for delivery of care. Understanding the diversity across healthcare systems allows us to explore that rich variability and understand better the nature of delivery systems and their impact on outcomes. However, because the delivery of ICU services is complex (for example, interplay of bed availability, cultural norms and population case-mix), the diversity among countries also creates challenges when interpreting and applying data. This complexity has profound influences on reported outcomes, often obscuring true differences. Future research should emphasize determination of resource data worldwide in order to understand current practices in different countries; this will permit rational pandemic and disaster planning, allow comparisons of in-ICU processes of care, and facilitate addition of pre- and post-ICU patient data to better interpret outcomes.

The facilitated values history: helping surrogates make authentic decisions for incapacitated patients with advanced illness

Many patients who develop incapacitating illness have not expressed clear treatment preferences. Therefore, surrogate decision makers are asked to make judgments about what treatment pathway is most consistent with the patient's values. Surrogates often struggle with such decisions. The difficulty arises because answering the seemingly straightforward question, "What do you think the patient would choose?" is emotionally, cognitively, and morally complex. There is little guidance for clinicians to assist families in constructing an authentic picture of the patient's values and applying them to medical decisions, in part because current models of medical decision making treat the surrogate as the expert on the patient's values and the physician as the expert on technical medical considerations. However, many surrogates need assistance in identifying and working through the sometimes conflicting values relevant to medical decisions near the end of life. We present a framework for clinicians to help surrogates overcome the emotional, cognitive, and moral barriers to high-quality surrogate decision making for incapacitated patients.

Moral distress and structural empowerment among a national sample of Israeli intensive care nurses

AIM

The aim of this study was to determine levels of structural empowerment, moral distress, and the association between them among intensive care nurses.

BACKGROUND

Structural empowerment is the ability to access sources of power. Moral distress is the painful feelings experienced when a person knows the right thing to do but cannot do so due to external constraints. Several studies suggest a theoretical relationship between these concepts.

DESIGN

Cross-sectional, descriptive correlational study.

METHODS

Members of the Evidence Based Nursing Practice Committee of the Israeli Society for Cardiology and Critical Care Nurses recruited a convenience sample of intensive care nurses from their respective institutions and units. Nurses were asked to complete three questionnaires (demographic and work characteristics, Moral Distress Scale, and the Conditions of Work Effectiveness Questionnaire-II). Data were collected between May-September 2009.

RESULTS

Intensive Care nurses had moderate levels of structural empowerment, low levels of moral distress frequency, and moderately high moral distress intensity. A weak correlation was found between moral distress frequency and structural empowerment. No other structural empowerment component was associated with moral distress. Work characteristics as opposed to demographic characteristics were more associated with the study variables.

CONCLUSIONS

This study weakly supports the association between structural empowerment and moral distress. It also provides further evidence to the theory of structural empowerment as characterized in the critical care environment. Further studies are indicated to determine what other factors might be associated with moral distress.

Withdrawal of life-sustaining treatment in a mixed intensive care unit: most common in patients with catastropic brain injury

OBJECTIVE

To determine the incidence of withdrawal of life-sustaining treatment in various groups of patients in a mixed intensive care unit (ICU).

DESIGN

Observational retrospective.

SETTING

University hospital mixed medical, neurological, neurosurgical and surgical ICU.

PATIENTS

All patients admitted to the ICU between 1 November 2006, and 31 October 2007.

RESULTS

1,353 Patients were admitted to our ICU between 1 November 2006, and 31 October 2007. During this period, 218 (16.1%) patients died in the ICU, 10 of which were excluded for further analysis. In 174 (83.7%) of the remaining 208 patients, life-sustaining treatment was withdrawn. Severe CNS injury was in 86 patients (49.4%) being the reason for withdrawal of treatment, followed by MODS in 67 patients (38.5%). Notably, treatment was withdrawn in almost all patients (95%) who died of CNS failure. Patients who died in the ICU were significantly older, more often admitted for medical than surgical reasons, and had higher SOFA and APACHE II scores compared with those who survived their ICU stay. Also, SOFA scores before discharge/death were significantly different from admission scores. Of the 1,135 patients who survived their ICU stay, only 51 patients (4.5%) died within 28 days after ICU discharge.

CONCLUSIONS

In 83, 7% of patients who die in the mixed ICU life-sustaining treatment is withdrawn. Severe cerebral damage was the leading reason to withdraw life-sustaining treatment.

Critically ill patients and end-of-life decision-making: the senior medical resident experience

In order to improve the understanding of educational needs among residents caring for the critically ill, narrative accounts of 19 senior physician trainees participating in level of care decision-making were analyzed. In this multicentre qualitative study involving 9 university centers in Canada, in-depth interviews were conducted in either English or French, and the transcripts then underwent a hermeneutic phenomenological analysis. The resident was the central figure in the narrated incident, along with the patients' relatives and other attending physicians. The vast majority of interviews recounted negative experiences that involved delivering bad news to patients' families and managing difficult communications with them and with physician colleagues. Emotional distress and suffering were often part of their decision-making process. Narrating their experiences was viewed as a positive event. Data analysis uncovered 6 general themes that were organized into 2 categories, the first one grouping together themes related to interactions with the patients' families and the second comprising themes related to interactions with physician coworkers. The findings suggest that physician trainees' narratives are a rich source of data regarding what constitutes meaningful training experiences and what they learn from them. Educational approaches that incorporate the telling of stories would allow students to express their feelings, doubts, and opinions about their work experiences and could thus foster personal and emotional learning in critical care.

Impact of an intensive communication strategy on end-of-life practices in the intensive care unit

PURPOSE

Since the 2005 French law on end of life and patients' rights, it is unclear whether practices have evolved. We investigated whether an intensive communication strategy based on this law would influence practices in terms of withholding and withdrawing treatment (WWT), and outcome of patients hospitalised in intensive care (ICU).

METHODS

This was a single-centre, two-period study performed before and after the 2005 law. Between these periods, an intensive strategy for communication was developed and implemented, comprising regular meetings and modalities for WWT. We examined medical records of all patients who died in the ICU or in hospital during both periods.

RESULTS

In total, out of 2,478 patients admitted in period 1, 678 (27%) died in the ICU and 823/2,940 (28%) in period 2. In period 1, among patients who died in the ICU, 45% died subsequent to a decision to WWT versus 85% in period 2 (p < 0.01). Among these, median time delay between ICU admission and initiation of decision-making process was significantly different (6-7 days in period 1 vs. 3-5 days in period 2, p < 0.05). Similarly, median time from admission to actual WWT decision was significantly shorter in period 2 (11-13 days in period 1 vs. 4-6 days in period 2, p < 0.05). Finally, median time from admission to death in the ICU subsequent to a decision to WWT was 13-15 days in period 1 versus 7-8 days in period 2, p < 0.05. Reasons for WWT were not significantly different between periods.

CONCLUSION

Intensive communication brings about quicker end-of-life decision-making in the ICU. The new law has the advantage of providing a legal framework.

[Practice of treatment restriction in Hungarian intensive care units]

End of life decisions affect most of patients in intensive care units, thus, it is important to know both local and international practice in accordance with law and ethical principles for intensive care physicians.

AIM

To search for local customs of end of life decisions (withholding or withdrawing the therapy, shortening of the dying process), and to compare the data with the international literature.

METHODS

In 2007-2008 the first Hungarian survey was performed with the purpose to learn more about local practice of end of life decisions. Questionnaires were sent out electronically to 743 registered members of Hungarian Society of Anesthesiology and Intensive Care. Respecting anonymity, 103 replies were statistically evaluated (response rate was 13.8%) and compared with data from other European countries.

RESULTS

As expected, it turned out from replies that the practice of domestic intensive care physicians is very paternal and this is promoted by legal regulations that share a similar character. Intensive care physicians generally make their decisions alone (3.75/5 point) without respecting the opinion of the patient (2.57/5 point) the relatives (2.14/5 point) or other medical personnel (2.37/5 point). Furthermore, they prefer not to start a therapy rather than withdraw an ongoing treatment. Nevertheless, the frequency of end of life decisions (3-9% of ICU patients) is smaller than other European countries.

CONCLUSIONS

There is a need for the expansion of patients' right in our country. For end of life decisions, self determinations must be supported and a dialogue must be established between lawmakers and physicians, in order to improve the legal support of this medical practice.

Awareness and use of recommendations for withholding and withdrawing therapy in Austrian intensive care units

During the past decade there has been growing interest in the development of practice guidelines on medical end-of-life decisions. A questionnaire about awareness and use of end-of-life decision guidelines was applied by e-mail in a cross-sectional survey among 1494 attendants of Austrian intensive care medicine conferences held in 2008. Of a total of 246 evaluable responses from physicians, only 140 said to have been aware of national end-of-life decision-making guidelines (56.9%). Those who read the recommendations at least in part believe to have derived benefit from the recommendations. Even though the response rate was low, Austrian intensive care medicine societies should be encouraged to better disseminate end-of-life decision guidelines among caregivers.

Do-not-resuscitate orders for critically ill patients in intensive care

End-of-life decision making frequently occurs in the intensive care unit (ICU). There is a lack of information on how a do-not-resuscitate (DNR) order affects treatments received by critically ill patients in ICUs. The objectives of this study were: (1) to compare the use of life support therapies between patients with a DNR order and those without; (2) to examine life support therapies prior to and after the issuance of a DNR order; and (3) to determine the clinical factors that influence the initiation of a DNR order in ICUs in Taiwan. A prospective, descriptive, and correlational study was conducted. A total of 202 patients comprising 133 (65.8%) who had a DNR order, and 69 (34.1%) who did not, participated in this study. In the last 48 hours of their lives, patients who had a DNR order were less likely to receive life support therapies than those who did not have a DNR order. Older age, being unmarried, the presence of an adult child as a surrogate decision maker, a perceived inability to survive ultimate discharge from the ICU, and longer hospitalization in the ICU were significant predictors of issuing a DNR order for critically ill patients. This study will draw attention to how, when, and by whom, critically ill patients’ preferences about DNR are elicited and honored.

Predictors of time to death after terminal withdrawal of mechanical ventilation in the ICU

BACKGROUND

Little information exists about the expected time to death after terminal withdrawal of mechanical ventilation. We sought to determine the independent predictors of time to death after withdrawal of mechanical ventilation.

METHODS

We conducted a secondary analysis from a cluster randomized trial of an end-of-life care intervention. We studied 1,505 adult patients in 14 hospitals in Washington State who died within or shortly after discharge from an ICU following terminal withdrawal of mechanical ventilation (August 2003 to February 2008). Time to death and its predictors were abstracted from the patients' charts and death certificates. Predictors included demographics, proxies of severity of illness, life-sustaining therapies, and International Classification of Diseases, 9th ed., Clinical Modification codes.

RESULTS

The median (interquartile range [IQR]) age of the cohort was 71 years (58-80 years), and 44% were women. The median (IQR) time to death after withdrawal of ventilation was 0.93 hours (0.25-5.5 hours). Using Cox regression, the independent predictors of a shorter time to death were nonwhite race (hazard ratio [HR], 1.17; 95% CI, 1.01-1.35), number of organ failures (per-organ HR, 1.11; 95% CI, 1.04-1.19), vasopressors (HR, 1.67; 95% CI, 1.49-1.88), IV fluids (HR, 1.16; 95% CI, 1.01-1.32), and surgical vs medical service (HR, 1.29; 95% CI, 1.06-1.56). Predictors of longer time to death were older age (per-decade HR, 0.95; 95% CI, 0.90-0.99) and female sex (HR, 0.86; 95% CI, 0.77-0.97).

CONCLUSIONS

Time to death after withdrawal of mechanical ventilation varies widely, yet the majority of patients die within 24 hours. Subsequent validation of these predictors may help to inform family counseling at the end of life.

Policies to improve end-of-life decisions in Flemish hospitals: communication, training of health care providers and use of quality assessments

Background

The prevalence and implementation of institutional end-of-life policies has been comprehensively studied in Flanders, Belgium, a country where euthanasia was legalised in 2002. Developing end-of-life policies in hospitals is a first step towards improving the quality of medical decision-making at the end-of-life. Implementation of policies through quality assessments, communication and the training and education of health care providers is equally important in improving actual end-of-life practice. The aim of the present study is to report on the existence and nature of end-of-life policy implementation activities in Flemish acute hospitals.

Methods

A cross-sectional mail survey was sent to all acute hospitals (67 main campuses) in Flanders (Belgium). The questionnaire asked about hospital characteristics, the prevalence of policies on five types of end-of-life decisions: euthanasia, palliative sedation, alleviation of symptoms with possible life-shortening effect, do-not-resuscitate decision, and withdrawing or withholding of treatment, the internal and external communication of these policies, training and education on aspects of end-of-life care, and quality assessments of end-of-life care on patient and family level.

Results

The response rate was 55%. Results show that in 2007 written policies on most types of end-of-life decisions were widespread in acute hospitals (euthanasia: 97%, do-not-resuscitate decisions: 98%, palliative sedation: 79%). While standard communication of these policies to health care providers was between 71% and 91%, it was much lower to patients and/or family (between 17% and 50%). More than 60% of institutions trained and educated their caregivers in different aspects on end-of-life care. Assessment of the quality of these different aspects at patient and family level occurred in 25% to 61% of these hospitals.

Conclusions

Most Flemish acute hospitals have developed a policy on end-of-life practices. However, communication, training and the education of health care providers about these policies is not always provided, and quality assessment tools are used in less than half of the hospitals.

Ethics and Advance Care Planning in a Culturally Diverse Society

Emerging international research suggests that in multicultural countries, such as Australia and the United States, there are significant disparities in end-of-life care planning and decision making by people of minority ethnic backgrounds compared with members of mainstream English-speaking background populations. Despite a growing interest in the profound influence of culture and ethnicity on patient choices in end-of-life care, and the limited uptake of advance care plans and advance directives by ethnic minority groups in mainstream health care contexts, there has been curiously little attention given to cross-cultural considerations in advance care planning and end-of-life care. Also overlooked are the possible implications of cross-cultural considerations for nurses, policy makers, and others at the forefront of planning and providing end-of-life care to people of diverse cultural and language backgrounds. An important aim of this article is to redress this oversight.

Characteristics of discussions on cardiopulmonary resuscitation between physicians and surrogates of critically ill patients

PURPOSE

In the intensive care unit (ICU), critically ill patients are often unable to participate in discussions about cardiopulmonary resuscitation (CPR), and decisions on CPR are often made by surrogate decision makers. The objective of this study is to determine the prevalence, content, and perceptions of CPR discussions between critically ill patients' surrogates and ICU physicians and their effect on resuscitation decisions.

MATERIALS AND METHODS

Eligible patients' surrogates were interviewed using a structured questionnaire more than 24 hours after admission to the medical ICUs at 2 university-affiliated medical centers. Data from surrogates who did and did not participate in a CPR discussion were compared and correlated with patient characteristics and outcomes.

RESULTS

Of 84 surrogates interviewed, 54% participated in more than 1 CPR discussion. Although most (73%) recalled discussing endotracheal intubation, 49% and 44% recalled discussing chest compressions or electrical cardioversion, respectively, and 68% to 84% stated they understood these components. Mortality was higher in the discussion group compared to the no-discussion group (37% vs. 8%; P < .05), although changes in CPR decisions were similar in both groups (25% vs 18%, P = .5).

CONCLUSIONS

Only half of critically ill patients' surrogates participated in CPR discussions. For those who did participate, most reported good understanding of resuscitation techniques, but less than half recalled the core components of CPR.

Terminal withdrawal of mechanical ventilation at a long-term acute care hospital: comparison with a medical ICU

BACKGROUND

Failure to wean from prolonged mechanical ventilation (MV) is common in long-term acute care hospitals (LTACHs), but the process of terminal withdrawal of MV in LTACHs is not well described. We compared terminal withdrawal of MV at an LTACH with that in a medical ICU (MICU).

METHODS

A retrospective medical chart review was done of all patients undergoing terminal withdrawal of MV in an LTACH (n = 30) and in a MICU (n = 74) over a 2-year period.

RESULTS

The decision to withdraw MV was more likely initiated by patient or family in the LTACH and by medical staff in the MICU (p < 0.0001). Social workers, pastoral care, and hospital administration were more likely to participate in the withdrawal process at the LTACH compared with the MICU (p < 0.05). Time from initiation of MV to orders for do not resuscitate, comfort measures only, or withdrawal of MV was significantly greater in the LTACH (weeks) compared with the MICU (days) (p < 0.05). The dose of benzodiazepines given during the final 24 h of life was greater in the MICU as compared with the LTACH (p < 0.05). Narcotic and benzodiazepine use in the hour before or after withdrawal of MV did not differ between the two groups. COPD and pneumonia were the most common causes of death among patients undergoing withdrawal of MV at the LTACH, as opposed to septic shock in the MICU (p < 0.05).

CONCLUSIONS

Terminal withdrawal of MV in the LTACH differs from that in the MICU with regard to decision making, benzodiazepine use, and cause of death.

Families with limited English proficiency receive less information and support in interpreted intensive care unit family conferences

OBJECTIVE

Family communication is important for delivering high quality end-of-life care in the intensive care unit, yet little research has been conducted to describe and evaluate clinician-family communication with non-English-speaking family members. We assessed clinician-family communication during intensive care unit family conferences involving interpreters and compared it with conferences without interpreters.

DESIGN

Cross-sectional descriptive study.

SETTING

Family conferences in the intensive care units of four hospitals during which discussions about withdrawing life support or delivery of bad news were likely to occur.

PARTICIPANTS

Seventy family members from ten interpreted conferences and 214 family members from 51 noninterpreted conferences. Nine different physicians led interpreted conferences and 36 different physicians led noninterpreted conferences.

MEASUREMENTS

All 61 conferences were audiotaped. We measured the duration of the time that families, interpreters, and clinicians spoke during the conference, and we tallied the number of supportive statements issued by clinicians in each conference.

RESULTS

The mean conference time was 26.3 +/- 13 mins for interpreted and 32 +/- 15 mins for noninterpreted conferences (p = 0.25). The duration of clinician speech was 10.9 +/- 5.8 mins for interpreted conferences and 19.6 +/- 10.2 mins for noninterpreted conferences (p = 0.001). The amount of clinician speech as a proportion of total speech time was 42.7% in interpreted conferences and 60.5% in noninterpreted conferences (p = 0.004). Interpreter speech accounted for 7.9 +/- 4.4 mins and 32% of speech in interpreter conferences. Interpreted conferences contained fewer clinician statements providing support for families, including valuing families' input (p = 0.01), easing emotional burdens (p < 0.01), and active listening (p < 0.01).

CONCLUSIONS

This study suggests that families with non-English-speaking members may be at increased risk of receiving less information about their loved one's critical illness as well as less emotional support from their clinicians. Future studies should identify ways to improve communication with, and support for, non-English-speaking families of critically ill patients.

"Living with dying": the evolution of family members' experience of mechanical ventilation

BACKGROUND

Communication with families about mechanical ventilation may be more effective once we gain a better understanding of what families experience and understand about this life support technology when their loved ones are admitted to the intensive care unit (ICU).

METHODS

We conducted in-depth interviews with family members of 27 critically ill patients who required mechanical ventilation for > or = 7 days and had an estimated ICU mortality of > or = 50%. Team members reviewed transcripts independently and used grounded theory analysis.

RESULTS

The central theme of family members' experience with mechanical ventilation was "living with dying." Initial reactions to the ventilator were of shock and surprise. Family members perceived no option except mechanical ventilation. Although the ventilator kept the patient alive, it also symbolized proximity to death. In time, families became accustomed to images of the ICU as ventilation became more familiar and routine. Their shock and horror were replaced by hope that the ventilator would allow the body to rest, heal, and recover. However, ongoing exposure to their loved one's critical illness and the new role as family spokesperson were traumatizing.

CONCLUSIONS

Family members' experiences and their understanding of mechanical ventilation change over time, influenced by their habituation to the ICU environment and its routines. They face uncertainty about death, but maintain hope. Understanding these experiences may engender more respectful, meaningful communication about life support with families.