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Harrison BH, DeGennaro R, Wiencek C. Innovative Strategies for Palliative Care in the Intensive Care Unit. AACN Adv Crit Care 2024; 35:157-167. [PMID: 38848573 DOI: 10.4037/aacnacc2024761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024]
Abstract
Palliative care is interdisciplinary care that addresses suffering and improves the quality of care for patients and families when patients are facing a life-threatening illness. Palliative care needs in the intensive care unit include communication regarding diagnosis and prognosis, goals-of-care conversations, multidimensional pain and symptom management, and end-of-life care that may include withdrawal of mechanical ventilation and life support. Registered nurses spend the greatest amount of time with patients and families who are facing death and serious illness, so nurses must be armed with adequate training, knowledge, and necessary tools to address patient and caregiver needs and deliver high-quality, patient-centered palliative care. Innovative approaches to integrating palliative care are important components of care for intensive care nurses. This article reviews 2 evidence-based practice projects, a serious illness support tool and the 3 Wishes Project, to add to the palliative care toolkit for registered nurses and other team members.
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Affiliation(s)
- Brittany H Harrison
- Brittany H. Harrison is Nurse Practitioner, University of Virginia (UVA) Health, 1215 Lee St, Charlottesville, VA 22901
| | - Regina DeGennaro
- Regina DeGennaro is Professor of Nursing, UVA School of Nursing, Charlottesville, Virginia
| | - Clareen Wiencek
- Clareen Wiencek is Professor of Nursing, UVA School of Nursing, Charlottesville, Virginia
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2
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Pringle CP, Filipp SL, Morrison WE, Fainberg NA, Aczon MD, Avesar M, Burkiewicz KF, Chandnani HK, Hsu SC, Laksana E, Ledbetter DR, McCrory MC, Morrow KR, Noguchi AE, O'Brien CE, Ojha A, Ross PA, Shah S, Shah JK, Siegel LB, Tripathi S, Wetzel RC, Zhou AX, Winter MC. Ventilator Weaning and Terminal Extubation: Withdrawal of Life-Sustaining Therapy in Children. Secondary Analysis of the Death One Hour After Terminal Extubation Study. Crit Care Med 2024; 52:396-406. [PMID: 37889228 PMCID: PMC10922051 DOI: 10.1097/ccm.0000000000006101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
OBJECTIVE Terminal extubation (TE) and terminal weaning (TW) during withdrawal of life-sustaining therapies (WLSTs) have been described and defined in adults. The recent Death One Hour After Terminal Extubation study aimed to validate a model developed to predict whether a child would die within 1 hour after discontinuation of mechanical ventilation for WLST. Although TW has not been described in children, pre-extubation weaning has been known to occur before WLST, though to what extent is unknown. In this preplanned secondary analysis, we aim to describe/define TE and pre-extubation weaning (PW) in children and compare characteristics of patients who had ventilatory support decreased before WLST with those who did not. DESIGN Secondary analysis of multicenter retrospective cohort study. SETTING Ten PICUs in the United States between 2009 and 2021. PATIENTS Nine hundred thirteen patients 0-21 years old who died after WLST. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS 71.4% ( n = 652) had TE without decrease in ventilatory support in the 6 hours prior. TE without decrease in ventilatory support in the 6 hours prior = 71.4% ( n = 652) of our sample. Clinically relevant decrease in ventilatory support before WLST = 11% ( n = 100), and 17.6% ( n = 161) had likely incidental decrease in ventilatory support before WLST. Relevant ventilator parameters decreased were F io2 and/or ventilator set rates. There were no significant differences in any of the other evaluated patient characteristics between groups (weight, body mass index, unit type, primary diagnostic category, presence of coma, time to death after WLST, analgosedative requirements, postextubation respiratory support modality). CONCLUSIONS Decreasing ventilatory support before WLST with extubation in children does occur. This practice was not associated with significant differences in palliative analgosedation doses or time to death after extubation.
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Affiliation(s)
- Charlene P Pringle
- Department of Pediatrics, Critical Care Medicine, University of Florida, Gainesville, FL
| | - Stephanie L Filipp
- Department of Pediatrics, Pediatric Research Hub, University of Florida Gainesville, FL
| | - Wynne E Morrison
- Department of Pediatrics, Critical Care Medicine, University of Florida, Gainesville, FL
- Department of Pediatrics, Pediatric Research Hub, University of Florida Gainesville, FL
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania Philadelphia, PA
- Justin Michael Ingerman Center for Palliative Care, Children's Hospital of Philadelphia Philadelphia, PA
- Division of Pediatric Critical Care, Children's Hospital of Philadelphia Philadelphia, PA
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles Los Angeles, CA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
- Division of Pediatric Critical Care Medicine, Loma Linda University Children's Hospital, Loma Linda, CA
- Pediatric Intensive Care, OSF HealthCare, Children's Hospital of Illinois, Peoria, IL Peoria, IL
- Division of Critical Care Medicine, Department of Pediatrics, Dallas, TX
- The University of Texas Southwestern Medical Center at Dallas, Children's Health Medical Center Dallas Dallas, TX
- KPMG Lighthouse, Dallas, TX
- Departments of Anesthesiology and Pediatrics, Wake Forest University School of Medicine, Winston Salem, NC
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
- Program Coordinator for Organ, Eye, and Tissue Donation Johns Hopkins Hospital, Baltimore, MD
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
- Michigan State University College of Human Medicine, East Lansing, MI
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
- Division of Pediatric Critical Care, Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA
- Division of Pediatric Critical Care Medicine, Cohen Children's Medical Center, New Hyde Park, NY
| | - Nina A Fainberg
- Division of Pediatric Critical Care, Children's Hospital of Philadelphia Philadelphia, PA
| | - Melissa D Aczon
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles Los Angeles, CA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
| | - Michael Avesar
- Division of Pediatric Critical Care Medicine, Loma Linda University Children's Hospital, Loma Linda, CA
| | - Kimberly F Burkiewicz
- Pediatric Intensive Care, OSF HealthCare, Children's Hospital of Illinois, Peoria, IL Peoria, IL
| | - Harsha K Chandnani
- Division of Pediatric Critical Care Medicine, Loma Linda University Children's Hospital, Loma Linda, CA
| | - Stephanie C Hsu
- Division of Critical Care Medicine, Department of Pediatrics, Dallas, TX
- The University of Texas Southwestern Medical Center at Dallas, Children's Health Medical Center Dallas Dallas, TX
| | - Eugene Laksana
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles Los Angeles, CA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
| | | | - Michael C McCrory
- Departments of Anesthesiology and Pediatrics, Wake Forest University School of Medicine, Winston Salem, NC
| | - Katie R Morrow
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Anna E Noguchi
- Program Coordinator for Organ, Eye, and Tissue Donation Johns Hopkins Hospital, Baltimore, MD
| | - Caitlin E O'Brien
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Apoorva Ojha
- Michigan State University College of Human Medicine, East Lansing, MI
| | - Patrick A Ross
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles Los Angeles, CA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Sareen Shah
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
- Division of Pediatric Critical Care, Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jui K Shah
- Division of Pediatric Critical Care Medicine, Loma Linda University Children's Hospital, Loma Linda, CA
| | - Linda B Siegel
- Division of Pediatric Critical Care Medicine, Cohen Children's Medical Center, New Hyde Park, NY
| | - Sandeep Tripathi
- Pediatric Intensive Care, OSF HealthCare, Children's Hospital of Illinois, Peoria, IL Peoria, IL
| | - Randall C Wetzel
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles Los Angeles, CA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Alice X Zhou
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles Los Angeles, CA
- Laura P. and Leland K. Whittier Virtual Pediatric Intensive Care Unit, Los Angeles, CA
| | - Meredith C Winter
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles Los Angeles, CA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA
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Harrison BH, Hundt E, Wiencek C. Use of the 3 Wishes Project to Help Individualize End-of-Life Care in a Medical Intensive Care Unit. Am J Crit Care 2024; 33:9-17. [PMID: 38161175 DOI: 10.4037/ajcc2024985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
BACKGROUND Multiple organizations recommend that individualized end-of-life (EOL) care should be standard practice. However, a standardized approach does not exist because EOL care should be individually tailored. The 3 Wishes Project is an EOL intervention that provides direction for individualized care with 3 goals: dignify death, celebrate the patient's life, and support family members and the intensive care unit clinicians caring for the patient. Patients and families are given the opportunity to choose 3 wishes during the dying process. OBJECTIVE To ascertain if the implementation of the 3 Wishes Project allowed the medical team to provide individualized EOL care. METHODS The Iowa Model was used for this evidence-based project. The project was implemented in the medical intensive care unit at an academic medical center. Outcomes were evaluated by the collection and analysis of qualitative and quantitative data. RESULTS From the 57 patients who died during the 2-month implementation period, 32 wish forms were collected; 31 patients participated and 1 declined. Overall participation among patients was 56%. The top 5 wishes were cloth hearts, blankets, heartbeat printouts, fingerprints and handprints, and music. The total cost was $992, and the average cost per wish was $6.98. Eighty-five percent (33 of 39) of the respondents to the medical team survey indicated that they either agreed or strongly agreed that the project allowed the medical team to consistently provide individualized EOL care. CONCLUSIONS The survey data support the 3 Wishes Project as a method that allowed the medical team to individualize EOL care and as a valuable tool for incorporation at the bedside.
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Affiliation(s)
- Brittany H Harrison
- Brittany H. Harrison completed her DNP at University of Virginia School of Nursing and is a nurse practitioner, University of Virginia Health, Charlottesville, Virginia
| | - Elizabeth Hundt
- Elizabeth Hundt is an assistant professor of nursing, University of Virginia School of Nursing, Charlottesville
| | - Clareen Wiencek
- Clareen Wiencek is a professor of nursing, University of Virginia School of Nursing, Charlottesville
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Kumar A, Sinha S, Mani RK. A Survey for Assessment of Practical Aspects of End-of-life Practices across Indian Intensive Care Units. Indian J Crit Care Med 2023; 27:531-536. [PMID: 37636851 PMCID: PMC10452772 DOI: 10.5005/jp-journals-10071-24500] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 07/13/2023] [Indexed: 08/29/2023] Open
Abstract
Background The end-of-life (EOL) decisions continue to be debated for their moral and legal standing. The acceptance of these decisions varies, based upon the perceptions and personal choices of the intensivists. Materials and methods An online questionnaire-based survey was designed and circulated among the practicing intensivists via Indian Society of Critical Care Medicine (ISCCM) e-mail. Results Out of 200 responses, 165 (82.5%) affirmed that EOL decisions are routinely undertaken in their intensive care units. The most prevalent reasons expressed for avoidance of EOL decisions are moral and ethical dilemmas and fear of litigation. There is notable variability in the practice of withholding (47.7%) vs withdrawal (3.5%) of therapies. A good proportion of intensivists follow do-not-intubate (91%) and do-not-resuscitate (86%) orders, whereas only 18% affirmed to be practicing terminal extubation. About 93% of the respondents acknowledged the use of monitoring toward the EOL, and 49% reported the use of preformatted documents. A meager 2% admitted to facing a medicolegal issue after taking an EOL decision. Conclusion The survey establishes a general acceptance among the Indian intensivists regarding providing compassionate care to terminally ill patients, especially toward the EOL. The pattern of responses, however, indicates significant dilemmas and hesitancy with regard to the decision-making process. How to cite this article Kumar A, Sinha S, Mani RK. A Survey for Assessment of Practical Aspects of End-of-life Practices across Indian Intensive Care Units. Indian J Crit Care Med 2023;27(8):531-536.
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Affiliation(s)
- Arun Kumar
- Department of Intensive Care, Medical Intensive Care Unit, Fortis Healthcare Ltd., Mohali, Punjab, India
| | - Sharmili Sinha
- Department of Critical Care Medicine, Apollo Hospitals, Bhubaneswar, Odisha, India
| | - Raj Kumar Mani
- Department of Critical Care and Pulmonology, Yashoda Super Specialty Hospital, Ghaziabad, Uttar Pradesh, India
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Downar J, Hua M, Wunsch H. Palliative Care in the Intensive Care Unit: Past, Present, and Future. Crit Care Clin 2023; 39:529-539. [PMID: 37230554 DOI: 10.1016/j.ccc.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
In this article, the authors review the origins of palliative care within the critical care context and describe the evolution of symptom management, shared decision-making, and comfort-focused care in the ICU from the 1970s to the early 2000s. The authors also review the growth of interventional studies in the past 20 years and indicate areas for future study and quality improvement for end-of-life care among the critically ill.
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Affiliation(s)
- James Downar
- Division of Palliative Care, Department of Medicine, University of Ottawa, 43 Rue Bruyere, Suite 268J, Ottawa K1N 5C8, Canada; Department of Critical Care, The Ottawa Hospital, 1053 Carling Avenue, Ottawa, ON K1Y 4E9, Canada.
| | - May Hua
- Department of Anesthesiology, Columbia University, 622 West 168th Street, New York, NY 10032, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 West 168th Street, New York, NY 10032, USA
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada; Department of Anesthesiology and Pain Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, 2075 Bayview Avenue, Room D1.08, Toronto, Ontario M4N 3M5, Canada
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Gouda SR, Hoehn KS. Why the Individual Provider Approach to Pediatric Palliative Care Consultation Exacerbates Healthcare Disparities: A Moral Argument for Standard Referral Criteria. THE JOURNAL OF CLINICAL ETHICS 2022. [DOI: 10.1086/jce2022334352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Tong W, Murali KP, Fonseca LD, Blinderman CD, Shelton RC, Hua M. Interpersonal Conflict between Clinicians in the Delivery of Palliative and End-of-Life Care for Critically Ill Patients: A Secondary Qualitative Analysis. J Palliat Med 2022; 25:1501-1509. [PMID: 35363575 PMCID: PMC9529295 DOI: 10.1089/jpm.2021.0631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2022] [Indexed: 11/12/2022] Open
Abstract
Background: Conflict between clinicians is prevalent within intensive care units (ICUs) and may hinder optimal delivery of care. However, little is known about the sources of interpersonal conflict and how it manifests within the context of palliative and end-of-life care delivery in ICUs. Objective: To characterize interpersonal conflict in the delivery of palliative care within ICUs. Design: Secondary thematic analysis using a deductive-inductive approach. We analyzed existing qualitative data that conducted semistructured interviews to examine factors associated with variable adoption of specialty palliative care in ICUs. Settings/Subjects: In the parent study, 36 participants were recruited from two urban academic medical centers in the United States, including ICU attendings (n = 17), ICU nurses (n = 11), ICU social workers (n = 1), and palliative care providers (n = 7). Measurements: Coders applied an existing framework of interpersonal conflict to guide initial coding and analysis, combined with a flexible inductive approach allowing new codes to emerge. Results: We characterized three properties of interpersonal conflict: disagreement, interference, and negative emotion. In the context of delivering palliative and end-of-life care for critically ill patients, "disagreement" centered around whether patients were appropriate for palliative care, which care plans should be prioritized, and how care should be delivered. "Interference" involved preventing palliative care consultation or goals-of-care discussions and hindering patient care. "Negative emotion" included occurrences of silencing or scolding, rudeness, anger, regret, ethical conflict, and grief. Conclusions: Our findings provide an in-depth understanding of interpersonal conflict within palliative and end-of-life care for critically ill patients. Further study is needed to understand how to prevent and resolve such conflicts.
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Affiliation(s)
- Wendy Tong
- Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Komal P. Murali
- School of Nursing, Columbia University, New York, New York, USA
| | - Laura D. Fonseca
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Craig D. Blinderman
- Adult Palliative Care Service, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Rachel C. Shelton
- Department of Sociomedical Sciences and Columbia University Mailman School of Public Health, New York, New York, USA
| | - May Hua
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York, USA
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Andersen SK, Vincent G, Butler RA, Brown EHP, Maloney D, Khalid S, Oanesa R, Yun J, Pidro C, Davis VN, Resick J, Richardson A, Rak K, Barnes J, Bezak KB, Thurston A, Reitschuler-Cross E, King LA, Barbash I, Al-Khafaji A, Brant E, Bishop J, McComb J, Chang CCH, Seaman J, Temel JS, Angus DC, Arnold R, Schenker Y, White DB. ProPACC: Protocol for a Trial of Integrated Specialty Palliative Care for Critically Ill Older Adults. J Pain Symptom Manage 2022; 63:e601-e610. [PMID: 35595373 PMCID: PMC9299559 DOI: 10.1016/j.jpainsymman.2022.02.344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Each year, approximately one million older adults die in American intensive care units (ICUs) or survive with significant functional impairment. Inadequate symptom management, surrogates' psychological distress and inappropriate healthcare use are major concerns. Pioneering work by Dr. J. Randall Curtis paved the way for integrating palliative care (PC) specialists to address these needs, but convincing proof of efficacy has not yet been demonstrated. DESIGN We will conduct a multicenter patient-randomized efficacy trial of integrated specialty PC (SPC) vs. usual care for 500 high-risk ICU patients over age 60 and their surrogate decision-makers from five hospitals in Pennsylvania. INTERVENTION The intervention will follow recommended best practices for inpatient PC consultation. Patients will receive care from a multidisciplinary SPC team within 24 hours of enrollment that continues until hospital discharge or death. SPC clinicians will meet with patients, families, and the ICU team every weekday. SPC and ICU clinicians will jointly participate in proactive family meetings according to a predefined schedule. Patients in the control arm will receive routine ICU care. OUTCOMES Our primary outcome is patient-centeredness of care, measured using the modified Patient Perceived Patient-Centeredness of Care scale. Secondary outcomes include surrogates' psychological symptom burden and health resource utilization. Other outcomes include patient survival, as well as interprofessional collaboration. We will also conduct prespecified subgroup analyses using variables such as PC needs, measured by the Needs of Social Nature, Existential Concerns, Symptoms, and Therapeutic Interaction scale. CONCLUSIONS This trial will provide robust evidence about the impact of integrating SPC with critical care on patient, family, and health system outcomes.
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Affiliation(s)
- Sarah K Andersen
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Grace Vincent
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Rachel A Butler
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Elke H P Brown
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Dave Maloney
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Sana Khalid
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Rae Oanesa
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - James Yun
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Carrie Pidro
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Valerie N Davis
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Judith Resick
- Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics (J.R., K.B.B., R.A., Y.S.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Aaron Richardson
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Kimberly Rak
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jackie Barnes
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Karl B Bezak
- Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics (J.R., K.B.B., R.A., Y.S.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Andrew Thurston
- Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Eva Reitschuler-Cross
- Department of Medicine, Division of General Internal Medicine (E.R.-C., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Linda A King
- Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ian Barbash
- Department of Critical Care Medicine (I.B., A.-K., E.B., J.B.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Department of Medicine, Division of Pulmonary, Allergy and Critical Care (I.B., J.M.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ali Al-Khafaji
- Department of Critical Care Medicine (I.B., A.-K., E.B., J.B.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Emily Brant
- Department of Critical Care Medicine (I.B., A.-K., E.B., J.B.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jonathan Bishop
- Department of Critical Care Medicine (I.B., A.-K., E.B., J.B.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jennifer McComb
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care (I.B., J.M.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Chung-Chou H Chang
- Department of Medicine, Division of General Internal Medicine (E.R.-C., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jennifer Seaman
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Acute and Tertiary Care (J.S.), University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA
| | - Jennifer S Temel
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston (J.S.T.), Massachusetts, USA
| | - Derek C Angus
- The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Robert Arnold
- Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA; The CRISMA Center, Department of Critical Care Medicine (I.B., C.-C.H.C.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Yael Schenker
- Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Department of Medicine, Division of General Internal Medicine, Section of Palliative Care and Medical Ethics (J.R., K.B.B., R.A., Y.S.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Douglas B White
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine (S.K.A., G.V., R.A.B., E.H.P.B., D.M., S.K., R.O., J.S., D.B.W.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Palliative Research Center (PaRC) (R.A.B., J.R., K.B.B., A.T., L.A.K., J.S., R.A., Y.S., D.B.W.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
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9
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Palliative Care Utilization Following Out-of-Hospital Cardiac Arrest in Pediatrics. Crit Care Explor 2022; 10:e0639. [PMID: 35211682 PMCID: PMC8860333 DOI: 10.1097/cce.0000000000000639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES: Pediatric out-of-hospital cardiac arrest (OHCA) is associated with significant morbidity and mortality. Pediatric palliative care (PPC) services could provide an integral component of the comprehensive care necessary for these patients and their families. The main objectives of this study are to examine the utilization of PPC following OHCA and compare the differences in characteristics between children who received PPC with those who did not. DESIGN: Retrospective cohort study. SETTING: An urban, tertiary PICU. PATIENTS: Children less than 21 years old admitted from October 2009 to October 2019 with an admitting diagnosis of OHCA and minimum PICU length of stay (LOS) of 48 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 283 patient charts reviewed, 118 patient encounters met inclusion criteria. Of those, 34 patients (28.8%) received a PPC consultation during hospitalization. Patients who received PPC had a longer PICU LOS (14.5 vs 4.0 d), a greater number of ventilator days (12.5 vs 4.0 d), and a larger proportion of do-not-resuscitate (DNR) statuses (41% vs 19%). When comparing the disposition of survivors, a greater proportion was discharged to rehab or nursing facilities (47% vs 28%), with no difference in mortality rates (53% vs 50%). In the multivariate logistic regression model, older age, longer LOS, and code status (DNR) were all associated with higher likelihood of PPC utilization. Data were analyzed using descriptive, Mann-Whitney U, and Fisher exact statistics. CONCLUSIONS: Our study demonstrates PPC services following OHCA are underutilized given the high degree of morbidity and mortality. The impact of automatic PPC consultation in all OHCA patients who survive beyond 48 hours should be explored further. Future studies are warranted to understand the benefits and barriers of PPC integration into standard postarrest care for patients and families.
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10
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Palma A, Aliaga-Castillo V, Bascuñan L, Rojas V, Ihl F, Medel JN. An Intensive Care Unit Team Reflects on End-of-Life Experiences With Patients and Families in Chile. Am J Crit Care 2022; 31:24-32. [PMID: 34972854 DOI: 10.4037/ajcc2022585] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Deaths in the intensive care unit (ICU) represent an experience of suffering for patients, their families, and professionals. End-of-life (EOL) care has been added to the responsibilities of the ICU team, but the evidence supporting EOL care is scarce, and there are many barriers to implementing the clinical recommendations that do exist. OBJECTIVES To explore the experiences and perspectives of the various members of an ICU care team in Chile regarding the EOL care of their patients. METHODS A qualitative study was performed in the ICU of a high-complexity academic urban hospital. The study used purposive sampling with focus groups as a data collection method. A narrative analysis based on grounded theory was done. RESULTS Four discipline-specific focus groups were conducted; participants included 8 nurses, 6 nursing assistants, 8 junior physicians, and 6 senior physicians. The main themes that emerged in the analysis were emotional impact and barriers to carrying out EOL care. The main barriers identified were cultural difficulties related to decision-making, lack of interprofessional clinical practice, and lack of effective communication. Communication difficulties within the team were described along with lack of self-efficacy for family-centered communication. CONCLUSION These qualitative findings expose gaps in care that must be filled to achieve high-quality EOL care in the ICU. Significant emotional impact, barriers related to EOL decision-making, limited interprofessional clinical practice, and communication difficulties were the main findings cross-referenced.
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Affiliation(s)
- Alejandra Palma
- Alejandra Palma is a palliative care physician, Departamento de Medicina Interna Norte, Sección de Cuidados Continuos y Paliativos, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Verónica Aliaga-Castillo
- Verónica Aliaga-Castillo is a physical therapist, Departamento de Kinesiología, Facultad de Medicina, Univer sidad de Chile, Santiago, Chile
| | - Luz Bascuñan
- Luz Bascuñan is a psychologist, Departamento de Bioética y Humanidades Médicas, Facultad de Medicina, Universidad de Chile
| | - Verónica Rojas
- Verónica Rojas is a licensed nurse, Departamento de Medicina Interna Norte, Unidad de Pacientes Críticos, Hospital Clínico Universidad de Chile, and Proyecto Internacional de Investigación para la Humaniza ción de los Cuidados Intensivos (Proyecto HU-CI), España
| | - Fernando Ihl
- Fernando Ihl is a palliative care physician, Departamento de Medicina Interna Norte, Sección de Cuidados Continuos y Paliativos, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Juan Nicolás Medel
- Juan Nicolás Medel is a critical care physician, Departa mento de Medicina Interna Norte, Unidad de Pacientes Críti cos, Hospital Clínico Universidad de Chile
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11
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Hastening Death in Canadian ICUs: End-of-Life Care in the Era of Medical Assistance in Dying. Crit Care Med 2021; 50:742-749. [PMID: 34605780 DOI: 10.1097/ccm.0000000000005359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Since 2016, Canada has allowed for euthanasia based on strict criteria under federal medical assistance in dying legislation. The purpose of this study was to determine how Canadian intensivists perceive medical assistance in dying and whether they believe their approach to withdrawal of life-sustaining therapies has changed following introduction of medical assistance in dying. DESIGN Electronic survey. SETTING Participants were recruited from 11 PICU programs and 14 adult ICU programs across Canada. All program leaders for whom contact information was available were approached for participation. PARTICIPANTS We invited intensivists and critical care trainees employed between December 2019 and May 2020 to participate using a snowball sampling technique in which department leaders distributed study information. All responses were anonymous. Quantitative data were analyzed using descriptive statistics. Categorical variables were analyzed using Pearson chi-square test. INTERVENTIONS Not applicable. MEASUREMENTS AND MAIN RESULTS We obtained 150 complete questionnaires (33% response rate), of which 50% were adult practitioners and 50% pediatric. Most were from academic centers (81%, n = 121). Of respondents, 86% (n = 130) were familiar with medical assistance in dying legislation, 71% in favor, 14% conflicted, and 11% opposed. Only 5% (n = 8) thought it had influenced their approach to withdrawal of life-sustaining therapies. Half of participants had no standardized protocol for withdrawal of life-sustaining therapies in their unit, and 41% (n = 62) had observed medications given in disproportionately high doses during withdrawal of life-sustaining therapies, with 13% having personally administered such doses. Most (80%, n = 120) had experienced explicit requests from families to hasten death, and almost half (47%, n = 70) believed it was ethically permissible to intentionally hasten death following withdrawal of life-sustaining therapies. CONCLUSIONS Most Canadian intensivists surveyed do not think that medical assistance in dying has changed their approach to end of life in the ICU. A significant minority are ethically conflicted about the current approach to assisted dying/euthanasia in Canada. Almost half believe it is ethical to intentionally hasten death during withdrawal of life-sustaining therapies if death is expected.
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12
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Wijdicks EFM, Hwang DY. Predicting Coma Trajectories: The Impact of Bias and Noise on Shared Decisions. Neurocrit Care 2021; 35:291-296. [PMID: 34426900 PMCID: PMC8382106 DOI: 10.1007/s12028-021-01324-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 07/28/2021] [Indexed: 11/30/2022]
Abstract
Coma trajectories are characterized by quick awakening or protracted awakening. Outcome is bookended by restored functionality or permanent cognitively and physically debilitated states. Given the stakes, prognostication cannot be easily questioned as a judgment call, and a scientific underpinning is elemental. Conventional wisdom in determining coma-outcome trajectories posits that (1) predictive models are better than personal experiences, (2) self-fulfilling prophesy is unchecked and driven by nihilism, with little regard for prior probability outcomes, and (3) recovery is impacted by patients’ prior wishes and preexisting medical conditions—but also by what families are told about the patient’s state and anticipated clinical course. Moreover, a predicted good outcome can be offset by a major subsequent complication, or a predicted poor outcome can be offset by aggressive care. This article examines some of these concepts, including how we decide on aggressiveness of care, how we judge quality of life, and the impact on outcome. Most patients who awaken quickly do well and can resume their pretrauma injury lives. In worse off, slow-to-awaken patients, outcomes are a mixed bag of limited innate resilience, depleted cognitive and physical reserves, and adjusted quality of life. Bias and noise are factors not easily measured in outcome prediction, but their influence on recovery trajectories raises some troubling issues.
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Affiliation(s)
- Eelco F M Wijdicks
- Neuroscience Intensive Care Units, Saint Marys Hospital, Mayo Clinic Campus, Rochester, MN, USA. .,Yale New Haven Hospital, New Haven, CT, USA. .,Division of Neurocritical Care and Hospital Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - David Y Hwang
- Neuroscience Intensive Care Units, Saint Marys Hospital, Mayo Clinic Campus, Rochester, MN, USA.,Yale New Haven Hospital, New Haven, CT, USA
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13
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Simeone IM, Berning JN, Hua M, Happ MB, Baldwin MR. Training Chaplains to Provide Communication-Board-Guided Spiritual Care for Intensive Care Unit Patients. J Palliat Med 2021; 24:218-225. [PMID: 32639178 PMCID: PMC7840304 DOI: 10.1089/jpm.2020.0041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2020] [Indexed: 11/12/2022] Open
Abstract
Background: Chaplain-led communication-board-guided spiritual care may reduce anxiety and stress during an intensive care unit (ICU) admission for nonvocal mechanically ventilated patients, but clinical pastoral education does not teach the assistive communication skills needed to provide communication-board-guided spiritual care. Objective: To evaluate a four-hour chaplain-led seminar to educate chaplains about ICU patients' psychoemotional distress, and train them in assistive communication skills for providing chaplain-led communication-board-guided spiritual care. Design: A survey immediately before and after the seminar, and one-year follow-up about use of communication-board-guided spiritual care. Subjects/Setting: Sixty-two chaplains from four U.S. medical centers. Measurements: Multiple-choice and 10-point integer scale questions about ICU patients' mental health and communication-board-guided spiritual care best practices. Results: Chaplain awareness of ICU sedation practices, signs of delirium, and depression, anxiety, and post-traumatic stress disorder in ICU survivors increased significantly (all p < 0.001). Knowledge about using tagged yes/no questions to communicate with nonvocal patients increased from 38% to 87%, p < 0.001. Self-reported skill and comfort in providing communication-board-guided spiritual care increased from a median (interquartile range) score of 4 (2-6) to 7 (5-8) and 6 (4-8) to 8 (6-9), respectively (both p < 0.001). One year later, 31% of chaplains reported providing communication-board-guided spiritual care in the ICU. Conclusions: A single chaplain-led seminar taught chaplains about ICU patients' psychoemotional distress, trained chaplains in assistive communication skills with nonvocal patients, and led to the use of communication-board-guided spiritual care in the ICU for up to one year later.
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Affiliation(s)
- Ilaria M. Simeone
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Joel N. Berning
- Pastoral Care and Education Department, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York, USA
| | - May Hua
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Mary Beth Happ
- Center for Research and Health Analytics, Ohio State University College of Nursing, Columbus, Ohio, USA
| | - Matthew R. Baldwin
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
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14
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Zhu Y, Zhu X, Xu L, Deng M. Clinical Factors Influencing End-of-Life Care in a Chinese Pediatric Intensive Care Unit: A Retrospective, post-hoc Study. Front Pediatr 2021; 9:601782. [PMID: 33898354 PMCID: PMC8058173 DOI: 10.3389/fped.2021.601782] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 03/15/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: End-of-life(EOL) care decision-making for infants and children is a painful experience. The study aimed to explore the clinical factors influencing the EOL care to withhold/withdraw life-sustaining treatment (WLST) in Chinese pediatric intensive care unit (PICU). Methods: A 14-year retrospective study (2006-2019) for pediatric patients who died in PICU was conducted. Based on the mode of death, patients were classified into WLST group (death after WLST) and fCPR group (death after full intervention, including cardiopulmonary resuscitation). Intergroup differences in the epidemiological and clinical factors were determined. Results: There were 715 patients enrolled in this study. Of these patients, 442 (61.8%) died after WLST and 273 (38.2%) died after fCPR. Patients with previous hospitalizations or those who had been transferred from other hospitals more frequently chose WLST than fCPR (both P < 0.01), and the mean PICU stay duration was significantly longer in the WLST group (P < 0.05). WLST patients were more frequently complicated with chronic underlying disease, especially tumor (P < 0.01). Sepsis, diarrhea, and cardiac attack (all P < 0.05) were more frequent causes of death in the fCPR group, whereas tumor as a direct cause of death was more frequently seen in the WLST group. Logistic regression analysis demonstrated that previous hospitalization and underlying diseases diagnosed before admission were strongly associated with EOL care with WLST decision (OR: 1.6; P < 0.05 and OR: 1.6; P < 0.01, respectively). Conclusions: Pediatric patients with previous hospitalization and underlying diseases diagnosed before admission were associated with the EOL care to WLST.
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Affiliation(s)
- Yueniu Zhu
- Department of Pediatric Critical Care Medicine, Xinhua Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiaodong Zhu
- Department of Pediatric Critical Care Medicine, Xinhua Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lili Xu
- Department of Pediatric Critical Care Medicine, Xinhua Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Mengyan Deng
- Department of Pediatric Critical Care Medicine, Xinhua Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
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15
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Takaoka A, Vanstone M, Neville TH, Goksoyr S, Swinton M, Clarke FJ, Smith OM, LeBlanc A, Foster D, Kao Y, Xu X, Hoad N, Toledo F, Cook DJ. Family and Clinician Experiences of Sympathy Cards in the 3 Wishes Project. Am J Crit Care 2020; 29:422-428. [PMID: 33130860 DOI: 10.4037/ajcc2020733] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND A recent randomized trial of bereaved family members of patients who died in an intensive care unit identified symptoms of depression and posttraumatic stress in recipients of semistructured condolence letters. OBJECTIVES To explore family member and clinician experiences with receiving or sending handwritten sympathy cards upon the death of patients involved in a personalized end-of-life intervention, the 3 Wishes Project. METHODS Interviews and focus groups were held with 171 family members and 222 clinicians at 4 centers to discuss their experiences with the 3 Wishes Project. Interview transcripts were searched to identify participants who discussed sympathy cards. Data related to sympathy cards were independently coded by 2 investigators through conventional content analysis. RESULTS Sympathy cards were discussed during 32 interviews (by 25 family members of 21 patients and by 11 clinicians) and 2 focus groups (8 other clinicians). Family members reported that personalized sympathy cards were a welcome surprise; they experienced them as a heartfelt act of compassion. Clinicians viewed cards as an opportunity to express shared humanity with families, reminding them that they and their loved one were not forgotten. Signing cards allowed clinicians to reminisce individually and collectively with colleagues. Family members and clinicians experienced sympathy cards as a meaningful continuation of care after a patient's death. CONCLUSIONS Inviting clinicians who cared for deceased patients to offer personalized, handwritten condolences to bereaved family members may cultivate sincere and individualized expressions of sympathy that bereaved families appreciate after the death of patients involved in the 3 Wishes Project.
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Affiliation(s)
- Alyson Takaoka
- Takaoka was a graduate student at the time the work was conducted, Marilyn Swinton is a research coordinator, and France J. Clarke is a respiratory therapist and research coordinator, Department of Health Research Methods, Evidence, and Impact, Meredith Vanstone is an associate professor, Department of Family Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Meredith Vanstone
- Takaoka was a graduate student at the time the work was conducted, Marilyn Swinton is a research coordinator, and France J. Clarke is a respiratory therapist and research coordinator, Department of Health Research Methods, Evidence, and Impact, Meredith Vanstone is an associate professor, Department of Family Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Thanh H. Neville
- Thanh H. Neville is an assistant professor and critical care physician, Department of Medicine, Division of Pulmonary and Critical Care, and Yuhan Kao is a clinical nurse specialist and Xueqing Xu is a nursing unit director, Department of Nursing, University of California Los Angeles, Los Angeles, California
| | - Sophia Goksoyr
- Sophia Goksoyr is a registered social worker, Allana LeBlanc is a clinical nurse specialist, and Denise Foster is a registered nurse and research coordinator, Department of Critical Care Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Marilyn Swinton
- Takaoka was a graduate student at the time the work was conducted, Marilyn Swinton is a research coordinator, and France J. Clarke is a respiratory therapist and research coordinator, Department of Health Research Methods, Evidence, and Impact, Meredith Vanstone is an associate professor, Department of Family Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - France J. Clarke
- Takaoka was a graduate student at the time the work was conducted, Marilyn Swinton is a research coordinator, and France J. Clarke is a respiratory therapist and research coordinator, Department of Health Research Methods, Evidence, and Impact, Meredith Vanstone is an associate professor, Department of Family Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Orla M. Smith
- Orla M. Smith is a registered nurse and associate scientist, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Allana LeBlanc
- Sophia Goksoyr is a registered social worker, Allana LeBlanc is a clinical nurse specialist, and Denise Foster is a registered nurse and research coordinator, Department of Critical Care Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Denise Foster
- Sophia Goksoyr is a registered social worker, Allana LeBlanc is a clinical nurse specialist, and Denise Foster is a registered nurse and research coordinator, Department of Critical Care Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Yuhan Kao
- Thanh H. Neville is an assistant professor and critical care physician, Department of Medicine, Division of Pulmonary and Critical Care, and Yuhan Kao is a clinical nurse specialist and Xueqing Xu is a nursing unit director, Department of Nursing, University of California Los Angeles, Los Angeles, California
| | - Xueqing Xu
- Thanh H. Neville is an assistant professor and critical care physician, Department of Medicine, Division of Pulmonary and Critical Care, and Yuhan Kao is a clinical nurse specialist and Xueqing Xu is a nursing unit director, Department of Nursing, University of California Los Angeles, Los Angeles, California
| | - Neala Hoad
- Neala Hoad is a registered nurse and research coordinator, Department of Critical Care, and Feli Toledo is a chaplain and registered psychotherapist, Department of Spiritual Care, St Joseph’s Healthcare Hamilton, Ontario, Canada
| | - Feli Toledo
- Neala Hoad is a registered nurse and research coordinator, Department of Critical Care, and Feli Toledo is a chaplain and registered psychotherapist, Department of Spiritual Care, St Joseph’s Healthcare Hamilton, Ontario, Canada
| | - Deborah J. Cook
- Deborah J. Cook is a critical care physician, Department of Critical Care, St Joseph’s Healthcare Hamilton, and a distinguished professor in the Departments of Medicine and Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University
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16
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Anantham D, Chai-Lim C, Zhou JX, Phua GC. Operationalization of critical care triage during a pandemic surge using protocolized communication and integrated supportive care. J Intensive Care 2020; 8:59. [PMID: 32834898 PMCID: PMC7407423 DOI: 10.1186/s40560-020-00475-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/26/2020] [Indexed: 02/07/2023] Open
Abstract
Triage becomes necessary when demand for intensive care unit (ICU) resources exceeds supply. Without triage, there is a risk that patients will be admitted to the ICU in the sequence that they present, disadvantaging those who either present later or have poorer access to healthcare. Moreover, if the patients with the best prognosis are not allocated life support, there is the possibility that overall mortality will increase. Before formulating criteria, principles such as maximizing lives saved and fairness ought to have been agreed upon to guide decision-making. The triage process is subdivided into three parts, i.e., having explicit inclusion/exclusion criteria for ICU admission, prioritization of patients for allocation to available beds, and periodic reassessment of all patients already admitted to the ICU. Multi-dimensional criteria offer more holistic prognostication than only using age cutoffs. Appointed triage officers should also be enabled to make data-driven decisions. However, the process does not merely end with an allocation decision being made. Any decision has to be sensitively and transparently communicated to the patient and family. With infection control measures, there are challenges in managing communication and the psychosocial distress of dying alone. Therefore, explicit video call protocols and social services expertise will be necessary to mitigate these challenges. Besides symptom management and psychosocial management, supportive care teams play an integral role in coordination of complex cases. This scoping review found support for the three-pronged, triage-communication-supportive care approach to facilitate the smooth operationalization of the triage process in a pandemic.
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Affiliation(s)
- Devanand Anantham
- Duke-NUS Medical School, Singapore, Singapore
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Academia Building Level 3, 20 College Road, Singapore, S169856 Singapore
| | - Crystal Chai-Lim
- Duke-NUS Medical School, Singapore, Singapore
- Medical Social Services Department, Singapore General Hospital, Singapore, Singapore
| | - Jamie Xuelian Zhou
- Duke-NUS Medical School, Singapore, Singapore
- Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore, Singapore
| | - Ghee Chee Phua
- Duke-NUS Medical School, Singapore, Singapore
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Academia Building Level 3, 20 College Road, Singapore, S169856 Singapore
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Verdiner RE, Choukalas CG, Siddiqui S, Stahl DL, Galvagno SM, Jabaley CS, Bartz RR, Lane-Fall M, Goff K, Sreedharan R, Bennett S, Williams GW, Khanna A. COVID-Activated Emergency Scaling of Anesthesiology Responsibilities Intensive Care Unit. Anesth Analg 2020; 131:365-377. [PMID: 32398432 PMCID: PMC7219847 DOI: 10.1213/ane.0000000000004957] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2020] [Indexed: 02/06/2023]
Abstract
In response to the rapidly evolving coronavirus disease 2019 (COVID-19) pandemic and the potential need for physicians to provide critical care services, the American Society of Anesthesiologists (ASA) has collaborated with the Society of Critical Care Anesthesiologists (SOCCA), the Society of Critical Care Medicine (SCCM), and the Anesthesia Patient Safety Foundation (APSF) to develop the COVID-Activated Emergency Scaling of Anesthesiology Responsibilities (CAESAR) Intensive Care Unit (ICU) workgroup. CAESAR-ICU is designed and written for the practicing general anesthesiologist and should serve as a primer to enable an anesthesiologist to provide limited bedside critical care services.
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Affiliation(s)
| | | | - Shahla Siddiqui
- Department of Anesthesiology, Pain, and Intensive Care, Beth Israel Deaconess Medical Center, Harvard Medical School
| | | | - Samuel M. Galvagno
- Multi Trauma Critical Care Unit, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine
| | | | - Raquel R. Bartz
- Departments of Anesthesia and Medicine, Duke University School of Medicine
| | - Meghan Lane-Fall
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania
| | - Kristina Goff
- Department of Anesthesiology and Pain Management, UT Southwestern Medical Center
| | - Roshni Sreedharan
- Center for Excellence in Healthcare Communication, Anesthesiology Institute, Cleveland Clinic
| | - Suzanne Bennett
- Department of Anesthesiology, University of Cincinnati College of Medicine
| | - George W. Williams
- Department of Anesthesiology, UT Health McGovern Medical School at Houston
| | - Ashish Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine
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18
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Quader M, Akande O, Toldo S, Cholyway R, Kang L, Lesnefsky EJ, Chen Q. The Commonalities and Differences in Mitochondrial Dysfunction Between ex vivo and in vivo Myocardial Global Ischemia Rat Heart Models: Implications for Donation After Circulatory Death Research. Front Physiol 2020; 11:681. [PMID: 32714203 PMCID: PMC7344325 DOI: 10.3389/fphys.2020.00681] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 05/26/2020] [Indexed: 12/31/2022] Open
Abstract
Heart transplantation is the ultimate treatment option for patients with advanced heart failure. Since hearts from donation after brain death (DBD) donors are limited, donation after circulatory death (DCD) donor hearts could be another source for heart transplantation. DCD process involves ischemia-reperfusion (IR) injury. Mitochondrial dysfunction contributes to IR and is well established in the ex vivo (buffer perfused) ischemia animal model. However, DCD hearts undergo in vivo ischemia with a variable "ischemic period." In addition, the DCD hearts are exposed to an intense catecholamine surge that is not seen with ex vivo perfused hearts. Thus, the severity of mitochondrial damage in in vivo ischemia hearts could differ from the ex vivo ischemia hearts even following the same period of ischemia. The aim of our current study is to identify the mitochondrial dysfunction in DCD hearts and propose strategies to protect mitochondria. Adult Sprague Dawley rat hearts underwent in vivo or ex vivo ischemia for 25 min. Subsarcolemmal mitochondria (SSM) and interfibrillar mitochondria (IFM) were isolated from hearts following ischemia. We found that both ex vivo and in vivo ischemia led to decreased oxidative phosphorylation in SSM and IFM compared to time control or DBD hearts. The proportion of damage to SSM and IFM, including proton leak through the inner membrane, was higher with ex vivo ischemia compare to in vivo ischemia. Time control hearts showed a decrease in SSM and IFM function compared to DBD hearts. The calcium retention capacity (CRC) was also decreased in SSM and IFM with ex vivo and in vivo ischemia, indicating that ischemic damage to mitochondria sensitizes mitochondrial permeability transition pores (MPTP). Our study found differential mitochondrial damage between the in vivo ischemia and the ex vivo ischemia setup. Therefore, consideration should be given to the mode of ischemia while evaluating and testing myocardial protective interventions targeting mitochondria to reduce IR injury in hearts.
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Affiliation(s)
- Mohammed Quader
- Hunter Holmes McGuire Veterans Administration Medical Center, Richmond, VA, United States
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA, United States
- Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, United States
| | - Oluwatoyin Akande
- Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, United States
| | - Stefano Toldo
- Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, United States
- Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Renee Cholyway
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA, United States
| | - Le Kang
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, United States
| | - Edward J. Lesnefsky
- Hunter Holmes McGuire Veterans Administration Medical Center, Richmond, VA, United States
- Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, United States
- Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, United States
| | - Qun Chen
- Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, United States
- Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, United States
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Bobillo-Perez S, Segura S, Girona-Alarcon M, Felipe A, Balaguer M, Hernandez-Platero L, Sole-Ribalta A, Guitart C, Jordan I, Cambra FJ. End-of-life care in a pediatric intensive care unit: the impact of the development of a palliative care unit. BMC Palliat Care 2020; 19:74. [PMID: 32466785 PMCID: PMC7254653 DOI: 10.1186/s12904-020-00575-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 05/07/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this paper is to describe how end-of-life care is managed when life-support limitation is decided in a Pediatric Intensive Care Unit and to analyze the influence of the further development of the Palliative Care Unit. METHODS A 15-year retrospective study of children who died after life-support limitation was initiated in a pediatric intensive care unit. Patients were divided into two groups, pre- and post-palliative care unit development. Epidemiological and clinical data, the decision-making process, and the approach were analyzed. Data was obtained from patient medical records. RESULTS One hundred seventy-five patients were included. The main reason for admission was respiratory failure (86/175). A previous pathology was present in 152 patients (61/152 were neurological issues). The medical team and family participated together in the decision-making in 145 cases (82.8%). The family made the request in 10 cases (9 vs. 1, p = 0.019). Withdrawal was the main life-support limitation (113/175), followed by withholding life-sustaining treatments (37/175). Withdrawal was more frequent in the post-palliative group (57.4% vs. 74.3%, p = 0.031). In absolute numbers, respiratory support was the main type of support withdrawn. CONCLUSIONS The main cause of life-support limitation was the unfavourable evolution of the underlying pathology. Families were involved in the decision-making process in a high percentage of the cases. The development of the Palliative Care Unit changed life-support limitation in our unit, with differences detected in the type of patient and in the strategy used. Increased confidence among intensivists when providing end-of-life care, and the availability of a Palliative Care Unit may contribute to improvements in the quality of end-of-life care.
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Affiliation(s)
- Sara Bobillo-Perez
- Disorders of Immunity and Respiration of the Pediatric Critical Patient Research Group, Institut Recerca Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig Sant Joan de Déu, 2, Esplugues de Llobregat, 08950, Barcelona, Spain
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu, 2, 08950, Barcelona, Esplugues de Llobregat, Spain
| | - Susana Segura
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu, 2, 08950, Barcelona, Esplugues de Llobregat, Spain
| | - Monica Girona-Alarcon
- Disorders of Immunity and Respiration of the Pediatric Critical Patient Research Group, Institut Recerca Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig Sant Joan de Déu, 2, Esplugues de Llobregat, 08950, Barcelona, Spain
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu, 2, 08950, Barcelona, Esplugues de Llobregat, Spain
| | - Aida Felipe
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu, 2, 08950, Barcelona, Esplugues de Llobregat, Spain
| | - Monica Balaguer
- Disorders of Immunity and Respiration of the Pediatric Critical Patient Research Group, Institut Recerca Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig Sant Joan de Déu, 2, Esplugues de Llobregat, 08950, Barcelona, Spain
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu, 2, 08950, Barcelona, Esplugues de Llobregat, Spain
| | - Lluisa Hernandez-Platero
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu, 2, 08950, Barcelona, Esplugues de Llobregat, Spain
| | - Anna Sole-Ribalta
- Disorders of Immunity and Respiration of the Pediatric Critical Patient Research Group, Institut Recerca Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig Sant Joan de Déu, 2, Esplugues de Llobregat, 08950, Barcelona, Spain
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu, 2, 08950, Barcelona, Esplugues de Llobregat, Spain
| | - Carmina Guitart
- Disorders of Immunity and Respiration of the Pediatric Critical Patient Research Group, Institut Recerca Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig Sant Joan de Déu, 2, Esplugues de Llobregat, 08950, Barcelona, Spain
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu, 2, 08950, Barcelona, Esplugues de Llobregat, Spain
| | - Iolanda Jordan
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu, 2, 08950, Barcelona, Esplugues de Llobregat, Spain.
- Paediatric Infectious Diseases Research Group, Institut Recerca Hospital Sant Joan de Déu, CIBERESP, Passeig Sant Joan de Déu, 2, 08950, Esplugues de Llobregat, Barcelona, Spain.
| | - Francisco Jose Cambra
- Disorders of Immunity and Respiration of the Pediatric Critical Patient Research Group, Institut Recerca Hospital Sant Joan de Déu, Universitat de Barcelona, Passeig Sant Joan de Déu, 2, Esplugues de Llobregat, 08950, Barcelona, Spain
- Pediatric Intensive Care Unit Service, Hospital Sant Joan de Déu and University of Barcelona, Passeig Sant Joan de Déu, 2, 08950, Barcelona, Esplugues de Llobregat, Spain
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20
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Fehnel CR, Armengol de la Hoz M, Celi LA, Campbell ML, Hanafy K, Nozari A, White DB, Mitchell SL. Incidence and Risk Model Development for Severe Tachypnea Following Terminal Extubation. Chest 2020; 158:1456-1463. [PMID: 32360728 DOI: 10.1016/j.chest.2020.04.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 04/03/2020] [Accepted: 04/20/2020] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Palliative ventilator withdrawal (PVW) in the ICU is a common occurrence. RESEARCH QUESTION The goal of this study was to measure the rate of severe tachypnea as a proxy for dyspnea and to identify characteristics associated with episodes of tachypnea. STUDY DESIGN AND METHODS This study assessed a retrospective cohort of ICU patients from 2008 to 2012 mechanically ventilated at a single academic medical center who underwent PVW. The primary outcome of at least one episode of severe tachypnea (respiratory rate > 30 breaths/min) within 6 h after PVW was measured by using detailed physiologic and medical record data. Multivariable logistic regression was used to examine the association between patient and treatment characteristics with the occurrence of a severe episode of tachypnea post extubation. RESULTS Among 822 patients undergoing PVW, 19% and 30% had an episode of severe tachypnea during the 1-h and 6-h postextubation period, respectively. Within 1 h postextubation, patients with the following characteristics were more likely to experience tachypnea: no pre-extubation opiates (adjusted OR [aOR], 2.08; 95% CI, 1.03-4.19), lung injury (aOR, 3.33; 95% CI, 2.19-5.04), Glasgow Coma Scale score > 8 (aOR, 2.21; 95% CI, 1.30-3.77), and no postextubation opiates (aOR, 1.90; 95% CI, 1.19-3.00). INTERPRETATION Up to one-third of ICU patients undergoing PVW experience severe tachypnea. Administration of pre-extubation opiates (anticipatory dosing) represents a key modifiable factor that may reduce poor symptom control.
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Affiliation(s)
- Corey R Fehnel
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, MA; Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA.
| | - Miguel Armengol de la Hoz
- Division of Clinical Informatics, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA; Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA; Biomedical Engineering and Telemedicine Group, Biomedical Technology Centre CTB, ETSI Telecomunicación, Universidad Politécnica de Madrid, Madrid, Spain
| | - Leo A Celi
- Department of Medicine, Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, Boston, MA; Massachusetts Institute of Technology, Cambridge, MA
| | | | - Khalid Hanafy
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Ala Nozari
- Department of Medicine, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Douglas B White
- Department of Critical Care, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Susan L Mitchell
- Hebrew SeniorLife Hinda and Arthur Marcus Institute for Aging Research, Boston, MA; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
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21
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Ethical content of expert recommendations for end-of-life decision-making in intensive care units: A systematic review. J Crit Care 2020; 58:10-19. [PMID: 32278227 DOI: 10.1016/j.jcrc.2020.03.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/24/2020] [Accepted: 03/29/2020] [Indexed: 01/05/2023]
Abstract
PURPOSE Intensive care unit health care professionals must be skilled in providing end-of-life care. Crucial in this kind of care is end-of-life decision-making, which is a complex process involving a variety of stakeholders and requiring adequate justification. The aim of this systematic review is to analyse papers tackling ethical issues in relation to end-of-life decision-making in intensive care units. It explores the ethical positions, arguments and principles. METHODS A literature search was conducted in bibliographic databases and grey literature sources for the time period from 1990 to 2019. The constant comparative method was used for qualitative analysis of included papers in order to identify ethical content including ethical positions, ethical arguments, and ethical principles used in decision-making process. RESULTS In the 15 included papers we have identified a total of 43 ethical positions. Ten positions were identified as substantive, 33 as procedural. Twelve different ethical principles emerged from the ethical arguments. The most frequently used principles are the principles of beneficence, autonomy and nonmaleficence. CONCLUSIONS We have demonstrated that recommendations and guidelines designed specifically by intensive or critical care experts for intensive care units promote similar ethical positions, with minimal dissenting positions.
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22
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Robert R, Le Gouge A, Kentish-Barnes N, Adda M, Audibert J, Barbier F, Bourcier S, Bourenne J, Boyer A, Devaquet J, Grillet G, Guisset O, Hyacinthe AC, Jourdain M, Lerolle N, Lesieur O, Mercier E, Messika J, Renault A, Vinatier I, Azoulay E, Thille AW, Reignier J. Sedation practice and discomfort during withdrawal of mechanical ventilation in critically ill patients at end-of-life: a post-hoc analysis of a multicenter study. Intensive Care Med 2020; 46:1194-1203. [PMID: 31996960 DOI: 10.1007/s00134-020-05930-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 01/10/2020] [Indexed: 01/21/2023]
Abstract
PURPOSE Little is known on the incidence of discomfort during the end-of-life of intensive care unit (ICU) patients and the impact of sedation on such discomfort. The aim of this study was to assess the incidence of discomfort events according to levels of sedation. METHODS Post-hoc analysis of an observational prospective multicenter study comparing immediate extubation vs. terminal weaning for end-of-life in ICU patients. Discomforts including gasps, significant bronchial obstruction or high behavioural pain scale score, were prospectively assessed by nurses from mechanical ventilation withdrawal until death. Level of sedation was assessed using the Richmond Agitation-Sedation Scale (RASS) and deep sedation was considered for a RASS - 5. Psychological disorders in family members were assessed up until 12 months after the death. RESULTS Among the 450 patients included in the original study, 226 (50%) experienced discomfort after mechanical ventilation withdrawal. Patients with discomfort received lower doses of midazolam and equivalent morphine, and were less likely to have deep sedation than patients without discomfort (59% vs. 79%, p < 0.001). After multivariate logistic regression, extubation (as compared terminal weaning) was the only factor associated with discomfort, whereas deep sedation and administration of vasoactive drugs were two factors independently associated with no discomfort. Long-term evaluation of psychological disorders in family members of dead patients did not differ between those with discomfort and the others. CONCLUSION Discomfort was frequent during end-of-life of ICU patients and was mainly associated with extubation and less profound sedation.
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Affiliation(s)
- Rene Robert
- Université de Poitiers, Poitiers, France. .,Inserm CIC 1402, ALIVE, Poitiers, France. .,Service de Médecine Intensive Réanimation, CHU Poitiers, 2 rue la Milétrie, 86021, Poitiers Cedex, France.
| | | | - Nancy Kentish-Barnes
- Service de Médecine Intensive Réanimation, Groupe de Recherche Famiréa, CHU Saint-Louis, Paris, France
| | - Mélanie Adda
- APHM, URMITE, UMR CNRS 7278, Hôpital Nord, Réanimation des Détresses Respiratoires et Infections Sévères, Aix-Marseille Université, Marseille, France
| | - Juliette Audibert
- Service de Réanimation Polyvalente, CH de Chartres, Chartres, France
| | | | - Simon Bourcier
- Université Paris-Descartes, Paris, France.,Service de Médecine Intensive Réanimation, Assistance Publique des Hôpitaux de Paris, CHU Cochin, Paris, France
| | - Jeremy Bourenne
- APHM, Hôpital La Timone, Réanimation et surveillance continue, Aix-Marseille Université, Marseille, France
| | - Alexandre Boyer
- Université de Bordeaux, Bordeaux, France.,Service de Réanimation Médicale, CHU Bordeaux, Bordeaux, France
| | - Jérôme Devaquet
- Service de Réanimation Polyvalente, Hôpital Foch, Suresnes, France
| | - Guillaume Grillet
- CH Bretagne Sud, Service de Réanimation Polyvalente, Lorient, France
| | - Olivier Guisset
- Université de Bordeaux, Bordeaux, France.,Service de Réanimation Médicale, CHU Bordeaux, Hôpital Saint-André, Bordeaux, France
| | - Anne-Claire Hyacinthe
- Service de Réanimation Polyvalente, Centre Hospitalier Annecy Genevois, Pringy, France
| | - Mercé Jourdain
- Université de Lille, Lille, France.,Service de Réanimation Polyvalente, Inserm U1190, CHRU de Lille - Hôpital Roger Salengro, Lille, France
| | - Nicolas Lerolle
- Université d'Angers, Angers, France.,Département de Réanimation médicale et Médecine hyperbare, CHU Angers, Angers, France
| | - Olivier Lesieur
- Service de Réanimation Polyvalente, CH de La Rochelle, La Rochelle, France
| | - Emmanuelle Mercier
- Université de Tours, Tours, France.,CHU de Tours, Service de Médecine Intensive Réanimation, Hôpital Bretonneau, Tours, France.,Réseau CRICS, Tours, France
| | - Jonathan Messika
- APHP; Nord-Université de Paris, Service de Réanimation médico-chirurgicale, Hôpital Louis Mourier, Colombes; Inserm U 1137, Paris, France, Colombes, France
| | - Anne Renault
- Université de Bretagne Occidentale, Brest, France.,Service de Réanimation Médicale, CHU de la Cavale Blanche, Brest, France
| | - Isabelle Vinatier
- Service de Réanimation Polyvalente, CHD de la Vendée, La Roche-sur-Yon, France
| | - Elie Azoulay
- Service de Médecine Intensive Réanimation, CHU Poitiers, 2 rue la Milétrie, 86021, Poitiers Cedex, France
| | - Arnaud W Thille
- Université de Poitiers, Poitiers, France.,Inserm CIC 1402, ALIVE, Poitiers, France.,Service de Médecine Intensive Réanimation, CHU Poitiers, 2 rue la Milétrie, 86021, Poitiers Cedex, France
| | - Jean Reignier
- Université de Nantes, Nantes, France.,Service de Médecine Intensive Réanimation, CHU de Nantes, Nantes, France
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23
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Ganz FD. Improving Family Intensive Care Unit Experiences at the End of Life: Barriers and Facilitators. Crit Care Nurse 2020; 39:52-58. [PMID: 31154331 DOI: 10.4037/ccn2019721] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Experiencing the end of life of a family member in the intensive care unit is clearly difficult. An important role of critical care nurses is to help family members through this challenging period. This article highlights a few clinically significant barriers and facilitators related to improving family experiences at the patient's end of life that have received less attention in the literature thus far. Facilitators include specific aspects of communication, the nurse's role as the coordinator of care, bereavement care, promoting a "good death," and caring for health care providers. Barriers include medical uncertainty and differences in values and culture.
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Affiliation(s)
- Freda DeKeyser Ganz
- Freda DeKeyser Ganz is Department Chair, Hadassah-Hebrew University School of Nursing, Jerusalem, Israel.
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24
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Yeow ME, Chen E. Ventilator Withdrawal in Anticipation of Death: The Simulation Lab as an Educational Tool in Palliative Medicine. J Pain Symptom Manage 2020; 59:165-171. [PMID: 31610274 DOI: 10.1016/j.jpainsymman.2019.09.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 09/27/2019] [Accepted: 09/30/2019] [Indexed: 11/18/2022]
Abstract
Simulation is a growing model of education in many medical disciplines. Withdrawal of mechanical ventilation is an important skill set for palliative medicine practitioners who must be facile with a variety of end-of-life scenarios and is well suited to the simulation laboratory. We describe a novel approach using high-fidelity simulation to design a curriculum to teach Hospice & Palliative Medicine fellows the practical aspects of managing a compassionate terminal extubation. This simulation session aims to equip palliative fellows with a knowledge base of respiratory physiology and mechanical ventilation as well as the practical experience of performing a terminal extubation. We designed a three-hour simulation session which includes a one-hour didactic followed by two hours of simulation, with four cases that focus on different teaching points regarding symptom management and practical aspects of removing the endotracheal tube. The session was designed as an annual session for Hospice & Palliative Medicine fellows in our region during a collaborative educational conference. Based on feedback, the session is scheduled for the beginning of the academic year and each fellow is given the opportunity to physically remove the endotracheal tube. Simulation can be effectively used to teach practical and complex bedside skills such as withdrawal of mechanical ventilation to palliative medicine trainees. This method of teaching could be expanded to teach other advanced hospice and palliative care skills.
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Affiliation(s)
- Mei-Ean Yeow
- Center for Palliative Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Elaine Chen
- Division of Pulmonary & Critical Care Medicine and Section of Palliative Medicine, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
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25
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Bodnar J. The Use of Propofol for Continuous Deep Sedation at the End of Life: A Definitive Guide. J Pain Palliat Care Pharmacother 2019; 33:63-81. [DOI: 10.1080/15360288.2019.1667941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- John Bodnar
- John Bodnar, Penn Hospice at Chester County, West Chester, Pennsylvania, USA
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26
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THE IMPORTANCE OF AN INTERPROFESSIONAL PALLIATIVE APPROACH FOR THE CRITICAL PATIENT. ENFERMERIA INTENSIVA 2019; 30:1-3. [PMID: 30712653 DOI: 10.1016/j.enfi.2018.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 11/19/2018] [Indexed: 11/22/2022]
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27
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Moynihan KM, Snaman JM, Kaye EC, Morrison WE, DeWitt AG, Sacks LD, Thompson JL, Hwang JM, Bailey V, Lafond DA, Wolfe J, Blume ED. Integration of Pediatric Palliative Care Into Cardiac Intensive Care: A Champion-Based Model. Pediatrics 2019; 144:peds.2019-0160. [PMID: 31366685 PMCID: PMC6855829 DOI: 10.1542/peds.2019-0160] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2019] [Indexed: 01/04/2023] Open
Abstract
Integration of pediatric palliative care (PPC) into management of children with serious illness and their families is endorsed as the standard of care. Despite this, timely referral to and integration of PPC into the traditionally cure-oriented cardiac ICU (CICU) remains variable. Despite dramatic declines in mortality in pediatric cardiac disease, key challenges confront the CICU community. Given increasing comorbidities, technological dependence, lengthy recurrent hospitalizations, and interventions risking significant morbidity, many patients in the CICU would benefit from PPC involvement across the illness trajectory. Current PPC delivery models have inherent disadvantages, insufficiently address the unique aspects of the CICU setting, place significant burden on subspecialty PPC teams, and fail to use CICU clinician skill sets. We therefore propose a novel conceptual framework for PPC-CICU integration based on literature review and expert interdisciplinary, multi-institutional consensus-building. This model uses interdisciplinary CICU-based champions who receive additional PPC training through courses and subspecialty rotations. PPC champions strengthen CICU PPC provision by (1) leading PPC-specific educational training of CICU staff; (2) liaising between CICU and PPC, improving use of support staff and encouraging earlier subspecialty PPC involvement in complex patients' management; and (3) developing and implementing quality improvement initiatives and CICU-specific PPC protocols. Our PPC-CICU integration model is designed for adaptability within institutional, cultural, financial, and logistic constraints, with potential applications in other pediatric settings, including ICUs. Although the PPC champion framework offers several unique advantages, barriers to implementation are anticipated and additional research is needed to investigate the model's feasibility, acceptability, and efficacy.
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Affiliation(s)
- Katie M. Moynihan
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital Boston, Massachusetts;,Department of Pediatrics, Medical School, Harvard University, Boston, Massachusetts
| | - Jennifer M. Snaman
- Department of Pediatrics, Medical School, Harvard University, Boston, Massachusetts;,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Erica C. Kaye
- Division of Quality of Life and Palliative Care, Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Wynne E. Morrison
- Pediatric Advanced Care Team, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; Departments of,Anesthesiology and Critical Care and
| | - Aaron G. DeWitt
- Pediatric Advanced Care Team, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; Departments of,Anesthesiology and Critical Care and
| | - Loren D. Sacks
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California
| | - Jess L. Thompson
- Department of Cardiothoracic Surgery, Children’s Heart Center, University of Oklahoma, Oklahoma City, Oklahoma; and
| | - Jennifer M. Hwang
- Pediatric Advanced Care Team, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; Departments of,Pediatrics, Perelman School of Medicine, The University of Pennsylvania and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Valerie Bailey
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital Boston, Massachusetts
| | - Deborah A. Lafond
- PANDA Palliative Care Team, Children’s National and School of Medicine, The George Washington University, Washington, District of Columbia
| | - Joanne Wolfe
- Department of Pediatrics, Medical School, Harvard University, Boston, Massachusetts;,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Elizabeth D. Blume
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital Boston, Massachusetts;,Department of Pediatrics, Medical School, Harvard University, Boston, Massachusetts
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Sviri S, Geva D, vanHeerden PV, Romain M, Rawhi H, Abutbul A, Orenbuch-Harroch E, Bentur N. Implementation of a structured communication tool improves family satisfaction and expectations in the intensive care unit. J Crit Care 2019; 51:6-12. [DOI: 10.1016/j.jcrc.2019.01.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 01/12/2019] [Accepted: 01/13/2019] [Indexed: 10/27/2022]
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Abstract
ABSTRACTThe legalization of medical assistance in dying (MAID) in Canada has presented an opportunity for physicians, policy makers, and patients to rethink end-of-life care. This article reviews the key features of the Alberta MAID framework and puts it in the context of other provinces and their MAID programs. We also compared policies and MAID practices in different provinces/territories of Canada. In addition, we used the Alberta MAID database to provide the current state of patient demographics and access to MAID services in Alberta in 2017-2018. Significant differences were identified between provincial/territorial MAID program processes and practices. Alberta, Ontario, and Quebec have more comprehensive frameworks. Alberta has dedicated resources to the support of MAID. The median age of those who received MAID service in Alberta from July 2017 to April 2018 was 70 years; a higher proportion were males (55%) and the majority included patients with a cancer diagnosis (70%). Approximately 39 per cent of MAID events happened in a hospital setting, and 38 per cent occurred in patients' homes. We have presented some recommendations on MAID program development, implementation, and review based on Alberta's experience with MAID over the past two years.
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30
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Rajdev K, Loghmanieh N, Farberov MA, Demissie S, Maniatis T. Are Health-Care Providers Well Prepared in Providing Optimal End-of-Life Care to Critically Ill Patients? A Cross-Sectional Study at a Tertiary Care Hospital in the United States. J Intensive Care Med 2018; 35:1080-1094. [PMID: 30501452 DOI: 10.1177/0885066618811794] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
It is important for health-care providers to be comfortable in providing end-of-life (EOL) care to critically ill patients and realizing when continuing aggressive measures would be futile. Therefore, there is a need to understand health-care providers' self-perceived skills and barriers to providing optimum EOL care. A total of 660 health-care providers from medicine and surgery departments were asked via e-mail to complete an anonymous survey assessing their self-reported EOL care competencies, of which 238 responses were received. Our study identified several deficiencies in the self-reported EOL care competencies among health-care providers. Around 34% of the participants either disagreed (strongly disagree or disagree) or were neutral when asked whether they feel well prepared for delivering EOL care. Around 30% of the participants did not agree (agree and strongly agree) that they were well prepared to determine when to refer patients to hospice. 51% of the participants, did not agree (agree and strongly agree) that clear and accurate information is delivered by team members to patients/family. The most common barrier to providing EOL care in the intensive care unit was family not accepting the patient's poor prognosis. Nursing staff (registered nurse) had higher knowledge and attitudes mean competency scores than the medical staff. Attending physicians reported stronger knowledge competencies when compared to residents and fellows. More than half of the participants denied having received any previous training in EOL care. 82% of the participants agreed that training should be mandatory in this field. Most of the participants reported that the palliative care team is involved in EOL care when the patient is believed to be terminally ill. Apart from a need for a stronger training in the field of EOL care for health-care providers, the overall policies surrounding EOL and palliative care delivery require further evaluation and improvement to promote better outcomes in caring patients at the EOL.
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Affiliation(s)
- Kartikeya Rajdev
- Department of Medicine, Northwell Health Staten Island University Hospital, Staten Island, NY, USA
| | - Nina Loghmanieh
- Department of Palliative Medicine, Northwell Health Staten Island University Hospital, Staten Island, NY, USA
| | - Maria A Farberov
- Department of Medicine, Northwell Health Staten Island University Hospital, Staten Island, NY, USA
| | - Seleshi Demissie
- Department of Biostatistics, Northwell Health Staten Island University Hospital, Staten Island, NY, USA
| | - Theodore Maniatis
- Department of Pulmonary and Critical Care Medicine, Northwell Health Staten Island University Hospital, Staten Island, NY, USA
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Medical students’ knowledge and feeling about end-of-life decisions: A national French survey. Anaesth Crit Care Pain Med 2018; 37:635-636. [DOI: 10.1016/j.accpm.2018.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/16/2018] [Accepted: 08/17/2018] [Indexed: 11/20/2022]
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Bodnar J. Terminal Withdrawal of Mechanical Ventilation: A Hospice Perspective for the Intensivist. J Intensive Care Med 2018; 34:156-164. [PMID: 30189788 DOI: 10.1177/0885066618797918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The intensive care unit (ICU) and hospice inpatient unit (IPU) environments differ in many ways. Although both endeavor to provide the best care possible for their patients, the day-to-day goals of these environments are almost antithetical. Similarly, the experiences and expertise of the staff differ. When performing a similar clinical task, it may be addressed in different ways because each group is engrained in their primary day-to-day focus. Terminal withdrawal of mechanical ventilation is a procedure that is performed in both ICUs and some hospice IPUs. Previous examinations of this subject have been based largely upon the correlative background, practices, and perceptions of the ICU prescriber. The purpose of this review is to examine how the manner in which this procedure is performed in the hospice environment may differ in ways that the intensivist can incorporate into their own plan of care, or better appreciate when making the decision to remove mechanical ventilation in the critical care unit or transfer the patient to a hospice environment for the procedure to be completed.
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Affiliation(s)
- John Bodnar
- 1 Neighborhood Hospice, Penn Medicine Chester County Hospital, West Chester, PA, USA
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González-Rincón M, Díaz de Herrera-Marchal P, Martínez-Martín ML. The role of the nurse at the end of the life of a critically ill patient. ENFERMERIA INTENSIVA 2018; 30:78-91. [PMID: 29903540 DOI: 10.1016/j.enfi.2018.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 12/21/2017] [Accepted: 02/05/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Analyze the role of the nurse at the end of the life of a critically ill patient. METHOD Bibliographic review from a search of the health science databases such as PubMed, CINAHL, Cuiden, Scopus, Cochrane, as well as specialized platforms, general and thematic browsers. The limits were language (English or Spanish) and publication date (2005-2015). RESULTS 180 articles met the inclusion criteria, and 16 of them were selected for analysis. The main results were grouped into three categories of analysis: direct patient care, family-focussed care and the nurse's role within the team. CONCLUSIONS the described roles place the nurse as a key element in humanising death in the ICU and so nurses can and must lead change, playing an active role in creating strategies that really promote the integration of a palliative care approach in ICU.
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Affiliation(s)
| | | | - M L Martínez-Martín
- Sección Departamental Enfermería, Facultad de Medicina, Universidad Autónoma de Madrid, Madrid, España
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Blazquez V, Rodríguez A, Sandiumenge A, Oliver E, Cancio B, Ibañez M, Miró G, Navas E, Badía M, Bosque MD, Jurado MT, López M, Llauradó M, Masnou N, Pont T, Bodí M. Factors related to limitation of life support within 48h of intensive care unit admission: A multicenter study. Med Intensiva 2018; 43:352-361. [PMID: 29747939 DOI: 10.1016/j.medin.2018.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/09/2018] [Accepted: 03/22/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine factors related to limitations on life support within 48h of intensive care unit (ICU) admission. STUDY DESIGN Prospective multicenter study. SETTING Eleven ICUs. PATIENTS All patients who died and/or had limitations on life support after ICU admission during a four-month period. VARIABLES Patient characteristics, hospital characteristics, characteristics of limitations on life support. Time-to-first-limitation was classified as early (<48h of admission) or late (≥48h). We performed univariate, multivariate analyses and CHAID (chi-square automatic interaction detection) analysis of variables associated with limitation of life support within 48h of ICU admission. RESULTS 3335 patients were admitted; 326 (9.8%) had limitations on life support. A total of 344 patients died; 247 (71.8%) had limitations on life support (range among centers, 58.6%-84.2%). The median (p25-p75) time from admission to initial limitation was 2 (0-7) days. CHAID analysis found that the modified Rankin score was the variable most closely related with early limitations. Among patients with Rankin >2, early limitations were implemented in 71.7% (OR=2.5; 95% CI: 1.5-4.4) and lung disease was the variable most strongly associated with early limitations (OR=12.29; 95% CI: 1.63-255.91). Among patients with Rankin ≤2, 48.8% had early limitations; patients admitted after emergency surgery had the highest rate of early limitations (66.7%; OR=2.4; 95% CI: 1.1-5.5). CONCLUSION Limitations on life support are common, but the practice varies. Quality of life has the greatest impact on decisions to limit life support within 48h of admission.
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Affiliation(s)
- V Blazquez
- Intensive Care Unit, University Hospital Joan XXIII, Institut d'Investigació Sanitària Pere Virgili, Tarragona, Spain
| | - A Rodríguez
- Intensive Care Unit, University Hospital Joan XXIII, Institut d'Investigació Sanitària Pere Virgili, University Rovira i Virgili, CIBERES, Tarragona, Spain
| | - A Sandiumenge
- Transplant Coordination, University Hospital Vall d'Hebron, Barcelona, Spain
| | - E Oliver
- Transplant Coordination, University Hospital Bellvitge, Barcelona, Spain
| | - B Cancio
- Intensive Care Unit, University Hospital Moises Broggi, Barcelona, Spain
| | - M Ibañez
- Intensive Care Unit, University Hospital Verge de la Cinta de Tortosa, Tortosa, Spain
| | - G Miró
- Intensive Care Unit, Consorci Sanitari del Maresme, Mataró, Spain
| | - E Navas
- Intensive Care Unit, University Hospital Mutua de Terrassa, Terrassa, Spain
| | - M Badía
- Intensive Care Unit, University Hospital Arnau de Vilanova, Lleida, Spain
| | - M D Bosque
- Intensive Care Unit, University Hospital General de Catalunya, Barcelona, Spain
| | - M T Jurado
- Intensive Care Unit, Hospital de Terrassa, Terrassa, Spain
| | - M López
- Intensive Care Unit, University Hospital de Vic, Vic, Spain
| | - M Llauradó
- International University of Catalunya, Barcelona, Spain
| | - N Masnou
- Transplant Coordination, University Hospital Dr. Trueta, Girona, Spain
| | - T Pont
- Transplant Coordination, University Hospital Vall d'Hebron, Barcelona, Spain
| | - M Bodí
- Intensive Care Unit, University Hospital Joan XXIII, Institut d'Investigació Sanitària Pere Virgili, University Rovira i Virgili, CIBERES, Tarragona, Spain.
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Trevick SA, Lord AS. Post-traumatic Stress Disorder and Complicated Grief are Common in Caregivers of Neuro-ICU Patients. Neurocrit Care 2018; 26:436-443. [PMID: 28054288 DOI: 10.1007/s12028-016-0372-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND To explore the effect of end of life and other palliative decision making scenarios on the mental health of family members of patients in the neuro-intensive care unit. METHODS Decision makers of patients in the neuro-ICU at a large, urban, academic medical center meeting palliative care triggers were identified from November 10, 2014, to August 27, 2015. Interviews were conducted at 1 and 6 months post-enrollment. At 1 month, the Inventory of Complicated Grief-Revised (ICG-R), Impact of Events Scale-Revised (IES-R), and the Family Satisfaction-ICU (FS-ICU) were performed along with basic demographic questionnaires. At 6 months, only the ICG-R and IES-R were repeated. RESULTS At 1 month, 9 (35%) subjects had significant symptoms in at least one of the three domains of traumatic response. Two (7.7%) subjects met full criteria for PTSD (IES-R ≥ 1.5). At 6 months, 5 (22%) subjects met criteria for PTSD and 5 (22%) for Complicated Grief (ICG-R ≥ 36). Fifteen (50%) had at least one domain of PTSD symptoms identified in follow-up. Time spent at bedside and lower household income were associated with PTSD at 1 and 6 months, respectively. In all, clinically significant psychological outcomes were identified in 9 (30%) of subjects. CONCLUSIONS Clinically significant grief and stress reactions were identified in 30% of decision makers for severely ill neuro-ICU patients. Though factors including time at bedside during hospitalization and total household income may have some predictive value for these disorders, further evaluation is required to help identify family members at risk of psychopathology following neuro-ICU admissions.
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Affiliation(s)
- Stephen A Trevick
- Division of Neurocritical Care, Department of Neurology, Northwestern University Mcgaw Medical Center, Chicago, IL, USA.
| | - Aaron S Lord
- Division of Neurocritical Care, Department of Neurology, NYU School of Medicine, New York, NY, USA
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Suttle ML, Jenkins TL, Tamburro RF. End-of-Life and Bereavement Care in Pediatric Intensive Care Units. Pediatr Clin North Am 2017; 64:1167-1183. [PMID: 28941542 PMCID: PMC5747301 DOI: 10.1016/j.pcl.2017.06.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Most childhood deaths in the United States occur in hospitals. Pediatric intensive care clinicians must anticipate and effectively treat dying children's pain and suffering and support the psychosocial and spiritual needs of families. These actions may help family members adjust to their loss, particularly bereaved parents who often experience reduced mental and physical health. Candid and compassionate communication is paramount to successful end-of-life (EOL) care as is creating an environment that fosters meaningful family interaction. EOL care in the pediatric intensive care unit is associated with challenging ethical issues, of which clinicians must maintain a sound and working understanding.
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Affiliation(s)
- Markita L. Suttle
- Department of Critical Care Medicine, Nationwide Children's Hospital
| | - Tammara L. Jenkins
- Pediatric Trauma and Critical Illness Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development
| | - Robert F. Tamburro
- Pediatric Trauma and Critical Illness Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development
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37
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A Randomized Trial of Palliative Care Discussions Linked to an Automated Early Warning System Alert. Crit Care Med 2017; 45:234-240. [PMID: 27768613 DOI: 10.1097/ccm.0000000000002068] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine whether an Early Warning System could identify patients wishing to focus on palliative care measures. DESIGN Prospective, randomized, pilot study. SETTING Barnes-Jewish Hospital, Saint Louis, MO (January 15, 2015, to December 12, 2015). PATIENTS A total of 206 patients; 89 intervention (43.2%) and 117 controls (56.8%). INTERVENTIONS Palliative care in high-risk patients targeted by an Early Warning System. MEASUREMENTS AND MAIN RESULTS Advanced directive documentation was significantly greater prior to discharge in the intervention group (37.1% vs 15.4%; p < 0.001) as were first-time requests for advanced directive documentation (14.6% vs 0.0%; p < 0.001). Documentation of resuscitation status was also greater prior to discharge in the intervention group (36.0% vs 23.1%; p = 0.043). There was no difference in the number of patients requesting a change in resuscitation status between groups (11.2% vs 9.4%; p = 0.666). However, changes in resuscitation status occurred earlier and on the general medicine units for the intervention group compared to the control group. The number of patients transferred to an ICU was significantly lower for intervention patients (12.4% vs 27.4%; p = 0.009). The median (interquartile range) ICU length of stay was significantly less for the intervention group (0 [0-0] vs 0 [0-1] d; p = 0.014). Hospital mortality was similar (12.4% vs 10.3%; p = 0.635). CONCLUSIONS This study suggests that automated Early Warning System alerts can identify patients potentially benefitting from directed palliative care discussions and reduce the number of ICU transfers.
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38
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López Camps V, García García MA, Martín Delgado MC, Añón Elizalde JM, Masnou Burrallo N, Rubio Sanchiz O, Estella García A, Monzón Marín JL. National survey on the indicators of quality in Bioethics of the SEMICYUC in the departments of Intensive Care Medicine in Spain. Med Intensiva 2017; 41:523-531. [PMID: 28389026 DOI: 10.1016/j.medin.2017.01.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 01/11/2017] [Accepted: 01/24/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Multiple interventions are performed in critical patients admitted to Intensive Care Units (ICUs). This study explores the presence in the daily practice of ICUs of elements related to the 6 bioethics quality indicators of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units, and the participation of their members in the hospital ethics committees. MATERIALS AND METHODS A multicenter observational study was carried out, using a survey exploring descriptive aspects of the ICUs, with 25 questions related to bioethics quality indicators, and assessing the participation of ICU members in the hospital ethics committees. The ICUs were classified by size (larger or smaller than 10 beds) and type of hospital (public/private-public concerted center, with/without teaching). RESULTS The 68 analyzed surveys revealed: daily informing of the family (97%), carried out in the information room (82%); end-of-life care protocols (44%); life support limitation form (48.43%); and physical containment protocol (40%). Compliance with the informed consent process referred to different procedures is: tracheostomy (92%), vascular procedures (76%), and extrarenal clearance (25%). The presence of ICU members in the hospital ethics committee is currently frequent (69%). CONCLUSIONS Information supplied to relatives is adequate, although there are ICUs without an information room. Compliance with the informed consent requirements of various procedures is insufficient. The participation of ICU members in the hospital ethics committees is frequent. The results obtained suggest a chance for improvement in the bioethical quality of the ICU.
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Affiliation(s)
| | | | | | | | | | - O Rubio Sanchiz
- UCI, Hospital Sant Joan de Déu, Fundación Althaia, Manresa, Barcelona, España
| | - A Estella García
- UCI, Hospital de Jerez de la Frontera, Jerez de la Frontera, Cádiz, España
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Daly BJ, Douglas SL, O'Toole E, Rowbottom J, Hoffer A, Lipson AR, Burant C. Complexity Analysis of Decision-Making in the Critically Ill. J Intensive Care Med 2016; 33:557-566. [PMID: 27872409 DOI: 10.1177/0885066616678394] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
RATIONALE Despite multiple trials of interventions to improve end-of-life care of the critically ill, there is a persistent lack of understanding of factors associated with barriers to decision-making at the end of life. OBJECTIVE To apply the principles of complexity science in examining the extent to which transitions to end-of-life care can be predicted by physician, family, or patient characteristics; outcome expectations; and the evaluation of treatment effectiveness. METHODS A descriptive, longitudinal study was conducted in 3 adult intensive care units (ICUs). Two hundred sixty-four family surrogates of patients lacking decisional capacity and the physicians caring for the patients were interviewed every 5 days until ICU discharge or patient death. MEASUREMENTS Characteristics of patients, physicians, and family members; values and preferences of physicians and family; and evaluation of treatment effectiveness, expectations for patient outcomes, and relative priorities in treatment (comfort vs survival). The primary outcome, focus of care, was categorized as (1) maintaining a survival orientation (no treatment limitations), (2) transitioning to a stronger palliative focus (eg, some treatment limitations), or (3) transitioning to an explicit end-of-life, comfort-oriented care plan. MAIN RESULTS Physician expectations for survival and future cognitive status were the only variables consistently and significantly related to the focus of care. Neither physician or family evaluations of treatment effectiveness nor what was most important to physicians or family members was influential. CONCLUSION Lack of influence of family and physician views, in comparison to the consistent effect of survival probabilities, suggests barriers to incorporation of individual values in treatment decisions.
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Affiliation(s)
- Barbara J Daly
- 1 School of Nursing, Case Western Reserve University, Cleveland, OH, USA
| | - Sara L Douglas
- 1 School of Nursing, Case Western Reserve University, Cleveland, OH, USA
| | - Elizabeth O'Toole
- 2 School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - James Rowbottom
- 2 School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Alan Hoffer
- 2 School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Amy R Lipson
- 1 School of Nursing, Case Western Reserve University, Cleveland, OH, USA
| | - Christopher Burant
- 1 School of Nursing, Case Western Reserve University, Cleveland, OH, USA
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Perman SM, Stanton E, Soar J, Berg RA, Donnino MW, Mikkelsen ME, Edelson DP, Churpek MM, Yang L, Merchant RM. Location of In-Hospital Cardiac Arrest in the United States-Variability in Event Rate and Outcomes. J Am Heart Assoc 2016; 5:JAHA.116.003638. [PMID: 27688235 PMCID: PMC5121474 DOI: 10.1161/jaha.116.003638] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background In‐hospital cardiac arrest (IHCA) is a major public health problem with significant mortality. A better understanding of where IHCA occurs in hospitals (intensive care unit [ICU] versus monitored ward [telemetry] versus unmonitored ward) could inform strategies for reducing preventable deaths. Methods and Results This is a retrospective study of adult IHCA events in the Get with the Guidelines—Resuscitation database from January 2003 to September 2010. Unadjusted analyses were used to characterize patient, arrest, and hospital‐level characteristics by hospital location of arrest (ICU versus inpatient ward). IHCA event rates and outcomes were plotted over time by arrest location. Among 85 201 IHCA events at 445 hospitals, 59% (50 514) occurred in the ICU compared to 41% (34 687) on the inpatient wards. Compared to ward patients, ICU patients were younger (64±16 years versus 69±14; P<0.001) and more likely to have a presenting rhythm of ventricular tachycardia/ventricular fibrillation (21% versus 17%; P<0.001). In the ICU, mean event rate/1000 bed‐days was 0.337 (±0.215) compared with 0.109 (±0.079) for telemetry wards and 0.134 (±0.098) for unmonitored wards. Of patients with an arrest in the ICU, the adjusted mean survival to discharge was 0.140 (0.037) compared with the unmonitored wards 0.106 (0.037) and telemetry wards 0.193 (0.074). More IHCA events occurred in the ICU compared to the inpatient wards and there was a slight increase in events/1000 patient bed‐days in both locations. Conclusions Survival rates vary based on location of IHCA. Optimizing patient assignment to unmonitored wards versus telemetry wards may contribute to improved survival after IHCA.
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Affiliation(s)
- Sarah M Perman
- Department of Emergency Medicine, University of Colorado, School of Medicine, Aurora, CO
| | - Emily Stanton
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Robert A Berg
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA The Children's Hospital of Philadelphia and The University of Pennsylvania School of Medicine, Philadelphia, PA
| | | | - Mark E Mikkelsen
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Dana P Edelson
- Department of Internal Medicine, University of Chicago, Chicago, IL
| | | | - Lin Yang
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Raina M Merchant
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Wenwen Z, Xiaoyan W, Yufang Z, Lifeng C, Congcong S. Moral distress and its influencing factors: A cross-sectional study in China. Nurs Ethics 2016; 25:470-480. [PMID: 27585462 DOI: 10.1177/0969733016658792] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: The purpose of this study was to describe the current situation of moral distress and to explore its influencing factors among Chinese nurses. Methods: This is an exploratory, descriptive design study. A total of 465 clinical nurses from different departments in three Grade-III, Level-A hospitals in Jinan, Shandong Province, completed the questionnaires, including demographics questionnaire, Chinese version of Moral Distress Scale–Revised, and Job Diagnostic Survey. Ethical considerations: The study was approved by the university ethics board and the local health service director. Results: The total score of Moral Distress Scale–Revised was 36.01 ± 24.02 points. The mean frequency and intensity scores of moral distress were 1.13 ± 0.49 and 1.09 ± 0.58, respectively. The level of moral distress among Chinese clinical nurses was low, and the frequency and intensity of moral distress were on low to moderate level. The level of moral distress experienced by clinical nurses is associated with demographics features and job characteristics, including age, education degree, department, task significance, autonomy, and dealing with others. Conclusion: Our conclusion suggests that hospital and organizational administrations should attach much importance to the moral distress experienced by clinical nurses in China. Further studies should focus on interventions about how to reduce the levels of the frequency and intensity of moral distress among clinical nurses.
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Affiliation(s)
| | - Wu Xiaoyan
- Qilu Hospital, Shandong University, China
| | | | - Ci Lifeng
- Qilu Hospital, Shandong University, China
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42
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Abstract
Since the Harvard report of 1968, the concept of brain death has become widely recognized throughout the world. Most developed countries have accepted brain death as constituting death of the individual, and allow such patients to be used as ‘heart-beating’ organ donors. Although the US and most other countries accept a ‘whole-brain’ definition of brain death, the concept of brainstem death has been adopted in the UK. This article describes the UK diagnostic criteria in detail, and compares these with the criteria used in other countries. Management of the brain dead organ donor is described, and controversies relating to the concept of brain death are also discussed.
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Affiliation(s)
- JM Elliot
- Department of Anaesthesia, Good Hope Hospital, Sutton Coldfield, UK,
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43
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Chikhladze N, Janberidze E, Velijanashvili M, Chkhartishvili N, Jintcharadze M, Verne J, Kordzaia D. Mismatch between physicians and family members views on communications about patients with chronic incurable diseases receiving care in critical and intensive care settings in Georgia: a quantitative observational survey. BMC Palliat Care 2016; 15:63. [PMID: 27449224 PMCID: PMC4957836 DOI: 10.1186/s12904-016-0135-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Accepted: 07/08/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Physicians working in critical and intensive care settings encounter death of chronic incurable patients on a daily basis; however they have scant skills on how to communicate with the patients and their family members. The aim of the present survey is to examine communication of critical and intensive care physicians with patients' family members receiving treatment due to chronic incurable diseases/conditions and to compare the views of families with physicians working in critical and intensive care settings. METHODS The survey was conducted in four cities of Georgia (Tbilisi, Kutaisi, Batumi and Telavi) in 2014. Physicians working in critical and intensive care settings and family members were asked to fill in separate questionnaires, covering various aspects of communication including patients' prognosis, ways of death occurrence, treatment plans and religion. Participants ranked their responses on a scale ranging from "0" to "10", where "0" represented "never" and "10"-"always". After data collection, responses were recoded into three categories: 0-3 = never/rarely, 4-7 = somewhat and 8-10 = often/always. Differences were tested using Pearson's chi-square or Fisher's exact test as appropriate. P value of < 0.05 was considered as significant. RESULTS Sixty-five physicians and 59 patients' family members participated in this cross-sectional study. Majority of their responses was statistically significantly different. Only one quarter (23.7 %) of family members of patients receiving medical aid in critical and intensive care settings were satisfied with the communication level. In contrast, 78.5 % of physicians considered their communication with families as positive (p < 0.0001). CONCLUSIONS The survey revealed the mismatch between the views on communication of critical and intensive care settings physicians and family members of the patients with chronic incurable diseases receiving care in critical and intensive care settings. In order to provide the best care for chronic incurable patients and their family members, physicians working in critical and intensive care settings must have relevant clinical knowledge and ability to provide effective communication. Present results reflect important potential targets for educational interventions including critical and intensive care physicians training through online modules.
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Affiliation(s)
- Nana Chikhladze
- Iv. Javakhishvili Tbilisi State University (TSU), Tbilisi, Georgia
- Georgian National Association for Palliative Care, Tbilisi, Georgia
| | - Elene Janberidze
- Department of Gerontology and Palliative Care, of Al. Natishvili Institute of Morphology, TSU, Tbilisi, Georgia
- Georgian National Association for Palliative Care, Tbilisi, Georgia
| | - Mariam Velijanashvili
- Iv. Javakhishvili Tbilisi State University (TSU), Tbilisi, Georgia
- Georgian National Association for Palliative Care, Tbilisi, Georgia
| | - Nikoloz Chkhartishvili
- Georgian National Association for Palliative Care, Tbilisi, Georgia
- Infectious Diseases, AIDS and Clinical Immunology Research Center, Tbilisi, Georgia
| | | | | | - Dimitri Kordzaia
- Iv. Javakhishvili Tbilisi State University (TSU), Tbilisi, Georgia
- Department of Gerontology and Palliative Care, of Al. Natishvili Institute of Morphology, TSU, Tbilisi, Georgia
- Georgian National Association for Palliative Care, Tbilisi, Georgia
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Chooljian DM, Hallenbeck J, Ezeji-Okoye SC, Sebesta R, Iqbal H, Kuschner WG. Emotional Support for Health Care Professionals: A Therapeutic Role for the Hospital Ethics Committee. JOURNAL OF SOCIAL WORK IN END-OF-LIFE & PALLIATIVE CARE 2016; 12:277-288. [PMID: 27462956 DOI: 10.1080/15524256.2016.1200519] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Hospital ethics committees (HECs) are typically charged with addressing ethical disputes, conflicts, and dilemmas that arise in the course of patient care. HECs are not widely viewed as having a therapeutic role for health care professionals who experience psychological distress or anticipatory grief in the course of discharging professional duties. A case is presented in which an ethics consultation was requested, chiefly, to secure emotional support for health care professionals who had been asked by a patient to discontinue life-sustaining treatments. As the case demonstrates, HECs may be called upon to provide emotional support and reassurance to health care professionals who willingly carry out psychologically difficult actions, even though these actions may be ethically uncontroversial. In providing this service, the HEC may not necessarily engage in its customary activity of deliberating an ethics issue and resolving a conflict but may still provide valuable assistance, as in the case presented.
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Affiliation(s)
- David M Chooljian
- a Pulmonary Section, Medical Service, Veterans Affairs Loma Linda VA Healthcare System; and Division of Pulmonary and Critical Care Medicine, Department of Medicine , Loma Linda University School of Medicine , Loma Linda , California , USA
| | - James Hallenbeck
- b Extended Care (Nursing Home Care, Home Care, Hospice and Palliative Care), Veterans Affairs Palo Alto Health Care System; and Division of General Medical Disciplines, Department of Medicine , Stanford University School of Medicine , Palo Alto , California , USA
| | - Stephen C Ezeji-Okoye
- c Director's Office Veterans Affairs Palo Alto Healthcare System; and Division of General Medical Disciplines, Department of Medicine , Stanford University School of Medicine , Palo Alto , California , USA
| | - Robert Sebesta
- d Social Work Service , Central Texas Veterans Health Care System , Temple , Texas , USA
| | - Hasan Iqbal
- e Pulmonary Section, Medical Service , Veterans Affairs Palo Alto Health Care System , Palo Alto , California , USA
| | - Ware G Kuschner
- f Pulmonary Section, Medical Service, Veterans Affairs Palo Alto Health Care System; and Division of Pulmonary and Critical Care Medicine, Department of Medicine , Stanford University School of Medicine , Palo Alto , California , USA
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45
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Cox CE, Curtis JR. Using Technology to Create a More Humanistic Approach to Integrating Palliative Care into the Intensive Care Unit. Am J Respir Crit Care Med 2016; 193:242-50. [PMID: 26599829 DOI: 10.1164/rccm.201508-1628cp] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
A decade ago, the major obstacles to integration of palliative care into the intensive care unit (ICU) were the limited number of providers trained in palliative care, an immature evidence base, and a lack of appreciation for the importance of palliative care in the ICU. In 2016, the palliative care workforce has expanded markedly and there is growing appreciation of the benefits of palliative care, whether provided by a generalist (intensivist, nurse, social worker) or palliative care specialist. However, there is evidence that the quality of ICU-based palliative care is often suboptimal. A major barrier to more broadly addressing this quality problem is the lack of scalable ICU-based palliative care models that use technology to deliver efficient, collaborative palliative care in the ICU setting to the right patient at the right time. To address these challenges, we first review strengths and limitations of current care models as the basis for our novel conceptual framework that uses the electronic health record as a platform on which external innovations can be built, including: (1) screening for patients at risk for poor outcomes, (2) integrating patient- and family-reported needs, (3) personalizing care, and (4) directing generalist versus specialist triage algorithms. In the approaches considered, we describe current challenges and propose specific solutions that use technology to improve the quality of the human interaction in a stressful, complex environment.
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Affiliation(s)
- Christopher E Cox
- 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, and.,2 Program to Support People and Enhance Recovery, Duke University, Durham, North Carolina; and
| | - J Randall Curtis
- 3 Cambia Palliative Care Center of Excellence, Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, Washington
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46
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Delaney JW, Downar J. How is life support withdrawn in intensive care units: A narrative review. J Crit Care 2016; 35:12-8. [PMID: 27481730 DOI: 10.1016/j.jcrc.2016.04.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 03/17/2016] [Accepted: 04/03/2016] [Indexed: 01/20/2023]
Abstract
PURPOSE Decisions to withdraw life-sustaining therapy (WDLS) are relatively common in intensive care units across Canada. As part of preliminary work to develop guidelines for WDLS, we performed a narrative review of the literature to identify published studies of WDLS. MATERIALS AND METHODS A search of MEDLINE and EMBASE databases was performed. The results were reviewed and only articles relevant to WDLS were included. Any references within these articles deemed to be relevant were subsequently included. RESULTS The initial search identified 3687 articles. A total of 100 articles of interest were identified from the initial search and a review of their references. The articles were primarily composed of observational data and expert opinion. The information from the literature was organized into 6 themes: preparation for WDLS, monitoring parameters, pharmacologic symptom management, withdrawing life-sustaining therapies, withdrawal of mechanical ventilation, and bereavement. CONCLUSIONS This review describes current practices and opinions about WDLS, and also demonstrates the significant practice variation that currently exists. We believe that the development of guidelines to help increase transparency and standardize the process will be an important step to ensuring high quality care during WDLS.
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Affiliation(s)
| | - James Downar
- Division of Palliative Care, University of Toronto, Toronto, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
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47
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Guidelines for the withdrawal of life-sustaining measures. Intensive Care Med 2016; 42:1003-17. [PMID: 27059793 DOI: 10.1007/s00134-016-4330-7] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 03/11/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Withdrawal of life-sustaining measures is a common event in the intensive care unit yet it involves a complex balance of medical, legal and ethical considerations. Very few healthcare providers have been specifically trained to withdraw life-sustaining measures, and no comprehensive guidelines exist to help ensure clinicians deliver the highest quality of care to patients and families. Hence, we sought to develop guidelines for the process of withdrawing life-sustaining measures in the clinical setting. METHODS We convened an interdisciplinary group of ICU care providers from the Canadian Critical Care Society and the Canadian Association of Critical Care Nurses, and used a modified Delphi process to answer key clinical and ethical questions identified in the literature. RESULTS A total of 39 experienced clinicians completed the initial workshop, and 36 were involved in the subsequent Delphi rounds. The group developed a series of guidelines to address (1) preparing for withdrawal of life-sustaining measures; (2) assessment of distress; (3) pharmaceutical management of distress; and (4) discontinuation of life-sustaining measures and monitoring. The group achieved consensus on all aspects of the guidelines after the third Delphi round. CONCLUSION We present these guidelines to help physicians provide high-quality end of life (EOL) care in the ICU. Future studies should address their effectiveness from both critical care team and family perspectives.
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McAdam JL, Erikson A. Bereavement Services Offered in Adult Intensive Care Units in the United States. Am J Crit Care 2016; 25:110-7. [PMID: 26932912 DOI: 10.4037/ajcc2016981] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Losing a loved one in the intensive care unit (ICU) is stressful for family members. Providing bereavement support to them is recommended. However, little is known about the prevalence of bereavement services implemented in adult ICUs. OBJECTIVE To describe current bereavement follow-up services in adult ICUs. METHOD A cross-sectional prospective study design was used. ICU nurse leaders completed a 26-item online survey posted in the American Association of Critical-Care Nurses e-newsletter. The survey contained questions about current practices in bereavement care. Data were collected for 1 month and were analyzed by using descriptive statistics and binary logistic regression. RESULTS A total of 237 ICU nurse leaders responded to the survey. Hospital and ICU types were diverse, with most being community (n = 81, 34.2%) and medical (n = 61, 25.7%). Most respondents reported that their ICUs (n = 148, 62.4%) did not offer bereavement follow-up services, and many barriers were noted. When bereavement follow-up care was offered, it was mainly informal (eg, condolence cards, brochures). Multiple logistic regression indicated that ICUs in hospitals with palliative care were almost 8 times (odds ratio, 7.66) more likely to provide bereavement support than were ICUs in hospitals without palliative care. CONCLUSIONS The study findings provide insight into what type of bereavement evaluation methods are being used, what barriers are present that hinder use of bereavement follow-up services, and potential interventions to overcome those barriers in adult ICUs in the United States.
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Affiliation(s)
- Jennifer L. McAdam
- Jennifer L. McAdam is an associate professor, Samuel Merritt University, School of Nursing, Oakland, California. Alyssa Erikson is an assistant professor, California State University, Monterey Bay, Seaside, California
| | - Alyssa Erikson
- Jennifer L. McAdam is an associate professor, Samuel Merritt University, School of Nursing, Oakland, California. Alyssa Erikson is an assistant professor, California State University, Monterey Bay, Seaside, California
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Kon AA, Davidson JE, Morrison W, Danis M, White DB. Shared Decision Making in ICUs: An American College of Critical Care Medicine and American Thoracic Society Policy Statement. Crit Care Med 2016; 44:188-201. [PMID: 26509317 PMCID: PMC4788386 DOI: 10.1097/ccm.0000000000001396] [Citation(s) in RCA: 311] [Impact Index Per Article: 38.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Shared decision making is endorsed by critical care organizations; however, there remains confusion about what shared decision making is, when it should be used, and approaches to promote partnerships in treatment decisions. The purpose of this statement is to define shared decision making, recommend when shared decision making should be used, identify the range of ethically acceptable decision-making models, and present important communication skills. DESIGN The American College of Critical Care Medicine and American Thoracic Society Ethics Committees reviewed empirical research and normative analyses published in peer-reviewed journals to generate recommendations. Recommendations approved by consensus of the full Ethics Committees of American College of Critical Care Medicine and American Thoracic Society were included in the statement. MAIN RESULTS Six recommendations were endorsed: 1) DEFINITION: Shared decision making is a collaborative process that allows patients, or their surrogates, and clinicians to make healthcare decisions together, taking into account the best scientific evidence available, as well as the patient's values, goals, and preferences. 2) Clinicians should engage in a shared decision making process to define overall goals of care (including decisions regarding limiting or withdrawing life-prolonging interventions) and when making major treatment decisions that may be affected by personal values, goals, and preferences. 3) Clinicians should use as their "default" approach a shared decision making process that includes three main elements: information exchange, deliberation, and making a treatment decision. 4) A wide range of decision-making approaches are ethically supportable, including patient- or surrogate-directed and clinician-directed models. Clinicians should tailor the decision-making process based on the preferences of the patient or surrogate. 5) Clinicians should be trained in communication skills. 6) Research is needed to evaluate decision-making strategies. CONCLUSIONS Patient and surrogate preferences for decision-making roles regarding value-laden choices range from preferring to exercise significant authority to ceding such authority to providers. Clinicians should adapt the decision-making model to the needs and preferences of the patient or surrogate.
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Affiliation(s)
- Alexander A. Kon
- Naval Medical Center San Diego, San Diego, CA
- University of California San Diego, San Diego, CA
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Abstract
OBJECTIVE The process of withdrawal of life-sustaining therapy remains poorly described in the current literature despite its importance for patient comfort and optimal end-of-life care. We conducted a structured review of the published literature to summarize patterns of withdrawal of life-sustaining therapy processes in adult ICUs. DATA SOURCES Electronic journal databases were searched from date of first issue until April 2014. STUDY SELECTION Original research articles describing processes of life-support therapy withdrawal in North American, European, and Australian ICUs were included. DATA EXTRACTION From each article, we extracted definitions of withdrawal of life-sustaining therapy, descriptions and order of interventions withdrawn, drugs administered, and timing from withdrawal of life-sustaining therapy until death. DATA SYNTHESIS Fifteen articles met inclusion criteria. Definitions of withdrawal of life-sustaining therapy varied and focused on withdrawal of mechanical ventilation; two studies did not present operational definitions. All studies described different aspects of process of life-support therapy withdrawal and measured different time periods prior to death. Staggered patterns of withdrawal of life-support therapy were reported in all studies describing order of interventions withdrawn, with vasoactive drugs withdrawn first followed by gradual withdrawal of mechanical ventilation. Processes of withdrawal of life-sustaining therapy did not seem to influence time to death. CONCLUSIONS Further description of the operational processes of life-sustaining therapy withdrawal in a more structured manner with standardized definitions and regular inclusion of measures of patient comfort and family satisfaction with care is needed to identify which patterns and processes are associated with greatest perceived patient comfort and family satisfaction with care.
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