Challenges to the withdrawal of care in critically ill patients in India

Association between education in EOL care and variability in EOL practice: a survey of ICU physicians

PURPOSE

This study investigated the association between physician education in EOL and variability in EOL practice, as well as the differences between beliefs and practices regarding EOL in the ICU.

METHODS

Physicians from 11 ICUs at a university hospital completed a survey presenting a patient in a vegetative state with no family or advance directives. Questions addressed approaches to EOL care, as well physicians' personal, professional and EOL educational characteristics.

RESULTS

The response rate was 89%, with 105 questionnaires analyzed. Mean age was 38 ± 8 years, with a mean of 14 ± 7 years since graduation. Physicians who did not apply do-not-resuscitate (DNR) orders were less likely to have attended EOL classes than those who applied written DNR orders [0/7 vs. 31/47, OR = 0.549 (0.356-0.848), P = 0.001]. Physicians who involved nurses in the decision-making process were more likely to be ICU specialists [17/22 vs. 46/83, OR = 4.1959 (1.271-13.845), P = 0.013] than physicians who made such decisions among themselves or referred to ethical or judicial committees. Physicians who would apply "full code" had less often read about EOL [3/22 vs. 11/20, OR = 0.0939 (0.012-0.710), P = 0.012] and had less interest in discussing EOL [17/22 vs. 20/20, OR = 0.210 (0.122-0.361), P < 0.001], than physicians who would withdraw life-sustaining therapies. Forty-four percent of respondents would not do what they believed was best for their patient, with 98% of them believing a less aggressive attitude preferable. Legal concerns were the leading cause for this dichotomy.

CONCLUSIONS

Physician education about EOL is associated with variability in EOL decisions in the ICU. Moreover, actual practice may differ from what physicians believe is best for the patient.

Can lineage-specific markers be identified to characterize mesenchyme-derived cell populations in the human airways?

Mesenchyme-derived cells in the airway wall including airway smooth muscle cells, fibroblasts, and myofibroblasts are known to play important roles in airway remodeling. The lack of specific phenotypical markers makes it difficult to define these cell populations in primary cultures. Most relevant studies to date have used animal airway tissues, vascular tissues, or transformed cell lines with only limited studies attempting to phenotypically characterize human airway mesenchymal cells. The objectives of this study were to evaluate reported markers and identify novel markers to define these cell types. We could not identify any specific marker to define these cell populations in vitro that permitted unequivocal identification using immunocytochemistry. However, characteristic filamentous alpha-smooth muscle actin distribution was observed in a significant ( approximately 25%) proportion of human airway smooth muscle cells, whereas this was not observed in airway fibroblasts. A significantly higher proportion of airway fibroblasts expressed alpha(1)- and alpha(2)-integrin receptors compared with human airway smooth muscle cells as assessed by fluorescence activated cell sorting. Global gene expression profiling identified aldo-keto reductase 1C3 (AKR1C3) and cathepsin K as being novel markers to define airway smooth muscle cells, whereas integrin-alpha(8) (ITGA8) and thromboxane synthase 1 (TBXAS1) were identified as novel airway fibroblast-specific markers, and these findings were validated by RT-PCR. Ex vivo studies in human airway tissue sections identified high-molecular weight caldesmon and alpha-smooth muscle actin as being expressed in smooth muscle bundles, whereas ITGA8 and TBXAS1 were absent from these.

Managing a good death in critical care: can health policy help?

AIM

This paper discusses end-of-life care (EoLC) in critical care through exploration of what is known from the international literature and what is currently presented within UK policy.

BACKGROUND AND CONTEXT

EoLC is an important international critical care issue, and currently provides a key focus for health care policy in the UK. While society holds that critical care is delivered in a highly technical area with a strong focus on cure and recovery, mortality rates in this speciality remain at approximately 20%. When patient recovery is not an outcome, discussions with patient, family and extended care teams turn towards futility of treatment and end-of-life management. However, there are specific barriers to overcome in EoLC for the critically ill.

CONCLUSION

A key issue for EoLC in critical care is a lack of robust systems to prospectively identify individuals who are most at risk of dying. A further challenge is divergent perspectives within and across clinical teams on treatment withdrawal and limitation practices. To streamline patient management and underpin a hospice approach to care, EoLC policies are currently being used within the UK. While this provides a national framework to address some key critical care clinical issues in the UK, there is a need for further refinement of the tool to reflect the reality of EoLC for the critically ill. It is important that international best practice exemplars are examined and clinicians actively engage and contribute to ensure that any local EoLC frameworks are fit for purpose.