Changing patterns of terminal care management in an intensive care unit

The worldwide investigating nurses' attitudes towards do-not-resuscitate order: a review

Background

The acceptance or practical application of the do-not-resuscitate order is substantially dependent on internal or personal factors; in a way that decision-making about this issue can be specific to each person. Moreover, most nurses feel morally and emotionally stressed and confused during the process decision-making regarding DNR order. Therefore, the purpose of the present study was to evaluate nurses’ attitudes towards DNR order in a systematic review.

Methods

This critical survey was conducted using a systematic review protocol. To this end, the most relevant articles published in domestic and foreign databases with no time limits until October 2018 were searched. The inclusion and exclusion criteria were articles on DNR order, studies about nurses’ attitudes, descriptive and analytical research papers, as well as those with download links and full texts. The given articles were also assessed in terms of their quality and their main results were extracted.

Results

Of the total number of 1663 articles searched in the process of systematic review to investigate nurses’ attitudes towards DNR order, 88 articles were included in the full-text review step and finally 10 articles, meeting the inclusion criteria, were found. Assessing the quality of articles included in this review showed that 8 articles, in general, were of good quality and 2 studies were characterized with moderate quality. The main factors associated with nurses’ attitudes towards DNR order were grouped into three categories of (1) nurses’ attitudes towards DNR order, (2) guidelines for DNR order, and (3) decision-making by patients and their families about DNR order. In most of the studies examined, nurses’ attitudes towards DNR order were reported positive.

Conclusion

It seemed that nurses were willing to get involved in DNR order and each hospital was recommended to develop a written DNR policy directing individuals and avoiding their confusion in this respect.

Factors Associated With DNR Status After Nontraumatic Intracranial Hemorrhage

Background

We explored factors associated with admission and discharge code status after nontraumatic intracranial hemorrhage.

Methods

We extracted data from patients admitted to our institution between January 1, 2013, and March 1, 2016 with nontraumatic intracerebral hemorrhage or subarachnoid hemorrhage who had a discharge modified Rankin Scale (mRS) of 4 to 6. We reviewed data based on admission and discharge code status.

Results

Of 88 patients who met inclusion criteria, 6 (7%) were do not resuscitate (DNR) on admission (aDNR). Do not resuscitate on admission patients were significantly older than those who were full code on admission (P = 0.04). There was no significant difference between admission code status and sex, marital status, active cancer, premorbid mRS, admission Glasgow Coma scale (GCS), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, or bleed severity. At discharge, 66 (75%) patients were full code (dFULL), 11 (13%) were DNR (dDNR), and 11 (13%) were comfort care. African American and Hispanic patients were significantly more likely to be dFULL than Asian or white patients (P = .01) and less likely to be seen by palliative care (P = .004). Patients with less aggressive code status had higher median APACHE II scores (P = .008) and were more likely to have active cancer (P = .06). There was no significant difference between discharge code status and sex, age, marital status, premorbid mRS, discharge GCS, or bleed severity.

Conclusions

Limitation of code status after nontraumatic intracranial hemorrhage appears to be associated with older age, white race, worse APACHE II score, and active cancer. The role of palliative care after intracranial hemorrhage and the racial disparity in limitation and de-escalation of treatment deserves further exploration.

Risk Factors for Withdrawal of Life-Sustaining Treatment in Severe Traumatic Brain Injury

Studies demonstrate a significant variation in decision-making regarding withdrawal of life-sustaining treatment (WLST) practices for patients with severe traumatic brain injury (TBI). We investigated risk factors associated with WLST in severe TBI. We hypothesized age ≥65 years would be an independent risk factor. In addition, we compared survivors with patients who died in hospital after WLST to identify potential factors associated with in-hospital mortality. The Trauma Quality Improvement Program (2010–2016) was queried for patients with severe TBI of the head. Patients were compared by age (age < 65 and age ≥ 65 years) and survival after WLST (survivors versus non-survivors) at hospitalization discharge. A multivariable logistic regression model was used for analysis. From 1,403,466 trauma admissions, 328,588 (23.4%) patients had severe TBI. Age ≥ 65 years was associated with increased WLST (odds ratio: 1.76, confidence interval: 1.59–1.94, P < 0.001), whereas nonwhite race was associated with decreased WLST (odds ratio: 0.60, confidence interval: 0.55–0.65, P < 0.001). Compared with non-survivors of WLST, survivors were older (74 vs 61 years, P < 0.001) and more likely to have comorbidities such as hypertension (57% vs 38.5%, P < 0.001). Age ≥ 65 years was an independent risk factor for WLST, and nonwhite race was associated with decreased WLST. Patients surviving until discharge after WLST decision were older (≥74 years) and had multiple comorbidities.

Protocol for a randomised trial of an interprofessional team-delivered intervention to support surrogate decision-makers in ICUs

INTRODUCTION

Although shortcomings in clinician-family communication and decision making for incapacitated, critically ill patients are common, there are few rigorously tested interventions to improve outcomes. In this manuscript, we present our methodology for the Pairing Re-engineered Intensive Care Unit Teams with Nurse-Driven Emotional support and Relationship Building (PARTNER 2) trial, and discuss design challenges and their resolution.

METHODS AND ANALYSIS

This is a pragmatic, stepped-wedge, cluster randomised controlled trial comparing the PARTNER 2 intervention to usual care among 690 incapacitated, critically ill patients and their surrogates in five ICUs in Pennsylvania. Eligible subjects will include critically ill patients at high risk of death and/or severe long-term functional impairment, their main surrogate decision-maker and their clinicians. The PARTNER intervention is delivered by the interprofessional ICU team and overseen by 4-6 nurses from each ICU. It involves: (1) advanced communication skills training for nurses to deliver support to surrogates throughout the ICU stay; (2) deploying a structured family support pathway; (3) enacting strategies to foster collaboration between ICU and palliative care services and (4) providing intensive implementation support to each ICU to incorporate the family support pathway into clinicians' workflow. The primary outcome is surrogates' ratings of the quality of communication during the ICU stay as assessed by telephone at 6-month follow-up. Prespecified secondary outcomes include surrogates' scores on the Hospital Anxiety and Depression Scale, the Impact of Event Scale, the modified Patient Perception of Patient Centredness scale, the Decision Regret Scale, nurses' scores on the Maslach Burnout Inventory, and length of stay during and costs of the index hospitalisation.We also discuss key methodological challenges, including determining the optimal level of randomisation, using existing staff to deploy the intervention and maximising long-term follow-up of participants.

ETHICS AND DISSEMINATION

We obtained ethics approval through the University of Pittsburgh, Human Research Protection Office. The findings will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT02445937.

End of Life Care and Do Not Resuscitate Orders: How Much Does Age Influence Decision Making? A Systematic Review and Meta-Analysis

With population aging, “do not resuscitate” (DNAR) decisions, pertaining to the appropriateness of attempting resuscitation following a cardiac arrest, are becoming commoner. It is unclear from the literature whether using age to make these decisions represents “ageism.” We undertook a systematic review of the literature using CINAHL, Medline, and the Cochrane database to investigate the relationship between age and DNAR. All 10 studies fulfilling our inclusion criteria found that “do not attempt resuscitation” orders were more prevalent in older patients; eight demonstrated that this was independent of other mediating factors such as illness severity and likely outcome. In studies comparing age groups, the adjusted odds of having a DNAR order were greater in patients aged 75 to 84 and ≥85 years (adjusted odds ratio [AOR] 1.70, 95% confidence interval [CI] = [1.25, 2.33] and 2.96, 95% CI = [2.34, 3.74], respectively), compared with those <65 years. In studies treating age as a continuous variable, there was no significant increase in the use of DNAR with age (AOR 0.98, 95% CI = [0.84, 1.15]). In conclusion, age increases the use of “do not resuscitate” orders, but more research is needed to determine whether this represents “ageism.”

The Durban World Congress Ethics Round Table Conference Report: III. Withdrawing Mechanical ventilation--the approach should be individualized

PURPOSE

The purpose of this study is to determine the approaches used in withdrawing mechanical ventilator support.

MATERIALS AND METHODS

Speakers from the invited faculty of the World Federation of Societies of Intensive and Critical Care Medicine Congress in 2013 with an interest in ethics were asked to provide a detailed description of individual approaches to the process of withdrawal of mechanical ventilation.

RESULTS

Twenty-one participants originating from 13 countries, responded to the questionnaire. Four respondents indicated that they do not practice withdrawal of mechanical ventilation, and another 4 indicated that their approach is highly variable depending on the clinical scenario. Immediate withdrawal of ventilation was practiced by a large number of the respondents (7/16; 44%). A terminal wean was practiced by just more than a third of the respondents (6/16; 38%). Extubation was practiced in more than 70% of instances among most of the respondents (9/17; 53%). Two of the respondents (2/17; 12%) indicated that they would extubate all patients, whereas 14 respondents indicated that they would not extubate all their patients. The emphasis was on tailoring the approach used to suit individual case scenarios.

CONCLUSIONS

Withdrawing of ventilator support is not universal. However, even when withdrawing mechanical ventilation is acceptable, the approach to achieve this end point is highly variable and individualized.

Racial differences in withdrawal of mechanical ventilation do not alter mortality in neurologically injured patients

PURPOSE

Racial differences in withdrawal of mechanical ventilation (WMV) have been demonstrated among patients with severe neurologic injuries. We ascertained whether such differences might be accounted for by imbalances in socioeconomic status or disease severity, and whether such racial differences impact hospital mortality or result in greater discharge to long-term care facilities.

MATERIALS AND METHODS

We evaluated WMV among 1885 mechanically ventilated patients with severe neurologic injury (defined as Glasgow Coma Scale <9), excluding those progressing to brain death within the first 48 hours.

RESULTS

Withdrawal of mechanical ventilation was less likely in nonwhite patients (22% vs 31%, P < .001). Nonwhites were younger and were more likely to have Medicaid or no insurance, live in ZIP codes with low median household incomes, be unmarried, and have greater illness severity; but after adjustment for these variables, racial difference in WMV persisted (odds ratio, 0.56; 95% confidence interval, 0.42-0.76). Nonwhite patients were more likely to die instead with full support or progress to brain death, resulting in equivalent overall hospital mortality (40% vs 42%, P = .44). Among survivors, nonwhites were more likely to be discharged to long-term care facilities (27% vs 17%, P < .001).

CONCLUSIONS

Surrogates of nonwhite neurologically injured patients chose WMV less often even after correcting for socioeconomic status and other confounders. This difference in end-of-life decision making does not appear to alter hospital mortality but may result in more survivors left in a disabled state.

Attitudes towards ethical problems in critical care medicine: the Chinese perspective

INTRODUCTION

Critical care doctors are frequently faced with clinical problems that have important ethical and moral dimensions. While Western attitudes and practice are well documented, little is known of the attitudes or practice of Chinese critical care doctors.

METHODS

An anonymous, written, structured questionnaire survey was translated from previously reported ethical surveys used in Europe and Hong Kong. A snowball method was used to identify 534 potential participants from 21 regions in China.

RESULTS

A total of 315 (59%) valid responses were analysed. Most respondents (66%) reported that admission to an intensive care unit (ICU) was commonly limited by bed availability, but most (63%) would admit patients with a poor prognosis to ICU. Only 19% of respondents gave complete information to patients and family, with most providing individually adjusted information, based on prognosis and the recipient's educational level. Only 28% disclosed all details of an iatrogenic incident, despite 62% stating that they should. The use of do not resuscitate orders or limitation of life-sustaining therapy in terminally ill patients reported as uncommon and according to comparable reports, both are more common practice in Hong Kong or Europe. In contrast to European practices, doctors were more acquiescent to families in decision-making at the end of life.

CONCLUSIONS

A number of differences in ethical attitudes and related behaviour between Chinese, Hong Kong and European ICU doctors were documented. A likely explanation is differing cultural background, and doctors should be aware of likely expectations when treating patients from a different culture.

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.

Knowledge and attitudes toward brain stem death among university undergraduates

BACKGROUND

Withdrawal of life support and organ procurement for transplantation are the main implications of a diagnosis of brain stem death (BSD). Various factors may impact this important decision-making process. The present study sought to investigate the knowledge and attitudes about BSD among university undergraduates as a "well-informed" subgroup of our local population.

METHODS

A cross-sectional questionnaire survey was administered to a sample of nonmedical university undergraduate students in Hong Kong.

RESULTS

The subjects' overall knowledge of BSD was unsatisfactory. Only 24% of subjects knew that BSD was the equivalent of legal death in Hong Kong. Among subjects who agreed to withdraw life support treatment from themselves upon the diagnosis of BSD, 30% and 24% refused to do so for their family members or a stranger, respectively. Subjects who agreed to withdraw life support showed significantly better knowledge about BSD than did those who did not agree. Concerns about doctors' inclination to diagnose BSD to save resources and extract organs for transplantation were not observed to negatively affect subjects' decisions about life support withdrawal.

CONCLUSION

The level of knowledge is an important factor affecting an individual's decision concerning withdrawal of life support therapy upon the diagnosis of BSD. Adequate explanation and counseling are important to facilitate family members in coping with this important end-of-life issue.

Duration of withdrawal of life support in the intensive care unit and association with family satisfaction

RATIONALE

Most deaths in the intensive care unit (ICU) involve withholding or withdrawing multiple life-sustaining therapies, but little is known about how to proceed practically and how this process affects family satisfaction.

OBJECTIVES

To examine the duration of life-support withdrawal and its association with overall family satisfaction with care in the ICU.

METHODS

We studied family members of 584 patients who died in an ICU at 1 of 14 hospitals after withdrawal of life support and for whom complete medical chart and family questionnaires were available.

MEASUREMENTS AND MAIN RESULTS

Data concerning six life-sustaining interventions administered during the last 5 days of life were collected. Families were asked to rate their satisfaction with care using the Family Satisfaction in the ICU questionnaire. For nearly half of the patients (271/584), withdrawal of all life-sustaining interventions took more than 1 day. Patients with a prolonged (>1 d) life-support withdrawal were younger, stayed longer in the ICU, had more life-sustaining interventions, had less often a diagnosis of cancer, and had more decision makers involved. Among patients with longer ICU stays, a longer duration in life-support withdrawal was associated with an increase in family satisfaction with care (P = 0.037). Extubation before death was associated with higher family satisfaction with care (P = 0.009).

CONCLUSIONS

Withdrawal of life support is a complex process that depends on patient and family characteristics. Stuttering withdrawal is a frequent phenomenon that seems to be associated with family satisfaction. Extubation before death should be encouraged if possible.

Meeting physicians' responsibilities in providing end-of-life care

Despite many clinical examples of exemplary end-of-life care, a number of studies highlight significant shortcomings in the quality of end-of-life care that the majority of patients receive. In part, this stems from inconsistencies in training and supporting clinicians in delivering end-of-life care. This review describes the responsibilities of pulmonary and critical care physicians in providing end-of-life care to patients and their families. While many responsibilities are common to all physicians who care for patients with life-limiting illness, some issues are particularly relevant to pulmonary and critical care physicians. These issues include prognostication and decision making about goals of care, challenges and approaches to communicating with patients and their family, the role of interdisciplinary collaboration, principles and practice of withholding and withdrawing life-sustaining measures, and cultural competency in end-of-life care.

Interventions to Improve Care during Withdrawal of Life-Sustaining Treatments

Withdrawal of life-sustaining therapies is a common occurrence in the intensive care unit (ICU) setting and also occurs in other hospital settings, long-term care facilities, and even at home. Many studies have documented dramatic geographic variations in the prevalence of withdrawal of life-sustaining therapies, and some evidence suggests this variation may be driven more by physician attitudes and biases than by factors such as patient preferences or cultural differences. A number of studies of interventions in the ICU setting have provided some evidence that withdrawal of life-sustaining therapies is a process of care that can be improved. The interventions have included routine ethics or palliative care consultations, routine family conferences, and standardized order protocol for withdrawal of life support. For some of the interventions, for example, ethics consultations or palliative care consultations, the precise mechanisms by which the process of care is improved are not clear. Furthermore, many of these studies have used surrogate outcomes for quality, such as ICU length of stay. Emerging research suggests more direct outcome measures may be useful, including family satisfaction with care and assessments of the quality of dying. Despite these relative limitations, these studies provide convincing evidence that withdrawal of life-sustaining therapy is a process of care that presents opportunities for quality improvement and that interventions are successful at improving this care. Further research is needed to identify and test the most appropriate and responsive outcome measures and to identify the most effective and cost-effective interventions.

End-of-life decisions: a cohort study of the withdrawal of all active treatment in intensive care units in the United Kingdom

OBJECTIVE

To describe the epidemiology of active treatment withdrawal in a nationally representative cohort of intensive care units (ICUs) focusing on between-unit differences.

DESIGN AND SETTING

Cohort study in 127 adult general ICUs in England, Wales and Northern Ireland, 1995 to 2001.

PATIENTS

118,199 adult admissions to ICUs.

MEASUREMENTS AND RESULTS

The decision to withdraw all active treatment was made for 11,694 of 118,199 patients (9.9%). There were a total of 36,397 deaths (30.8%) before discharge from hospital, and 11,586 (31.8%) of these occurred after the decision to withdraw active treatment, with no change over time (p=0.54). Considerable variation existed between units regarding the percentage of ICU deaths that occurred after the decision to withdraw active treatment (1.7-96.1%). Median time to death after the decision to withdraw active treatment was 2.4 h; 8% survived more than 24 h. After multilevel modelling, the factors independently associated with the decision to withdraw active treatment were: older age, pre-existing severe medical conditions, emergency surgery or medical admission, cardiopulmonary resuscitation in the 24 h prior to admission, and ventilation or sedation/paralysis in the first 24 h after admission. Substantial between unit variability remained after accounting for case-mix differences in admissions.

CONCLUSIONS

Although we were unable to examine partial withdrawal or withholding of care in this study, we found that the withdrawal of all active treatment is widespread in ICUs in the United Kingdom. There was little change in this practice over the period examined. However, there was considerable variation by unit, even after accounting for patient factors and differences in size and type of ICU, suggesting improved guidelines may be useful to facilitate uniform decision making.

Adjustment for do-not-resuscitate orders reverses the apparent in-hospital mortality advantage for minorities

PURPOSE

The use of do-not-resuscitate (DNR) orders may differ by sex or ethnicity, and DNR status may be associated with outcomes for hospitalized patients. Thus, we sought to determine whether differences in rates of DNR by sex and ethnicity influenced differences in mortality.

SUBJECTS AND METHODS

We included all patients admitted to nonfederal California hospitals in 1999 with stroke, congestive heart failure, pneumonia, chronic obstructive pulmonary disease, chronic renal failure, angina, or diabetes mellitus. Rates of physician orders for DNR written within 24 hours of hospital admission and in-hospital mortality were compared between sexes and ethnicities after adjustment for age, admission source and diagnosis, payment type, and comorbidity scores in multivariable logistic regression models.

RESULTS

Of 327890 patients included, 25196 (7.7%) had DNR orders. In adjusted models, women were more likely to have DNR orders than men (odds ratio [OR] 1.19; 95% confidence interval 1.16-1.23; P <0.001) and non-Hispanic whites were more likely to have DNR orders than other ethnicities (OR 1.75; 1.69-1.82; P <0.001). Overall, 13549 (4.1%) patients died in the hospital. Risk of death was greater in those with a DNR order (OR 7.0; 6.7-7.3; P <0.001). Non-Hispanic whites appeared to have a greater risk of in-hospital death in adjusted models (OR 1.09; 1.04-1.12; P <0.001) when DNR status was ignored; however, the risk of death appeared to be lower in non-Hispanic whites in the complete model with DNR included (OR 0.94; 0.90-0.99; P = 0.01). A survival advantage for women was also more apparent after including DNR status in the adjusted model.

CONCLUSIONS

Women and non-Hispanic whites are more likely to have DNR orders. DNR status affected the measurement of sex-ethnic differences in mortality risk.

Communicating about end-of-life care with patients and families in the intensive care unit

Discussing end-of-life care and death with patients and their families is an extremely important part of providing a good quality care in the intensive care unit (ICU). Although there is little empiric research to guide ICU clinicians in the most effective way to have these conversations, there is a developing literature and experience and an increasing emphasis on making this an important part of the care we provide. Much like other ICU procedures or skills,providing sensitive and effective communication about end-of-life care requires training, practice, and supervision, as well as planning and preparation. Although different clinicians may have different approaches and should change their approach to match the needs of individual patients and their families, this article reviews some of the fundamental components to discussing end-of-life care in the ICU that should be part of the care of patients with life-threatening illnesses in the ICU.

Evaluation of a standardized order form for the withdrawal of life support in the intensive care unit

OBJECTIVE

The intensive care unit remains a setting where death is common, and a large proportion of these deaths are preceded by withdrawal of life support. We describe a quality improvement project implementing and evaluating a "withdrawal of life support order form" to improve quality of end-of-life care in the intensive care unit.

DESIGN

Before-after evaluation.

SETTING

County-owned, university-operated, tertiary, level I trauma center.

SUBJECTS

Subjects were 143 nurses and 61 physicians.

INTERVENTIONS

We conducted a before-after evaluation of the order form's implementation. The order form has sections on preparations, sedation/analgesia, withdrawal of mechanical ventilation, and the principles of life support withdrawal. To evaluate the form, we surveyed intensive care unit clinicians regarding satisfaction with the form, measured nurse-assessed quality of dying and death with a 14-item survey (scored 0 for worst possible death to 100 for best possible), and performed chart review to assess narcotic and benzodiazepine use and time from ventilator withdrawal to death.

MEASUREMENTS AND MAIN RESULTS

We surveyed 143 nurses and 61 physicians about satisfaction with the form. Among nurses reporting that the form was used (n = 73), most (84%) reported that the order form was helpful and they were most satisfied with the sedation and mechanical ventilation sections. Almost all physicians found the form helpful (95%), and > 70% of physicians found three of the four sections helpful (sedation, mechanical ventilation, and preparations). We obtained quality of dying and death scores for 41 patient deaths before and 76 deaths after the intervention. These scores did not significantly change (mean preintervention score, 78.3; mean postintervention score, 74.2; p = .54) before and after the intervention. Total doses of narcotics and benzodiazepines increased after implementation of the order form in the hour before ventilator withdrawal, the hour after ventilator withdrawal, and the hour before death (p < or = .03). There was no change in the median time from ventilator withdrawal to death (preintervention 37 mins, postintervention 39 mins; p = .49).

CONCLUSIONS

Nurses and physicians found the withdrawal of life support order form helpful. The order form did not improve nurses' assessment of patients' dying experience. Medications for sedation increased during the postorder form period without evidence of significantly hastening death. Although the order form was helpful to clinicians and changed medication delivery, demonstrating clear improvements in quality of dying may require larger sample sizes, more sensitive measures, or more effective interventions.

Analysis of terminal events in 109 successive deaths in a Belgian intensive care unit

OBJECTIVE

To determine the incidence of end-of-life decisions in intensive care unit (ICU) patients.

DESIGN AND SETTING

Prospective data collection and questionnaire in a 31-bed medicosurgical ICU in a university hospital.

PATIENTS AND PARTICIPANTS

All 109 ICU patients who died during a 3-month period (April-June 2001). Members of the ICU team were also invited to complete a questionnaire regarding the circumstances of each patient's death. Cardiopulmonary resuscitation was performed in 21 of the patients; other mechanisms leading to death were brain death (n=19), refractory shock (n=17), and refractory hypoxemia (n=2). The decision was taken in the remaining 50 patients to withdraw (n=43) or withhold (n=7) therapy. Questionnaires were completed for 68 patients, by physician and nurse in 40 cases, physician only in 20 cases, and nurse only in 8 cases. Questionnaires were obtained for 34 of 50 patients for whom a decision was made to limit therapy.

RESULTS

Respondents generally felt that the decision was timely (n=28, 82%), 5 (15%) felt the decision was too late, and one (3%) that the decision was made too soon, before the family could be informed.

CONCLUSIONS

Therapeutic limitations are frequent in patients dying in the ICU, with withdrawing more common than withholding life support. Generally members of the ICU staff were satisfied with the end-of-life decisions made.

Improving care for patients dying in the intensive care unit

It is impossible for ICU clinicians to avoid caring for dying patients and their families. For many, this is an extremely rewarding aspect of their clinical practice. There is ample evidence that there is room to improve the care of patients who are near death in the ICU. Despite the considerable holes in our knowledge about optimal care of dying critically ill patients, there is considerable agreement on the general principles of caring for these patients and about how to measure the outcomes of palliative care in the ICU. Practical approaches to improving the quality of end-of-life care exist and should be implemented.

Limitation of life support: Frequency and practice in a Hong Kong intensive care unit*

OBJECTIVE

To examine the frequency and the decision-making processes involved in limiting (withdrawing and withholding) life support therapy in critically ill Chinese patients in the intensive care unit.

DESIGN

Prospective survey of patients who had life support limited between April 1997 and March 1999.

SETTING

Medical and surgical intensive care unit of a teaching hospital.

PATIENTS

All patients admitted to the intensive care unit of the Prince of Wales Hospital who subsequently died and/or had life support limited. Brain-dead patients were excluded from analysis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 490 patients who died in the intensive care unit, limitation of life support occurred in 288 (58.8%). Relatives or patients requested limitation of life support in 32 cases (11%). The family and/or patient concurred with limitation of life support in 273 occasions (95%). Therapy was withheld in 30.8% and withdrawn in 28.0% of deaths. Therapy limited included inotropes, additional oxygen, and renal replacement therapy.

CONCLUSIONS

Limitation of therapy in dying Chinese patients occurs frequently in intensive care patients, and both patients and relatives concur with medical decisions to limit therapy in these patients. Withholding therapy rather than withdrawing therapy occurs more frequently than in Western populations.

Life-sustaining treatment decisions in Portuguese intensive care units: a national survey of intensive care physicians

Introduction

The objective of the present study was to evaluate the opinion of Portuguese intensive care physicians regarding 'do-not-resuscitate' (DNR) orders and decisions to withhold/withdraw treatment.

Methods

A questionnaire was sent to all physicians working on a full-time basis in all intensive care units (ICUs) registered with the Portuguese Intensive Care Society.

Results

A total of 266 questionnaires were sent and 175 (66%) were returned. Physicians from 79% of the ICUs participated. All participants stated that DNR orders are applied in their units, and 98.3% stated that decisions to withhold treatment and 95.4% stated that decisions to withdraw treatment are also applied. About three quarters indicated that only the medical group makes these decisions. Fewer than 15% of the responders stated that they involve nurses, 9% involve patients and fewer than 11% involve patients' relatives in end-of-life decisions. Physicians with more than 10 years of clinical experience more frequently indicated that they involve nurses in these decisions (P < 0.05), and agnostic/atheist doctors more frequently involve patients' relatives in decisions to withhold/withdraw treatment (P < 0.05). When asked about who they thought should be involved, more than 26% indicated nurses, more than 35% indicated the patient and more than 25% indicated patients' relatives. More experienced doctors more frequently felt that nurses should be involved (P < 0.05), and male doctors more frequently stated that patients' relatives should be involved in DNR orders (P < 0.05). When a decision to withdraw treatment is made, 76.8% of 151 respondents indicated that they would initiate palliative care; no respondent indicated that they would administer drugs to accelerate the expected outcome.

Conclusion

The probability of survival from the acute episode and patients' wishes were the most important criteria influencing end-of-life decisions. These decisions are made only by the medical group in most of the responding ICUs, with little input from nursing staff, patients, or patients' relatives, although many respondents expressed a wish to involve them more in this process. Sex, experience and religious beliefs of the respondents influences the way in which these decisions are made.

Research design in end-of-life research: state of science

PURPOSE

The volume of research on end-of-life care, death, and dying has exploded during the past decade. This article reviews the conceptual and methodological adequacy of end-of-life research to date, focusing on limitations of research to date and ways of improving future research.

DESIGN AND METHODS

A systematic search was conducted to identify the base of end-of-life research. Approximately 400 empirical articles were identified and are the basis of this review.

RESULTS

Although much has been learned from research to date, limitations in the knowledge base are substantial. The most fundamental problems identified are conceptual and include failure to define dying; neglect of the distinctions among quality of life, quality of death, and quality of end-of-life care. Methodologically, the single greatest problem is the lack of longitudinal studies that cover more than the time period immediately before death.

IMPLICATIONS

Gaps in the research base include insufficient attention to psychological and spiritual issues, the prevalence of psychiatric disorder and the effectiveness of the treatment of such disorders among dying persons, provider and health system variables, social and cultural diversity, and the effects of comorbidity on trajectories of dying.

Studying communication about end-of-life care during the ICU family conference: Development of a framework

PURPOSE

Family-clinician communication in the intensive care unit (ICU) about withholding and withdrawing life support occurs frequently, yet few data exist to guide clinicians in its conduct. The purpose of this study was to develop an understanding of the way this communication is currently conducted.

METHODS

We identified family conferences in the ICUs of 4 Seattle-area hospitals. Conferences were eligible if the physician leading the conference believed that discussion about withholding or withdrawing life support or the delivery of bad news was likely to occur and if all conference participants consented to participate. Fifty conferences were audiotaped, transcribed, and analyzed by using the principles of grounded theory.

RESULTS

We developed 2 frameworks for describing and understanding this communication. The first framework describes communication content, including introductions, information exchange, discussions of the future, and closings. The second framework describes communication styles and support provided to families and other clinicians and includes a variety of techniques such as active listening, acknowledging informational complexity and emotional difficulty of the situation, and supporting family decision making. These frameworks identify what physicians discuss, how they present and respond to issues, and how they support families during these conferences.

CONCLUSIONS

This article describes a qualitative methodology to understand clinician-family communication during the ICU family conference concerning end-of-life care and provides a frame of reference that may help guide clinicians who conduct these conferences. We also identify strategies clinicians use to improve communication and enhance the support provided. Further analyses and studies are needed to identify whether this framework or these strategies can improve family understanding or satisfaction or improve the quality care in the ICU.

Education, ethics, and end-of-life decisions in the intensive care unit

OBJECTIVE

To examine the influence of education and clinical experience on residents' attitudes toward withdrawal of life support.

DESIGN

Self-administered survey.

SETTING

Four Canadian teaching hospitals.

SUBJECTS

Residents rotating through four intensive care units.

MEASUREMENTS AND MAIN RESULTS

The survey examined ethics education and experience regarding end-of-life care, importance of factors influencing withdrawal of life support, confidence in decisions, and recommendations for enhancing end-of-life education. The response rate was 83.9% (52 of 62). A minority of residents reported an appropriate amount of formal teaching on ethical principles (17.3%), patient-centered education (28.8%), and informal discussion (28.8%) before their intensive care unit rotation. During their rotation, most residents cared for patients in whom withdrawal of life support was considered. Although they usually attended family meetings, residents were never (34.6%) or rarely (42.3%) the primary discussant. Before the intensive care unit rotation, confidence in withdrawal decisions was related to male sex (p =.001) and previous patient-centered ethics education (p =.02). At the end of the intensive care unit rotation, only resident involvement in family meetings (p =.02) and being the primary discussant at such meetings (p =.01) were associated with confidence. After we adjusted for pre-rotation confidence in withdrawal of life support decision-making, the only predictor of post-rotation confidence was family meeting involvement (p <.001). Residents recommended more patient-centered discussion, observation of attending physicians discussing end-of-life issues, and opportunity to lead family meetings.

CONCLUSIONS

Experiential, case-based, patient-centered curricula are associated with resident confidence in withdrawal of life support decisions in the intensive care unit.

Factors associated with withdrawal of mechanical ventilation in a neurology/neurosurgery intensive care unit

OBJECTIVE

The objective of this study was to identify factors associated with the decision to withdraw mechanical ventilation from patients in a neurology/neurosurgery intensive care unit. Specifically, the following factors were considered: the severity of the neurologic illness, the healthcare delivery system, and social factors.

DESIGN

Retrospective analysis of prospectively collected clinical database.

SETTING

Neurology/neurosurgery intensive care unit of a large academic tertiary care hospital.

PATIENTS

Patients were 2,109 nonelective admissions to the neurology/neurosurgery intensive care unit who received mechanical ventilation over a period of 82 months.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The average age was 56 +/- 19.7 yrs, 53% were male, and 81% were functionally normal before admission. The median Glasgow Coma Scale score was 14, the average Acute Physiology and Chronic Health Evaluation II severity of illness score was 13.5 +/- 8.3, and probability of death was 18.2 +/- 22.0%. Mechanical ventilation was withdrawn from 284 (13.5%). Factors that were independently associated with withdrawal of mechanical ventilation were as follows: more severe neurologic injury [admission Glasgow Coma Scale score (odds ratio 0.86/point, confidence interval 0.82-0.90), diagnosis of subarachnoid hemorrhage (odds ratio 2.44, confidence interval 1.50-3.99), or ischemic stroke (odds ratio 1.72, confidence interval 1.13-2.60)], older age (odds ratio 1.04/yr, confidence interval 1.03-1.05), and higher Acute Physiology and Chronic Health Evaluation II probability of death (odds ratio 1.03/%, confidence interval 1.02-1.04). Mechanical ventilation was less likely to be withdrawn if patients were African-American (odds ratio 0.50, confidence interval 0.36-0.68) or had undergone surgery (odds ratio 0.44, confidence interval 0.2- 0.67). Marital status, premorbid functional status, clinical service (neurology vs. neurosurgery), attending status (private vs. academic), and type of health insurance were not associated with decisions to withdraw mechanical ventilation.

CONCLUSIONS

We conclude that decisions to withdraw mechanical ventilation in the neurology/neurosurgery intensive care unit are based primarily on the severity of the acute neurologic condition and age but not on characteristics of the healthcare delivery system. Care is less likely to be withdrawn from African-American patients or those who had surgery.

End-of-life care: what do the American courts say?

End-of-life care of critically ill patients generally consists of two closely related practices: the withholding and withdrawal of life support, and the administration of palliative care. In the United States, the withholding or withdrawal of life support is legally justified by the principles of informed consent and informed refusal. The U.S. Supreme Court has held that competent patients may refuse any and all treatments, including those that sustain life. All states sanction such refusal by competent patients, and most states allow surrogates to refuse treatment on behalf of incompetent patients. Although some physicians use the concept of futility to unilaterally withhold or withdraw life support, the Supreme Court has not heard a futility case, and the only clear legal rule on futile treatment is the traditional malpractice test, which measures physician actions against standards of medical care. However, the Supreme Court has furnished guidelines on the administration of palliative care. By using the principle of double effect, these guidelines allow physicians to give sedative and analgesic agents to dying patients if they intend to relieve pain and suffering but not to hasten death.

The family conference as a focus to improve communication about end-of-life care in the intensive care unit: opportunities for improvement

The intensive care unit (ICU) represents a hospital setting in which death and discussion about end-of-life care are common, yet these conversations are often difficult. Such difficulties arise, in part, because a family may be facing an unexpected poor prognosis associated with an acute illness or exacerbation and, in part, because the ICU orientation is one of saving lives. Understanding and improving communication about end-of-life care between clinicians and families in the ICU is an important focus for improving the quality of care in the ICU. This communication often occurs in the "family conference" attended by several family members and members of the ICU team, including physicians, nurses, and social workers. In this article, we review the importance of communication about end-of-life care during the family conference and make specific recommendations for physicians and nurses interested in improving the quality of their communication about end-of-life care with family members. Because excellent end-of-life care is an important part of high-quality intensive care, ICU clinicians should approach the family conference with the same care and planning that they approach other ICU procedures. This article outlines specific steps that may facilitate good communication about end-of-life care in the ICU before, during, and after the conference. The article also provides direction for the future to improve physician-family and nurse-family communication about end-of-life care in the ICU and a research agenda to improve this communication. Research to examine and improve communication about end-of-life care in the ICU must proceed in conjunction with ongoing empiric efforts to improve the quality of care we provide to patients who die during or shortly after a stay in the ICU.

Negotiating natural death in intensive care

Recent empirical evidence of barriers to palliative care in acute hospital settings shows that dying patients may receive invasive medical treatments immediately before death, in spite of evidence of their poor prognosis being available to clinicians. The difficulties of ascertaining treatment preferences, predicting the trajectory of dying in critically ill people, and assessing the degree to which further interventions are futile are well documented. Further, enduring ethical complexities attending end of life care mean that the process of withdrawing or withholding medical care is associated with significant problems for clinical staff. Specific difficulties attend the legitimation of treatment withdrawal, the perceived differences between 'killing' and 'letting die' and the cultural constraints which attend the orchestration of 'natural' death in situations where human agency is often required before death can follow dying. This paper draws on ethnographic research to examine the way in which these problems are resolved during medical work within intensive care. Building on insights from the literature, an analysis of observational case study data is presented which suggests that the negotiation of natural death in intensive care hinges upon four strategies. These, which form a framework with which to interpret social interaction between physicians during end of life decision-making in intensive care, are as follows: firstly, the establishment of a 'technical' definition of dying--informed by results of investigations and monitoring equipment--over and above 'bodily' dying informed by clinical experience. Secondly, the alignment of the trajectories of technical and bodily dying to ensure that the events of non-treatment have no perceived causative link to death. Thirdly, the balancing of medical action with non-action, allowing a diffusion of responsibility for death to the patient's body; and lastly, the incorporation of patient's companions and nursing staff into the decision-making process.

Death in two Canadian intensive care units: institutional difference and changes over time

OBJECTIVE

To study and compare the mode of death in two different institutions' intensive care units (ICUs) for the two time periods, 1988 and 1993.

DESIGN

Retrospective chart review.

SETTING

Medical/surgical/trauma ICUs in two tertiary care teaching hospitals.

PATIENTS

Patients dying in the medical/surgical/trauma ICUs between January 1, 1988 and December 31, 1988; and January 1, 1993 and December 31, 1993. Data collection included demographics, origin of admission, date of ICU admission, date of death, Acute Physiology and Chronic Health Evaluation (APACHE) III diagnostic categories, APACHE II physiologic variables, organ system failures present at the time of admission and 24 hrs before death, and mode of dying. APACHE II scores and mortality risk were calculated. Data analysis included a multiple analysis of variance to assess overall effect, with subsequent analyses of variance to assess the effect of institution and year on each individual dependent variable. All results are reported as mean +/- SEM values.

RESULTS

A total of 439 charts were reviewed. Gender, age, and origin of admission were not different between the 2 yrs or the two institutions. Mean APACHE II scores and organ system failures were lower at Hospital A in 1998 vs. Hospital B, as was predicted mortality. These factors increased at Hospital A in 1993 and were similar to those at Hospital B. Withdrawal of support was much more common in 1993 than 1988 at both institutions (43% at Hospital A and 46% at Hospital B in 1988 vs. 66% at A and 80% at B in 1993), increasing to a greater extent in 1993 at Hospital B (p<.05). Length of stay in the ICU was significantly longer at Hospital A than at Hospital B in 1988 (9.4+/-1.4 vs. 4.3+/-0.6 days; p<.05) and in 1993 (8.2+/-2.9 vs. 3.8+/-0.5 days; p < .05).

CONCLUSIONS

There has been an increase in withdrawal of life support, in recent years, at both the institutions studied. Differences exist between institutions with respect to end-of-life decisions in the ICU. These differences are likely representative of widely prevalent regional differences and are the result of many factors.

Incorporating palliative care into critical care education: principles, challenges, and opportunities

OBJECTIVE

To identify the goals and methods for medical education about end-of-life care in the intensive care unit (ICU).

DATA SOURCES AND STUDY SELECTION

A status report on palliative care, a summary report of recent research on palliative care education, articles in the medical literature on end-of-life care and critical care, and expert opinion were considered.

DATA EXTRACTION

A working group, including specialists in critical care, palliative care, medical ethics, consumer advocacy, and communications, was convened at the "Medical Education for Care Near the End of Life National Consensus Conference." A modified nominal group process was used to develop a consensus.

DATA SYNTHESIS

In the ICU, life and death decisions are often made in a crisis mode or in the face of uncertainty, and may necessitate the withholding and withdrawal of life-supporting technologies. Because critical illness often diminishes the capacity of patients to make decisions, clinicians must often make decisions in conjunction with surrogates, rather than with patients. Discontinuity of care can threaten trusting relationships, and cultural diversity can have a particularly powerful impact on choices for care. In the face of these realities, it is possible and appropriate to give compassionate palliative care to dying patients and their families in the ICU.

CONCLUSIONS

Teaching care of the dying in the ICU should emphasize the following: a) the goals of care should guide the use of technology; b) understanding of prognostication and treatment withholding and withdrawal is essential; c) effective communication and trusting relationships are crucial to good care; d) cultural differences should be acknowledged and respected; and e) the delivery of excellent palliative care is appropriate and necessary when patients die in the ICU.

Revisiting medicalisation and 'natural' death

The contemporary conceptualisation of natural death in social science and health care literature may be seen as elision of potentially paradoxical ideas in which the process of dying, as opposed to the moment of death, is a key determinant of the manner in which death is regarded. In the predominant rhetoric, medical-technological intervention during dying is emblematic of inhumane and unnatural death. Highly technological clinical settings, where medical intervention in the process of dying is so clearly visible, are held up as extreme examples of the metamorphosis of death from 'natural' into 'unnatural' events. This paper examines the reification of 'natural' death within these writings, focusing on the taken for granted polarisation of technology and 'natural' death with which they are underpinned. The paper then turns to an assessment of the validity of this reification by examining some ethnographic case study data concerning the experiences of the close companions of three people who died, or came near to death, within intensive care: arguably an environment in which death is at its most highly medicalised. The data, which are drawn from a wider ethnography of death and dying in two general adult intensive care units, suggest that it is perceptions of the meaning of technology, rather than its simple minimisation or absence, which determine representations of death within highly technological settings. These perceptions in their turn depend crucially on the circumstances with which dying is attended. In this study the 'natural' process of death was preserved for the companions of dying people when medical technology delivered the outcomes they expected, appeared to be amenable to human manipulation and intention, was accessible to their understanding and seemed to 'fit' with the wider context of the dying person's life. The paper concludes by arguing that it is within the phenomenology of suffering associated with the critical illness or death of a close companion that some insights may be gleaned of the relationship between individual experience, the cultural representation of 'natural' death, and the attitudinal ambivalence with which medical technology is surrounded.

Should the ventilator be withdrawn? Attitudes of the general public, nurses and physicians

In a Swedish nation-wide study, 1196 members of the general public, and 121 physicians and 339 nurses drawn from 29 intensive care units were questioned about the use of ventilator treatment for severely ill patients. Response rates were 64%, 88% and 86%, respectively. Two typical case history scenarios were presented: one describing a conscious and competent patient with pneumonia and severe cancer, and the other describing a patient who had been comatose for 1 month following head trauma. In the case of the cancer patient, 49% of the general public, 63% of the physicians and 59% of the nurses answered that they would wish that the ventilator treatment be discontinued, if they were the patient. In the case of the comatose patient, 48% of the general public, 82% of the physicians and 70% of the nurses answered that they would wish that the ventilator treatment to be discontinued, if they were a relative of the patient. Respondents own preferences, in the three groups, for life support favoured withdrawal of ventilator treatment.

Forgoing life support in western European intensive care units: the results of an ethical questionnaire

OBJECTIVE

To determine current views of European intensive care physicians regarding end-of-life decisions.

DESIGN

A questionnaire was sent to all physician members of the European Society of Intensive Care Medicine. All questionnaires were anonymous.

RESULTS

A total of 504 completed questionnaires from 16 western European countries were analyzed. Eighty-seven percent of the respondents were male. Forty-six percent of respondents said that intensive care unit admissions were generally or commonly affected by bed shortages, particularly in the south. Nevertheless, 73% of units frequently admit patients with no hope of survival, although only 33% of respondents felt that such patients should be admitted. Eighty percent of respondents felt that written do-not-resuscitate orders should be applied, but only 58% did so, with a wide variation according to country (from 8% in Italy to 91% in The Netherlands). Ninety-three percent of physicians sometimes withhold treatment from patients with no hope of a meaningful life, but withdrawal of treatment is less common. Forty percent of respondents said that they would deliberately administer large doses of drugs to such patients until death ensued. Forty-nine percent of respondents involved staff, patients, and family in end-of-life decisions. Forty-five percent of respondents felt that an ethics consultation was useful in such situations. Physicians in the countries of southern Europe were less likely than those in the north to apply do-not-resuscitate orders, withhold treatment, and discuss such issues with the patients. However, they were more likely to value the opinion of an ethics consultant.

CONCLUSIONS

Intensive care unit admissions are frequently limited by the availability of beds across Europe, particularly in the south and in the United Kingdom, yet 73% of intensivists still admit patients with no hope of survival. When treating patients with no hope of survival, 40% of intensivists will deliberately administer large doses of drugs until death ensues. There are interesting differences between what a physician actually does and what he or she believes should be done with regard to various ethical questions. Important differences in attitudes also exist between European countries.

Ethnicity and attitudes towards life sustaining technology

The ethical and legal implications of decisions to withhold and withdraw life support have been widely debated. Making end-of-life decisions is never easy, and when the cultural background of doctor and patient differ, communication about these issues may become even more difficult. In this study, we examined the attitudes of people aged 65 and older from different ethnic groups toward foregoing life support. To this end, we conducted a survey of 200 respondents from each of four ethnic groups: European-American, African-American, Korean-American and Mexican-American (800 total), followed by in-depth ethnographic interviews with 80 respondents. European-Americans were the least likely to both accept and want life-support (p < 0.001). Mexican-Americans were generally more positive about the use of life-support and were more likely to personally want such treatments (p < 0.001). Ethnographic interviews revealed that this was due to their belief that life-support would not be suggested if a case was truly hopeless. Compared to European-Americans, Korean-Americans were very positive regarding life-support (RR = 6.7, p < 0.0001); however, they did not want such technology personally (RR = 1.2, p = 0.45). Ethnographic interviews revealed that the decision of life support would be made by their family. Compared to European-Americans, African-Americans felt that it was generally acceptable to withhold or withdraw life-support (RR = 1.6, p = 0.06), but were the most likely to want to be kept alive on life-support (RR = 2.1, p = 0.002). Ethnographic interviews documented a deep distrust towards the health care system and a fear that health care was based on one's ability to pay. We concluded that (a) ethnicity is strongly related to attitudes toward and personal wishes for the use of life support in the event of coma or terminal illness, and (b) this relationship was complex and in some cases, contradictory.

Withdrawal of life support in the neurological intensive care unit

OBJECTIVE

To describe the frequency and clinical course of terminal extubation in the neurological intensive care unit, to identify factors that influence the decision to withdraw life support, and to evaluate the experiences of surrogate decision-makers.

BACKGROUND

The right of patients to refuse life-prolonging treatment is widely accepted. However, it is unknown how frequently critically ill neurologic patients are removed from life support, and practice guidelines for withdrawing mechanical ventilation remain poorly defined.

METHODS

We reviewed the medical records of all patients cared for by the Columbia-Presbyterian neurocritical care service over a 3-year period who died, and identified a subgroup of non-brain-dead patients who were terminally extubated. We retrospectively analyzed the clinical course of these patients and interviewed their surrogate decision-makers.

RESULTS

Of 74 non-brain-dead patients, 32 (43%) were terminally extubated. Hispanic and white patients were more likely to be extubated than were African American patients (p = 0.02). The median duration of survival after extubation was 7.5 hours; 25% died within 1 hour, and 69% within 24 hours. Depth of coma did not predict the duration of survival after extubation. The most frequent signs after extubation were agonal or labored breathing (59%) and tachypnea (34%). Morphine or fentanyl was given to relieve respiratory distress in 68% of cases; the average dose of morphine was 6.3 mg/hour (range 2.5 to 20 mg/hour). In a structured interview of 24 surrogate decision-makers, 88% were satisfied or very satisfied with the overall process, and 75% felt the patient suffered minimally before death; all but one (96%) said that they would repeat the decision to withdraw life support.

CONCLUSIONS

Forty-three percent of our non-brain-dead patients who died were terminally extubated. The duration of survival after extubation exceeded 24 hours in one third, and was not predicted by level of consciousness. Two thirds of patients were treated with opioids for agonal respiratory distress. Most surrogate decision-makers were comfortable and satisfied with the process of withdrawing care.