Withholding and Withdrawal of Therapy in New Zealand Intensive Care Units (ICUs): A Survey of Clinical Directors

Would you like to be admitted to the ICU? The preferences of intensivists and general public according to different outcomes

BACKGROUND

Discussions about invasiveness of care (advanced directives) and end-of-life issues have become frequent among intensivists and patients. Nevertheless, there are considerable divergences in the attitudes between intensivists and patients toward end-of-life care in the intensive care units (ICU).

METHODS

The goal was to compare the preferences between intensivists and general public regarding ICU admission of a hypothetical patient with six different clinical outcomes. For that, intensivists and the general public (university graduate professionals outside the area of health) were invited to participate in this study. A survey was conducted with a hypothetical patient with six different clinical outcomes ranging from ICU discharge without any neurological sequelae, nor dependence for daily activities, to death. The WHOQOL-BREF was applied. Comparisons were made between the answers provided by intensivists regarding what they would choose for themselves and their patients, and the preferences of general public.

RESULTS

Between July 2013 and July 2016, 300 participants in 5 hospitals in São Paulo, Brazil were invited to participate in this study, of whom 257 (85.7%) responded the survey. Eighty-two intensivists responded what they would choose for themselves, 81 intensivists responded what they would choose for their patients, and 94 people from general public responded what they would choose for themselves. Quality of life did not differ among the groups. In all scenarios, except when the outcome was severe disability or death, intensivists were more likely to choose ICU admission for their patients than for themselves (p < .05 for all). Compared with general public, intensivists were more likely to choose ICU admission for themselves only when the best clinical scenario outcome is considered (p < .001). General public was significantly less prone to choosing ICU admission than intensivists when choosing for their patients, in three out of six scenarios (p < .001 for all).

CONCLUSIONS

Considerable divergences exist between intensivists' and patients' preferences toward end-of-life care. Advanced care planning and effective ongoing communication among intensivists, patients and relatives are essential to improve end-of-life decisions and the quality of care.

Physical impairment and perceived general health preceding critical illness is predictive of survival

PURPOSE

We hypothesized that item response based assessment of physical reserve preceding ICU admission is a predictor of survival.

METHODS

We evaluated physical functioning using the Academic Medical Center Linear Disability Score (ALDS) and quality of life using the first question (SF-1) and the physical component score (PCS-12) from the Short-form 12 (SF-12) before admission by patients or by close proxies within 72 h after ICU admission during 1 year.

RESULTS

We developed four logistic regression models to predict 1 year mortality using the predictors age, gender, ALDS, SF-1, PCS-12. A total of 510 patients participated. Twelve months after ICU discharge, 110 patients (22%) had died. Pre-admission ALDS (p = .004), and SF-1 (p = .012) improved the prediction models with age and gender PCS-12 showed no association with mortality (p = .062). Adding the ALDS (p = .049) and the SF-1 (p = .048) to a model with age, gender and the APACHE II score (improved the model. Adding PCS-12 showed no association with mortality (p = .355).

CONCLUSIONS

Physical reserve as assessed by ALDS and perceived general health, preceding ICU admission is predictive of mortality. Obtaining patient's physical reserve or pre-existing perceived general health should be part of routine assessment whether a patient may benefit from ICU admission.

Limitation of life support techniques at admission to the intensive care unit: a multicenter prospective cohort study

Purpose

To determine the frequency of limitations on life support techniques (LLSTs) on admission to intensive care units (ICU), factors associated, and 30-day survival in patients with LLST on ICU admission.

Methods

This prospective observational study included all patients admitted to 39 ICUs in a 45-day period in 2011. We recorded hospitals’ characteristics (availability of intermediate care units, usual availability of ICU beds, and financial model) and patients’ characteristics (demographics, reason for admission, functional status, risk of death, and LLST on ICU admission (withholding/withdrawing; specific techniques affected)). The primary outcome was 30-day survival for patients with LLST on ICU admission. Statistical analysis included multilevel logistic regression models.

Results

We recruited 3042 patients (age 62.5 ± 16.1 years). Most ICUs (94.8%) admitted patients with LLST, but only 238 (7.8% [95% CI 7.0–8.8]) patients had LLST on ICU admission; this group had higher ICU mortality (44.5 vs. 9.4% in patients without LLST; p < 0.001). Multilevel logistic regression showed a contextual effect of the hospital in LLST on ICU admission (median OR = 2.30 [95% CI 1.59–2.96]) and identified the following patient-related variables as independent factors associated with LLST on ICU admission: age, reason for admission, risk of death, and functional status. In patients with LLST on ICU admission, 30-day survival was 38% (95% CI 31.7–44.5). Factors associated with survival were age, reason for admission, risk of death, and number of reasons for LLST on ICU admission.

Conclusions

The frequency of ICU admission with LLST is low but probably increasing; nearly one third of these patients survive for ≥ 30 days.

Electronic supplementary material

The online version of this article (10.1186/s40560-018-0283-y) contains supplementary material, which is available to authorized users.

Current situation and associated factors of withdrawing or withholding life support to patients in an intensive care unit of cancer center in China

OBJECTIVES

To investigate the current situation and analyze the associated factors of withdrawing or withholding life support in the intensive care unit (ICU) of our cancer center.

METHODS

Three hundred and twenty-two cancer patients in critical status were admitted to our ICU in 2010 and 2011. They were included in the study and were classified into two groups: withdrawing or withholding life support (WWLS), and full life support (FLS). Demographic information and clinical data were collected and compared between the two groups. Factors associated with withdrawing or withholding life support were analyzed with univariate and multivariate logistic regression analysis.

RESULTS

Eighty-two of the 322 cases (25.5% of all) made the decisions to withdraw or withhold life support. Emergency or critical condition at hospital admission, higher scores of Acute Physiology and Chronic Health Evaluation II (APACHE II) in 12 hours after ICU admission, financial difficulties and humanistic care requirements are important factors associated with withdrawing or withholding life support.

CONCLUSIONS

Withdrawing or withholding life support is not uncommon in critically ill cancer patients in China. Characteristics and associated factors of the decision-making are related to the current medical system, medical resources and traditional culture of the country.

Factors associated with the withdrawal of life-sustaining therapies in patients with severe traumatic brain injury: a multicenter cohort study

PURPOSE

To identify factors associated with decisions to withdraw life-sustaining therapies in patients with severe traumatic brain injury (TBI).

MATERIALS AND METHODS

We conducted a 2-year multicenter retrospective cohort study (2005-2006) in mechanically ventilated patients aged 16 years and older admitted to the intensive care units (ICUs) of six Canadian level I trauma centers following severe TBI. One hundred and twenty charts were randomly selected at each center (n = 720). Data on ICU management strategies, patients' clinical condition, surgical procedures, diagnostic imaging, and decision to withdraw life-sustaining therapies were collected. The association of factors pertaining to the injury, interventions, and management strategies with decisions to withdraw life-sustaining therapies was evaluated among non-survivors.

RESULTS

Among the 228 non-survivors, 160 died following withdrawal of life-sustaining therapies. Patients were predominantly male (69.7 %) with a mean age of 50.7 (±21.7) years old. Brain herniation was more often reported in patients who died following decisions to withdraw life-sustaining therapies (odds ratio [OR] 2.91, 95 % confidence interval [CI] 1.16-7.30, p = 0.02) compared to those who died due to other causes (e.g., cardiac arrest, shock, etc.). Epidural hematomas (OR 0.18, 95 % CI 0.06-0.56, p < 0.01), craniotomies (OR 0.12, 95 % CI 0.02-0.68, p = 0.02), and other non-neurosurgical procedures (OR 0.08, 95 % CI 0.02-0.43, p < 0.01) were less often associated with death following withdrawal of life-sustaining therapies than death from other causes.

CONCLUSIONS

Death following decisions to withdraw life-sustaining therapies is associated with specific patient and clinical factors, and the intensity of care.

Palliative critical care in the intensive care unit: A 2011 perspective

Pain relief and palliative care play an increasingly important role in the overall approach to critically ill and injured patients. Despite significant progress in clinical patient care, our understanding of death and the dying process remains limited. For various reasons, people tend to delay facing questions associated with end-of-life, and the fear of the unknown often creates an environment of avoidance and an atmosphere of taboo. The topic of end-of-life care is multifaceted. It incorporates medical, ethical, spiritual, and religious aspects, among many others. Our ability to sustain the lives of the critically ill may be complicated by continuing life support in medically futile scenarios. This article, as well as the remainder of the IJCIIS Symposium on End-of-Life in Trauma/Intensive Care Unit, will explore the most important issues in the field of modern end-of-life care and palliative medicine, with a focus on critically ill and injured patients.

Access to reliable information about long-term prognosis influences clinical opinion on use of lifesaving intervention

BACKGROUND

Decompressive craniectomy has been traditionally used as a lifesaving rescue treatment in severe traumatic brain injury (TBI). This study assessed whether objective information on long-term prognosis would influence healthcare workers' opinion about using decompressive craniectomy as a lifesaving procedure for patients with severe TBI.

METHOD

A two-part structured interview was used to assess the participants' opinion to perform decompressive craniectomy for three patients who had very severe TBI. Their opinion was assessed before and after knowing the predicted and observed risks of an unfavourable long-term neurological outcome in various scenarios.

RESULTS

Five hundred healthcare workers with a wide variety of clinical backgrounds participated. The participants were significantly more likely to recommend decompressive craniectomy for their patients than for themselves (mean difference in visual analogue scale [VAS] -1.5, 95% confidence interval -1.3 to -1.6), especially when the next of kin of the patients requested intervention. Patients' preferences were more similar to patients who had advance directives. The participants' preferences to perform the procedure for themselves and their patients both significantly reduced after knowing the predicted risks of unfavourable outcomes, and the changes in attitude were consistent across different specialties, amount of experience in caring for similar patients, religious backgrounds, and positions in the specialty of the participants.

CONCLUSIONS

Access to objective information on risk of an unfavourable long-term outcome influenced healthcare workers' decision to recommend decompressive craniectomy, considered as a lifesaving procedure, for patients with very severe TBI.

Comparison of physician prediction with 2 prognostic scoring systems in predicting 2-year mortality after intensive care admission: a linked-data cohort study

PURPOSE

Patients who survive an episode of critical illness continue to experience significant mortality after hospital discharge. This study assessed the accuracy of physician prediction of 2-year mortality and compared it with 2 objective prognostic models.

METHODS

Sensitivity (probability of a prediction of death in patients who died within 2 years) and specificity (probability of a prediction of survival in patients who survived at least 2 years) of physicians' 2-year prediction were compared with those from 2 objective prognostic models, Acute Physiology and Chronic Health Evaluation (APACHE) II and Predicted Risk Existing Disease Intensive Care Therapy (PREDICT).

RESULTS

Physician prediction of 2-year mortality was available for 2497 (94.8%) intensive care unit admissions. Specificity was high (85.2%; 95% confidence interval [CI], 83.7-86.4), but sensitivity (65.0%; 95% CI, 61.1-68.8) and positive predictive value (57.4%; 95% CI, 53.6-61.2) were relatively low, suggesting overpessimistic prediction of 2-year mortality. Age, Charlson comorbidity index, and APACHE score were independent risk factors for an inaccurate physician prediction. The diagnostic odds ratio for the physician predictions was at least comparable with the APACHE and PREDICT models, which both had very good discrimination of mortality at 2-year follow-up.

CONCLUSIONS

Physicians tended to overpredict the risk of 2-year mortality of critically ill patients, but accuracy was comparable with 2 objective prognostic models.

Estimating long-term survival of critically ill patients: the PREDICT model

Background

Long-term survival outcome of critically ill patients is important in assessing effectiveness of new treatments and making treatment decisions. We developed a prognostic model for estimation of long-term survival of critically ill patients.

Methodology and Principal Findings

This was a retrospective linked data cohort study involving 11,930 critically ill patients who survived more than 5 days in a university teaching hospital in Western Australia. Older age, male gender, co-morbidities, severe acute illness as measured by Acute Physiology and Chronic Health Evaluation II predicted mortality, and more days of vasopressor or inotropic support, mechanical ventilation, and hemofiltration within the first 5 days of intensive care unit admission were associated with a worse long-term survival up to 15 years after the onset of critical illness. Among these seven pre-selected predictors, age (explained 50% of the variability of the model, hazard ratio [HR] between 80 and 60 years old = 1.95) and co-morbidity (explained 27% of the variability, HR between Charlson co-morbidity index 5 and 0 = 2.15) were the most important determinants. A nomogram based on the pre-selected predictors is provided to allow estimation of the median survival time and also the 1-year, 3-year, 5-year, 10-year, and 15-year survival probabilities for a patient. The discrimination (adjusted c-index = 0.757, 95% confidence interval 0.745–0.769) and calibration of this prognostic model were acceptable.

Significance

Age, gender, co-morbidities, severity of acute illness, and the intensity and duration of intensive care therapy can be used to estimate long-term survival of critically ill patients. Age and co-morbidity are the most important determinants of long-term prognosis of critically ill patients.

Outcome of patients who have therapy withheld or withdrawn in ICU

Many deaths among patients treated in intensive care units (ICUs) occur following the withdrawal or withholding of life support. Following limitation of life support, most of these patients die in the ICU or ward after the decision to limit life support is made, although some may survive to hospital discharge. This study described the characteristics of patients who had life support limitations in ICU and their subsequent in-hospital and out-of-hospital survival using linked data from the state's death registry. Among 26,019 ICU admissions between 1987 and 2002 there were 396 patients (1.5%) who had life support limitations. The hospital mortality of the patients who had life support limitations was 97.7% and this accounted for 16.2% of the hospital mortality of all ICU admissions. Of the 396 patients who had life support limitations, 315 patients (79.5%) died in the ICU, 72 patients (18.2%) died in the wards and nine patients (2.3%) were discharged from hospital. Of these nine patients who survived to hospital discharge, four died within 10 days of hospital discharge and a further two died within six months. There were two patients, both with significant neurological disabilities at hospital discharge, who survived for longer than three years after hospital discharge. Long-term survival in critically ill patients who had life support limitations was very rare in this ICU.

The involvement of intensive care nurses in end-of-life decisions: a nationwide survey

OBJECTIVE

To investigate the prevalence and predictors of intensive care nurses' active involvement in end-of-life (EOL) decisions.

DESIGN AND SETTING

A survey of intensive care nurses from 36 intensive care units (ICUs) in New Zealand.

MEASUREMENTS AND RESULTS

A total of 611 ICU nurses from 35 ICUs responded to this survey. The response rate was estimated to be between 43% and 81%. Seventy-eight percent of respondents reported active involvement in EOL decisions, especially the senior nurses (level IV vs. I nurses, OR 7.9; nurse educators vs. level I nurses, OR 4.3). Asian (OR 0.2) and Pacific Islander nurses (OR 0.2) were less often involved than European nurses. Sixty-eight percent of respondents preferred more involvement in EOL decisions, and this preference was associated with the perception that EOL decisions are often made too late (OR 2.2). Sixty-five percent believed their active involvement in EOL decisions would improve nursing job satisfaction.

CONCLUSIONS

Most ICU nurses in New Zealand reported that they are often involved in EOL decisions, especially senior and European nurses.