Admission to intensive care unit at the end-of-life: is it an informed decision?

Manuscript Title: Defining and Characterizing Inappropriate Goals of Care Designation-A 10 year retrospective multicenter ICU cohort study

BACKGROUND

Goals of Care Designation (GCD) is a medical order used to describe and communicate the general aim of care. It includes a "code status" that guides the healthcare team on which interventions to offer during acute clinical deterioration. Inappropriate GCD occurs when there is lack of communication on the patient's wishes and values in the context of their health status, documentation of the conversation and plan, or agreement on medical effectiveness between patient, family and health care team stakeholders. The frequency of inappropriate GCD, the contributing factors, and their outcomes in ICUs are unknown.

METHODS

Using an existing quality assurance database, we conducted a retrospective multicenter cohort study of adult patients who died in the ICU between January 1, 2010 and December 31, 2019 to determine the frequency, etiology, and associated stakeholder and contextual features of patients flagged with goals of care concern by physician reviewers.

RESULTS

Of 4656 patients who died in the ICU and underwent a standardized morbidity and mortality review, 265 cases (5.7%) met criteria for inappropriate GCD for further analysis. Cases had one or more elements of suboptimal communication (n=119, 44.9%), documentation practices (n=77, 29.1%), or agreement of stakeholders (n = 115, 43.4%). Escalation in GCD to more intensive resuscitation orders occurred in 57 cases (21.5%) with common contextual features of crisis communication in the ER, or in preparation for a surgery or procedure.

CONCLUSION

We validated one definition of inappropriate GCD through a large retrospective cohort that can be used as a baseline incidence for future QI endeavors. Through this cohort analysis, a breadth of system opportunities to reduce inappropriate care through optimization of communication, documentation, and stakeholder decision-making processes is described.

Dying in the ICU : Changes in end of life decisions from 2011 to 2018 in the ICU of a communal tertiary hospital in Germany

BACKGROUND

With modern intensive care medicine, even older patients and those with pre-existing conditions can survive critical illnesses and major operations; however, unreflected application of intensive care treatment might lead to a state called chronic critical illness. Today, withholding treatment and/or treatment withdrawal precede many deaths in the intensice care unit (ICU). We looked at changes in measures at the end of life and withholding or withdrawal of treatment in the ICU of a German tertiary hospital in 2017/2018 compared to 2011/2012.

METHODS

In this retrospective explorative study, we analyzed end of life practices in adult patients who died in an intermediate care unit (IMC)/ICU of Klinikum Hanau in 2017/2018. We compared these data with data from the same hospital in 2011/2012 RESULTS: Of the 1246 adult patients who died in Klinikum Hanau in 2017/2018, 433 (35%) died in an ICU or IMC unit. Deceased ICU patients were 74.0 ± 12.5 years and 86.6% were older than 60 years. At least one life-sustaining measure was withheld in 278 (76.2%) and withdrawn in 159 (46.3%) of patients. More than three quarters of patients (n = 276, 75.6%) had a do not resuscitate (DNR) order and in about half of the patients invasive ventilation (n = 175, 49.9%) or renal replacement therapy (n = 191, 52.3%) was limited. In 113 patients (31.0%) catecholamine treatment was withdrawn, in 72 (19.7%) patients invasive ventilation and in 49 (13.4%) patients renal replacement therapy. Compared to 2011/2012, we saw an increase by ~15% (absolute increase) in withholding and withdrawal of treatment and observed an effect of documents like advance directive or healthcare proxy.

CONCLUSION

In 76.2% of deceased ICU patients withholding treatment and in 43.6% treatment withdrawal preceded death. Compared to 2011/2012 treatment was withheld or withdrawn more often. Compared to 2011/2012, we saw an increase (~15% absolute) in withholding and withdrawal of treatment. After withholding or withdrawal of treatment, most patients died within 3 and 2 days, respectively.

Dying in the Intensive Care Unit (ICU): A Retrospective Descriptive Analysis of Deaths in the ICU in a Communal Tertiary Hospital in Germany

BACKGROUND

Modern intensive care methods led to an increased survival of critically ill patients over the last decades. But an unreflected application of modern intensive care measures might lead to prolonged treatment for incurable diseases, and an inadaequate or too aggressive therapy can prolong the dying process of patients. In this study, we analysed end-of-life decisions regarding withholding and withdrawal of intensive care measures in a German intensive care unit (ICU) of a communal tertiary hospital.

METHODS

Patient datasets of all adult patients dying in an ICU or an intermediate care unit (IMC) in a tertiary communal hospital (Klinikum Hanau, Germany) between 01.01.2011 and 31.12.2012 were analysed for withholding and withdrawal of intensive care measures.

RESULTS

During the two-year period, 1317 adult patients died in Klinikum Hanau. Of these, 489 (37%) died either in an ICU/IMC unit. The majority of those deceased patients (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (n = 427, 87%) was 60 years or older. In 306 (62%) of 489 patients, at least one life-sustaining measure was withheld or withdrawn. In 297 (61%) of 489 patients dying in ICU/IMC, any type of therapy was withheld, and in 139 patients (28%), any type of therapy was withdrawn. Mostly, cardiopulmonary resuscitation (.

CONCLUSIONS

About one-third of patients dying in the hospital died in ICU/IMC. At least one life-sustaining therapy was limited/withdrawn in more than 60% of those patients. Withholding of a therapy was more common than active therapy withdrawal. Ventilation and renal replacement therapy were withdrawn in less than 5% of patients, respectively.

Situating requests for medical aid in dying within the broader context of end-of-life care: ethical considerations

BACKGROUND

Medical aid in dying (MAiD) was introduced in Quebec in 2015. Quebec clinical guidelines recommend that MAiD be approached as a last resort when other care options are insufficient; however, the law sets no such requirement. To date, little is known about when and how requests for MAiD are situated in the broader context of decision-making in end-of-life care; the timing of MAiD raises potential ethical issues.

METHODS

A retrospective chart review of all MAiD requests between December 2015 and June 2017 at two Quebec hospitals and one long-term care centre was conducted to explore the relationship between routine end-of-life care practices and the timing of MAiD requests.

RESULTS

Of 80 patients requesting MAiD, 54% (43) received the intervention. The median number of days between the request for MAiD and the patient's death was 6 days. The majority of palliative care consults (32%) came less than 7 days prior to the MAiD request and in another 25% of cases occurred the day of or after MAiD was requested. 35% of patients had no level of intervention form, or it was documented as 1 or 2 (prolongation of life remains a priority) at the time of the MAiD request and 19% were receiving life-prolonging interventions.

INTERPRETATION

We highlight ethical considerations relating to the timing of MAiD requests within the broader context of end-of-life care. Whether or not MAiD is conceptualised as morally distinct from other end-of-life options is likely to influence clinicians' approach to requests for MAiD as well as the ethical importance of our findings. We suggest that in the wake of the 2015 legislation, requests for MAiD have not always appeared to come after an exploration of other options as professional practice guidelines recommend.

Consensus statement for cancer patients requiring intensive care support

This consensus statement is directed to intensivists, hematologists, and oncologists caring for critically ill cancer patients and focuses on the management of these patients.

Futile Treatment-A Review

The main goal of intensive care medicine is helping patients survive acute threats to their lives, while preserving and restoring life quality. Because of medical advancements, it is now possible to sustain life to an extent that would previously have been difficult to imagine. However, the goals of medicine are not to preserve organ function or physiological activity but to treat and improve the health of a person as a whole. When dealing with medical futilities, physicians and other members of the care team should be aware of some ethical principles. Knowing these principles could make decision-making easier, especially in cases where legal guidelines are insufficient or lacking. Understanding of these principles can relieve the pressure that healthcare professionals feel when they have to deal with medical futility. Efforts should be made to promote an ethics of care, which means caring for patients even after further invasive treatment has been deemed to be futile. Treatments that improve patients' comfort and minimize suffering of both patients and their families are equally as important as those aimed at saving patients' lives.

Predictors of Transition to Hospice Care Among Hospitalized Older Adults With a Diagnosis of Dementia in Texas: A Population-Based Study

BACKGROUND

Decedent older adults with dementia are increasingly less likely to die in a hospital, though escalation of care to a hospital setting, often including critical care, remains common. Although hospice is increasingly reported as the site of death in these patients, the factors associated with transition to hospice care during end-of-life (EOL) hospitalizations of older adults with dementia and the extent of preceding escalation of care to an intensive care unit (ICU) setting among those discharged to hospice have not been examined.

METHODS

We identified hospitalizations aged ≥ 65 years with a diagnosis of dementia in Texas between 2001 and 2010. Potential factors associated with discharge to hospice were evaluated using multivariate logistic regression modeling, and occurrence of hospice discharge preceded by ICU admission was examined.

RESULTS

There were 889,008 elderly hospitalizations with a diagnosis of dementia during study period, with 40,669 (4.6%) discharged to hospice. Discharges to hospice increased from 908 (1.5%) to 7,398 (6.3%) between 2001 and 2010 and involved prior admission to ICU in 45.2% by 2010. Non-dementia comorbidities were generally associated with increased odds of hospice discharge, as were development of organ failure, the number of failing organs, or use of mechanical ventilation. However, discharge to hospice was less likely among non-white minorities (lowest among blacks: adjusted odds ratio (aOR): 0.67; 95% confidence interval (CI): 0.65 - 0.70) and those with non-commercial primary insurance or the uninsured (lowest among those with Medicaid: aOR (95% CI): 0.41 (0.37 - 0.46)).

CONCLUSIONS

This study identified potentially modifiable factors associated with disparities in transition to hospice care during EOL hospitalizations of older adults with dementia, which persisted across comorbidity and severity of illness measures. The prevalent discharge to hospice involving prior critical care suggests that key discussions about goals-of-care likely took place following further escalation of care to ICU. Together these findings can inform system- and clinician-level interventions to facilitate timely and consistent use of hospice to meet patients' goals of care.

Non-beneficial treatments in hospital at the end of life: a systematic review on extent of the problem

PURPOSE

To investigate the extent of objective 'non-beneficial treatments (NBTs)' (too much) anytime in the last 6 months of life in routine hospital care.

DATA SOURCES

English language publications in Medline, EMBASE, PubMed, Cochrane library, and the grey literature (January 1995-April 2015).

STUDY SELECTION

All study types assessing objective dimensions of non-beneficial medical or surgical diagnostic, therapeutic or non-palliative procedures administered to older adults at the end of life (EOL).

DATA EXTRACTION

A 13-item quality score estimated independently by two authors.

RESULTS OF DATA SYNTHESIS

Evidence from 38 studies indicates that on average 33-38% of patients near the EOL received NBTs. Mean prevalence of resuscitation attempts for advanced stage patients was 28% (range 11-90%). Mean death in intensive care unit (ICU) was 42% (range 11-90%); and mean death rate in a hospital ward was 44.5% (range 29-60%). Mean prevalence of active measures including dialysis, radiotherapy, transfusions and life support treatment to terminal patient was 7-77% (mean 30%). Non-beneficial administration of antibiotics, cardiovascular, digestive and endocrine treatments to dying patients occurred in 11-75% (mean 38%). Non-beneficial tests were performed on 33-50% of patients with do-not-resuscitate orders. From meta-analyses, the pooled prevalence of non-beneficial ICU admission was 10% (95% CI 0-33%); for chemotherapy in the last six weeks of life was 33% (95% CI 24-41%).

CONCLUSION

This review has confirmed widespread use of NBTs at the EOL in acute hospitals. While a certain level of NBT is inevitable, its extent, variation and justification need further scrutiny.

Factors influencing communication and decision-making about life-sustaining technology during serious illness: a qualitative study

OBJECTIVES

We aimed to identify factors influencing communication and decision-making, and to learn how physicians and nurses view their roles in deciding about the use of life-sustaining technology for seriously ill hospitalised patients and their families.

DESIGN

The qualitative study used Flanagan's critical incident technique to guide interpretive description of open-ended in-depth individual interviews.

SETTING

Participants were recruited from the medical wards at 3 Canadian hospitals.

PARTICIPANTS

Interviews were completed with 30 healthcare professionals (9 staff physicians, 9 residents and 12 nurses; aged 25-63 years; 73% female) involved in decisions about the care of seriously ill hospitalised patients and their families.

MEASURES

Participants described encounters with patients and families in which communication and decision-making about life-sustaining technology went particularly well and unwell (ie, critical incidents). We further explored their roles, context and challenges. Analysis proceeded using constant comparative methods to form themes independently and with the interprofessional research team.

RESULTS

We identified several key factors that influenced communication and decision-making about life-sustaining technology. The overarching factor was how those involved in such communication and decision-making (healthcare providers, patients and families) conceptualised the goals of medical practice. Additional key factors related to how preferences and decision-making were shaped through relationships, particularly how people worked toward 'making sense of the situation', how physicians and nurses approached the inherent and systemic tensions in achieving consensus with families, and how physicians and nurses conducted professional work within teams. Participants described incidents in which these key factors interacted in dynamic and unpredictable ways to influence decision-making for any particular patient and family.

CONCLUSIONS

A focus on more meaningful and productive dialogue with patients and families by (and between) each member of the healthcare team may improve decisions about life-sustaining technology. Work is needed to acknowledge and support the non-curative role of healthcare and build capacity for the interprofessional team to engage in effective decision-making discussions.

Association of goals of care meetings for hospitalized cancer patients at risk for critical care with patient outcomes

BACKGROUND

Caring for cancer patients with advanced and refractory disease requires communication about care preferences, particularly when patients become ill enough to be at risk for critical care interventions potentially inconsistent with their preferences.

AIM

To describe the use of goals of care discussions in patients with advanced/refractory cancer at risk for critical care interventions and evaluate associations between these discussions and outcomes.

DESIGN

Cohort study describing patients/families' perceptions of goals of care meetings and comparing health care utilization outcomes of patients who did and did not have discussions.

SETTING/PARTICIPANTS

Inpatient units of an academic cancer center. Included patients had metastatic solid tumors or relapsed/refractory lymphoma or leukemia and were at risk for critical care, defined as requiring supplemental oxygen and/or cardiac monitor.

RESULTS

Of 86 patients enrolled, 34 (39%) had a reported goals of care discussion (study group). Patients/families reported their needs and goals were addressed moderately to quite a bit during the meetings. Patients in the study group were less likely to receive critical care (0% vs 22%, p = 0.003) and more likely to be discharged to hospice (48% vs 30%, p = 0.04) than the control group. Only one patient in the study group died during the index hospitalization (on comfort care) (3%) compared with 9(17%) in the control group (p = 0.08).

CONCLUSION

Goals of care meetings for advanced/refractory cancer inpatients at risk for critical care interventions can address patient and family goals and needs and improve health care utilization. These meetings should be part of routine care for these patients.

Quality of dying in the ICU: is it worse for patients admitted from the hospital ward compared to those admitted from the emergency department?

OBJECTIVE

Although most intensive care unit (ICU) admissions originate in the emergency department (ED), a substantial number of admissions arrive from hospital wards. Patients transferred from the hospital ward often share clinical characteristics with those admitted from the ED, but family expectations may differ. An understanding of the impact of ICU admission source on family perceptions of end-of-life care may help improve patient and family outcomes by identifying those at risk for poor outcomes.

DESIGN AND SETTING

This was a cohort study of patients with chronic illness and acute respiratory failure requiring mechanical ventilation who died after admission to an ICU in any of the 14 participating hospitals in the Seattle-Tacoma area between 2003 and 2008 (n = 1,500).

MEASUREMENTS

Using regression models adjusted for hospital site and patient-, nurse- and family-level characteristics, we examined associations between ICU admission source (hospital ward vs. ED) and (1) family ratings of satisfaction with ICU care; (2) family and nurse ratings of quality of dying; (3) chart-based indicators of palliative care.

MAIN RESULTS

Admission from the hospital ward was associated with lower family ratings of quality of dying [β -0.90, 95% confidence interval (CI) -1.54, -0.26, p = 0.006] and satisfaction (total score β -3.97, 95% CI -7.89, -0.05, p = 0.047; satisfaction with care domain score β -5.40, 95% CI -9.44, -1.36, p = 0.009). Nurses did not report differences in quality of dying. Patients from hospital wards were less likely to have family conferences [odds ratio (OR) 0.68, 95% CI 0.52, 0.88, p = 0.004] or discussion of prognosis in the first 72 h after ICU admission (OR 0.72, 95% CI 0.56, 0.91, p = 0.007) but were more likely to receive spiritual care (OR 1.48, 95% CI 1.14, 1.93, p = 0.003) or have life support withdrawn (OR 1.38, 95% CI 1.04, 1.82, p = 0.025).

CONCLUSION

Admission from the hospital ward is associated with family perceptions of a lower quality of dying and less satisfaction with ICU care. Differences in receipt of palliative care suggest that family of patients from the hospital ward receive less communication. Nurse ratings of quality of dying did not significantly differ by ICU admission source, suggesting dissimilarities between family and nurse perspectives. This study identifies a patient population at risk for poor quality palliative and end-of-life care. Future studies are needed to identify interventions to improve care for patients who deteriorate on the wards following hospital admission.

Factors associated with in-hospital death by site of consultation among elderly inpatients receiving pain and palliative care consultations

BACKGROUND

Despite palliative care implementation, most deaths still occur in hospitals.

OBJECTIVES

To identify factors associated with in-hospital death among elderly patients receiving palliative care, by site of consultation.

DESIGN

Prospective observational study.

SETTING/SUBJECTS

All inpatients aged 65 years and older receiving pain and palliative care consultations in a 533-bed acute tertiary care hospital in Honolulu, Hawaii, from January 2005 through December 2009.

MEASUREMENTS

During consultation, demographics, diagnoses, consultation site (intensive care unit [ICU], non-ICU medical, non-ICU surgical, and rehabilitation floors), consultation indication (assistance with establishing goals of care versus pain and/or symptom management), Karnofsky scores, length of stay (LOS), discharge disposition, and in-hospital death were collected. Multiple logistic regression analyses examined factors associated with in-hospital death.

RESULTS

Of 1630 elderly inpatients receiving palliative care, 305 (19%) died in-hospital. In-hospital death among non-ICU medical patients was associated with needing consultation to assist with plan of care (odds ratio [OR]=1.89, 95% confidence interval [CI]=1.27-2.80). Likelihood of in-hospital death increased 2% for each additional hospital day before consultation (OR=1.02, 95% CI=1.01-1.03). Among elderly ICU patients, likelihood of in-hospital death increased 8% for each additional hospital day before consultation (OR=1.08, 95% CI=1.01-1.16).

CONCLUSION

Among elderly non-ICU medical patients receiving palliative care consultations, the need for a consultation to assist with plan of care was associated with in-hospital death, while length of stay prior to consultation was important among both elderly ICU and non-ICU medical patients. Elderly hospitalized patients may benefit from earlier identification and palliative care consultation for assistance with plan of care to avoid in-hospital death.

Factors associated with futile end-of-life intensive care in a cancer hospital

BACKGROUND

Management of critically ill patients involves weighing potential benefit of advanced life support against preserving quality of life, avoidance of futile measures and rational use of resources.

AIM

Our study aims to identify the predisposing factors involved in the institution and maintenance of futile intensive care support in terminally ill cancer patients in whom no additional treatment for the malignant disease would be offered.

DESIGN

We retrospectively analysed the medical records of patients who died in a tertiary cancer hospital (Hospital A C Camargo, São Paulo, Brazil) during an eight month period. Medical futility was defined when a patient, despite having been stated in the hospital records as having no possible lifespan extending treatment, was admitted to intensive care and received advanced life support. These cases were compared to controls who received palliative end-of-life care.

RESULTS

Three hundred and forty-seven deaths were recorded, of which 238 did not undergo futile treatment, 71 received full code treatment and 38 received futile treatments. Statistically significant predisposing factors for medical futility were, in our analysis, lack of palliative care team consultation (p < 0.001) and hematologic malignancy (p = 0.036). Qualitative analysis of medical records traced futile treatments to physicians' lacking proactive attitudes in considering prognosis and talking to families.

CONCLUSIONS

We conclude that a significant minority of end-of-life care consists of futile treatments. Strategies to increase Oncologists' and Critical Care specialists' alertness to these issues and expand indications of Palliative Care consultations are recommended.

Managing futility in critically ill patients with cardiac disease

Despite extraordinary innovations in cardiology and critical care, cardiovascular disease remains the leading cause of death globally, and heart failure has one of the highest disease burdens of any medical condition in the Western world. The lethality of many cardiac conditions, for which symptoms and prognoses are worse than for many malignancies, is widely under-recognized. A number of strategies have been developed within specialties such as oncology to improve the care of patients with life-threatening conditions. For reasons that are multifactorial, these options are often denied to critically ill patients with cardiac disease. Cardiologists and intensivists often regard death as failure, continuing to pursue active treatment while potentially denying patients access to alternatives such as symptom control and end-of-life care. Patient autonomy is central to the delivery of high-quality care, demanding shared decision-making to ensure patient preferences are acknowledged and respected. Although many cardiologists and intensivists do provide thoughtful and patient-centred care, the pressure to intervene can lead to physician-centric care focused around the needs and wishes of medical staff to the detriment of patients, families, health-care workers, and society as a whole.

Hospice eligibility in patients who died in a tertiary care center

BACKGROUND

Hospice is a service that patients, families, and physicians find beneficial, yet a majority of patients die without receiving hospice care. Little is known about how many hospitalized patients are hospice eligible at the time of hospitalization.

METHODS

Retrospective chart review was used to examine all adult deaths (n = 688) at a tertiary care center during 2009. Charts were selected for full review if the death was nontraumatic and the patient had a hospital admission within 12 months of the terminal admission. The charts were examined for hospice eligibility based on medical criteria, evidence of a hospice discussion, and hospice enrollment.

RESULTS

Two hundred nine patients had an admission in the year preceding the terminal admission and a nontraumatic death. Sixty percent were hospice eligible during the penultimate admission. Hospice discussions were documented in 14% of the hospice-eligible patients. Patients who were hospice eligible had more subspecialty consults on the penultimate admission compared to those not hospice eligible (P = 0.016), as well as more overall hospitalizations in the 12 months preceding their terminal admission (P = 0.0003), and fewer days between their penultimate admission and death (P = 0.001).

CONCLUSION

The majority of terminally ill inpatients did not have a documented discussion of hospice with their care provider. Educating physicians to recognize the stepwise decline of most illnesses and hospice admission criteria will facilitate a more informed decision-making process for patients and their families. A consistent commitment to offer hospice earlier than the terminal admission would increase access to community or home-based care, potentially increasing quality of life.

Are physicians ethically obligated to address hospice as an alternative to "usual" treatment of advancing end-stage disease?

Hospice care is ideally suited to meet the psychosocial and spiritual needs of dying patients, providing the opportunity to settle financial, property, and inheritance issues; to mend lacerations in important lifetime relationships, including forgiving and asking forgiveness; and to assure a degree of autonomous control over the environment and the social and spiritual processes that attend one's death. Physicians are not only imprecise in prognosticating a patient's time to die, they tend to be over-optimistic in their predictions. A "no" answer to the question, "Would I be surprised if this patient died in the next year?" is a reasonable starting-point for discussing hospice care as a potential treatment plan, now or in the future. Physicians have a duty to present palliative care in hospice as an alternative to the recurrent hospital interventions that are typical in the last six to 12 months of life tor patients who are failing and have declining prospects for one-year survival.

Support of cancer patients' spiritual needs and associations with medical care costs at the end of life

BACKGROUND

Although spiritual care is associated with less aggressive medical care at the end of life (EOL), it remains infrequent. It is unclear if the omission of spiritual care impacts EOL costs.

METHODS

A prospective, multisite study of 339 advanced cancer patients accrued subjects from September 2002 to August 2007 from an outpatient setting and followed them until death. Spiritual care was measured by patients' reports that the health care team supported their religious/spiritual needs. EOL costs in the last week were compared among patients reporting that their spiritual needs were inadequately supported versus those who reported that their needs were well supported. Analyses were adjusted for confounders (eg, EOL discussions).

RESULTS

Patients reporting that their religious/spiritual needs were inadequately supported by clinic staff were less likely to receive a week or more of hospice (54% vs 72.8%; P = .01) and more likely to die in an intensive care unit (ICU) (5.1% vs 1.0%, P = .03). Among minorities and high religious coping patients, those reporting poorly supported religious/spiritual needs received more ICU care (11.3% vs 1.2%, P = .03 and 13.1% vs 1.6%, P = .02, respectively), received less hospice (43.% vs 75.3% ≥1 week of hospice, P = .01 and 45.3% vs 73.1%, P = .007, respectively), and had increased ICU deaths (11.2% vs 1.2%, P = .03 and 7.7% vs 0.6%, P = .009, respectively). EOL costs were higher when patients reported that their spiritual needs were inadequately supported ($4947 vs $2833, P = .03), particularly among minorities ($6533 vs $2276, P = .02) and high religious copers ($6344 vs $2431, P = .005).

CONCLUSIONS

Cancer patients reporting that their spiritual needs are not well supported by the health care team have higher EOL costs, particularly among minorities and high religious coping patients.

Assessing Challenges in End-of-Life Conversations With Elderly Patients With Multiple Morbidities

Introduction: This study reports on physicians' experiences in conducting end-of-life conversations with elderly patients who suffered from multiple co-morbidities (MCM). Our hypothesis was that both the lack of prognostic certainty and the lack of good communication tools contributed to physicians' discomfort with conducting EOL conversations with patients and families of patients with these conditions especially when compared with patients and families of patients who had a single, clear terminal diagnosis (e.g. pancreatic cancer). Methods: Focus group questions were semi-structured and explored three general themes: (1) differences between having an end-of-life conversation with patients/families with MCM versus those with a single, terminal diagnosis; (2) timing of the end-of-life conversation; and (3) approaches to the end-of-life conversation. Results: Three themes emerged: (1) It is more difficult for them to have EOL conversations with patients with MCM and their families, as opposed to conversations with families and patients who have a clear, terminal diagnosis. (2) In deciding when to raise the subject of EOL care, participants reported that they rely on a number of physical and/or social signs to prompt these discussions. Yet a major reason for the difficulty that providers face in initiating these discussions with MCM patients and families is that there is a lack of a clear threshold or prompting event. (3) Participants mentioned three types of approaches to initiating EOL conversations: (a) direct approach, (b) indirect approach, (c) collaborative approach. Conclusion: Prognostic indicies and communication scripts may better prepare physicians to facilitate end-of-life conversations with MCM patients/families.

A qualitative study of family involvement in decisions about life support in the intensive care unit

We explored family involvement in decisions about life support interventions in the intensive care unit study using a critical incident technique to focus on specific case exemplars contributed by participants. A total of 6 family members and 9 health care professionals were interviewed. Participants described 2 options (life support or comfort care) and values associated with options: maintaining quality of life, surviving critical illness, minimizing pain and suffering, not being attached to machines, needing adjustment time, and judicious health care resource use. Barriers to involvement included not being offered alternative options; no specific trigger to initiate decision making; dominant influence of professionals' values; and families lacking understandable information. Family members are unlikely to engage in decision making unless professionals identify the decision and address other barriers to family involvement.

Bringing generalists into the hospital: outcomes of a family medicine hospitalist model in Singapore

PURPOSE

The aim of this study was to assess a newly introduced hospitalist care model in a Singapore hospital. Clinical outcomes of the family medicine hospitalists program were compared with the traditional specialists-based model using the hospital's administrative database.

METHODS

Retrospective cohort study of hospital discharge database for patients cared for by family medicine hospitalists and specialists in 2008. Multivariate analysis models were used to compare the clinical outcomes and resource utilization between patients cared for by family medicine hospitalists and specialist with adjustment for demographics, and comorbidities.

RESULTS

Of 3493 hospitalized patients in 2008 who met the criteria of the study, 601 patients were under the care of family medicine hospitalists. As compared with patients cared for by specialists, patients cared for by family medicine hospitalists had a shorter hospital length of stay (adjusted LOS, geometric mean, GM, 4.4 vs. 5.3 days; P < 0.001) and lower hospitalization costs (adjusted cost, GM, $2250.7 vs. $2500.0; P= 0.003), but a similar in-patient mortality rate (4.2% vs. 5.3%, P= 0.307) and 30-day all-cause unscheduled readmission rate (7.5% vs. 8.4%, P= 0.231) after adjustment for age, ethnicity, gender, intensive care unit (ICU) admission, numbers of organ failures, and comorbidities.

CONCLUSION

The family medicine hospitalist model was associated with reductions in hospital LOS and cost of care without adversely affecting mortality or 30-day all-cause readmission rate. These findings suggest that the hospitalist care model can be adapted for health systems outside North America and may produce similar beneficial effects in care efficiency and cost savings.

Cross-cultural communication and use of the family meeting in palliative care

Terminally-ill patients and their families often report poor communication and limited understanding of the patient's diagnosis, prognosis, and treatment plan; these deficits can be exacerbated by cross-cultural issues. Although family meetings are frequently recommended to facilitate provider-family communication, a more structured, evidence-based approach to their use may improve outcomes. Drawing on research and guidelines from critical care, palliative care, and cross-cultural communication, we propose a framework for conducting family meetings with consideration for cross-cultural issues.

Differences in level of care at the end of life according to race

BACKGROUND

Tailoring care for patients and their families at the end of life is important.

PURPOSE

To examine factors associated with patients' choices for level of care at the end of life.

METHODS

Data on demographics and level of care (full code, do not resuscitate, or withdrawal of life support) were collected on 1072 patients who died between January 1998 and June 2006 on a cardiac care unit. Logistic regression was used to identify factors associated with level of care.

RESULTS

Median (interquartile range) age of blacks was 64 (50-74) years and of whites was 70 (62-78) years. At the time of death, the level of care differed significantly between blacks and whites: 41.8% (n = 112) of blacks versus 26.7% (n = 194) of whites chose full code (P <.001), 37.3% (n = 96) of blacks versus 43.9% (n = 317) of whites chose do not resuscitate (P = .03), and 20.9% (n = 54) of blacks versus 29.3% (n = 210) of whites chose withdrawal of life support (P = .005). After age, sex, diagnosis, and lengths of stay in intensive care unit and hospital were controlled for, blacks were more likely than whites to choose full code status at the time of death (odds ratio 1.91 [95% confidence interval, 2.63-1.39], P < .001).

CONCLUSIONS

Blacks are 1.9 times as likely as others to choose full code at time of death. Cultural differences should be acknowledged when providing end-of-life care.

End-of-life discussions, goal attainment, and distress at the end of life: predictors and outcomes of receipt of care consistent with preferences

PURPOSE

Physicians have an ethical obligation to honor patients' values for care, including at the end of life (EOL). We sought to evaluate factors that help patients to receive care consistent with their preferences.

METHODS

This was a longitudinal multi-institutional cohort study. We measured baseline preferences for life-extending versus symptom-directed care and actual EOL care received in 325 patients with advanced cancer. We also measured associated sociodemographic, health, and communication characteristics, including EOL discussions between patients and physicians.

RESULTS

Preferences were assessed a median of 125 days before death. Overall, 68% of patients (220 of 325 patients) received EOL care consistent with baseline preferences. The proportion was slightly higher among patients who recognized they were terminally ill (74%, 90 of 121 patients; P = .05). Patients who recognized their terminal illness were more likely to prefer symptom-directed care (83%, 100 of 121 patients; v 66%, 127 of 191 patients; P = .003). However, some patients who were aware they were terminally ill wished to receive life-extending care (17%, 21 of 121 patients). Patients who reported having discussed their wishes for EOL care with a physician (39%, 125 of 322 patients) were more likely to receive care that was consistent with their preferences, both in the full sample (odds ratio [OR] = 2.26; P < .0001) and among patients who were aware they were terminally ill (OR = 3.94; P = .0005). Among patients who received no life-extending measures, physical distress was lower (mean score, 3.1 v 4.1; P = .03) among patients for whom such care was consistent with preferences.

CONCLUSION

Patients with cancer are more likely to receive EOL care that is consistent with their preferences when they have had the opportunity to discuss their wishes for EOL care with a physician.

Continuous Deep Sedation Until Death: Palliation or Physician-Assisted Death?

Published literature have not discerned end-of-life palliative versus life-shortening effects of pharmacologically maintaining continuous deep sedation until death (ie, dying in deep sleep) compared with common sedation practices relieving distress in the final conscious phase of dying. Continuous deep sedation predictably suppresses brainstem vital centers and shortens life. Continuous deep sedation remains controversial as palliation for existential suffering and in elective death requests by discontinuation of chronic ventilation or circulatory support with mechanical devices. Continuous deep sedation contravenes the double-effect principle because: (1) it induces permanent coma (intent of action) for the contingency relief of suffering and for social isolation (desired outcomes) and (2) because of its predictable and proportional life-shortening effect. Continuous deep sedation should be distinguished from common sedation practices for palliation and characterized instead as physician-assisted death.

A comfortable place to say goodbye

No death is easy, but we hope to die peacefully, with our loved ones surrounding us, comforted by each other's presence and the knowledge that the right decision has been made. The nurse's actions in the intensive care unit setting can promote hope for a comfortable place to say goodbye for the patient and his/her loved ones and the nursing staff and physicians. When nurses make the intensive care unit a comfortable place for the dying patients and their loved ones, we also make the patients' deaths comfortable for us. The problems encountered in implementing end-of-life care are explored in this article, as well as strategies to instill hope in families.

Assessment of implementation of an order protocol for end-of-life symptom management

OBJECTIVES

Designing comfort care plans to treat symptoms at the end-of-life in the hospital is challenging. We evaluated the implementation of an inpatient end-of-life symptom management order (ESMO) protocol that guides the use of opiate medications and other modalities to provide palliation.

METHODS

Physicians and nurses caring for patients using the ESMO protocol were surveyed about care provided and their experiences.

RESULTS

Over 342 days, 127 patients (2.6 per week) were treated using the ESMO protocol and we surveyed a nurse and/or physician for 105 (83%) patients. Most patients were comatose, obtunded/stuperous, or disoriented when the ESMO protocol was initiated and most had a life expectancy of less than 1 day. One fourth of physicians felt that the protocol was instituted too late, principally citing family unwillingness to reorient toward comfort care. Providers reported that opiates were titrated appropriately, although a minority revealed discomfort with end-of-life opiate use. Nearly all clinicians found the ESMO protocol to be valuable.

CONCLUSIONS

A standardized protocol is a useful, but not fully sufficient, step toward improving care for dying hospitalized patients.

Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment

CONTEXT

Talking about death can be difficult. Without evidence that end-of-life discussions improve patient outcomes, physicians must balance their desire to honor patient autonomy against a concern of inflicting psychological harm.

OBJECTIVE

To determine whether end-of-life discussions with physicians are associated with fewer aggressive interventions.

DESIGN, SETTING, AND PARTICIPANTS

A US multisite, prospective, longitudinal cohort study of patients with advanced cancer and their informal caregivers (n = 332 dyads), September 2002-February 2008. Patients were followed up from enrollment to death, a median of 4.4 months later. Bereaved caregivers' psychiatric illness and quality of life was assessed a median of 6.5 months later.

MAIN OUTCOME MEASURES

Aggressive medical care (eg, ventilation, resuscitation) and hospice in the final week of life. Secondary outcomes included patients' mental health and caregivers' bereavement adjustment.

RESULTS

One hundred twenty-three of 332 (37.0%) patients reported having end-of-life discussions before baseline. Such discussions were not associated with higher rates of major depressive disorder (8.3% vs 5.8%; adjusted odds ratio [OR], 1.33; 95% confidence interval [CI], 0.54-3.32), or more worry (mean McGill score, 6.5 vs 7.0; P = .19). After propensity-score weighted adjustment, end-of-life discussions were associated with lower rates of ventilation (1.6% vs 11.0%; adjusted OR, 0.26; 95% CI, 0.08-0.83), resuscitation (0.8% vs 6.7%; adjusted OR, 0.16; 95% CI, 0.03-0.80), ICU admission (4.1% vs 12.4%; adjusted OR, 0.35; 95% CI, 0.14-0.90), and earlier hospice enrollment (65.6% vs 44.5%; adjusted OR, 1.65;95% CI, 1.04-2.63). In adjusted analyses, more aggressive medical care was associated with worse patient quality of life (6.4 vs 4.6; F = 3.61, P = .01) and higher risk of major depressive disorder in bereaved caregivers (adjusted OR, 3.37; 95% CI, 1.12-10.13), whereas longer hospice stays were associated with better patient quality of life (mean score, 5.6 vs 6.9; F = 3.70, P = .01). Better patient quality of life was associated with better caregiver quality of life at follow-up (beta = .20; P = .001).

CONCLUSIONS

End-of-life discussions are associated with less aggressive medical care near death and earlier hospice referrals. Aggressive care is associated with worse patient quality of life and worse bereavement adjustment.

End-of-life care in UK critical care units--a literature review

AIM

To appraise literature concerning end-of-life care (ELC) in adult critical care units in the UK in order to improve clinical practice.

OBJECTIVE

To understand the interplay between legal and ethical, political, societal aspects of ELC for sustainable quality care.

BACKGROUND

Significant changes in health care policy for the critically ill patient have occurred since 1999. Simultaneously, the government is committed to improving care for the dying by integrating the palliative care ethos across the National Institutes of Health (NHS) to include non-cancer sufferers. Death continues to be a feature of critical illness, particularly following the decision to withhold/withdraw life-prolonging treatments.

SEARCH STRATEGY

A search of MEDLINE, BNI, CINAHL and PSYCinfo using key words revealed very few results; consequently, the search was broadened to include ASSIA, King's Fund, TRIP, Healthstar, NHS Economic Evaluation Data, Cochrane, professional journals and government documents.

CONCLUSIONS

The literature reveals a paradigm shift from critical to palliative care, in other words, from a reductionist approach to a more humanistic approach in the acute setting. When treatment is deemed futile, quality ELC involving the assessment, ongoing assessment and care after death becomes the new goal for the critical care team. To practice ELC competently, nurses require organizational and educational support at local and national levels.

RELEVANCE TO CLINICAL PRACTICE

Although medico-legal decision-making is not part of their professional role, critical care nurses have an extraordinary opportunity to make a difference to the dying patient and their family and their acceptance of death.

Provider insights about palliative care barriers and facilitators: results of a rapid ethnographic assessment

Palliative care remains underutilized in the United States. This may represent failure of translation of research into practice (diffusion of innovation). Qualitative methods can identify barriers to and facilitators of diffusion of innovation. The aim is to identify potential barriers to and facilitators of inpatient palliative care utilization at a large urban hospital, as articulated by health professionals. Rapid ethnographic assessment methods were used among health professionals with subsequent extraction of predominant themes illuminating factors influencing adoption of palliative care services. In all, 3 stakeholder categories and 7 major themes emerged. Analysis revealed consistent need for organized, cross-disciplinary education/training services and a clearly-defined team approach. Denial at all stakeholder levels and in most themes was a barrier to implementation of palliative care. Consistent, defined educational, policymaking, and procedural standards were requirements for best adoption of palliative care. Denial was a striking obstruction to diffusion of innovation.

Perceptions of "futile care" among caregivers in intensive care units

BACKGROUND

Many caregivers in intensive care units (ICUs) feel that they sometimes provide inappropriate or excessive care, but little is known about their definition of "futile care" or how they attempt to limit its impact. We sought to explore how ICU staff define medically futile care, why they provide it and what strategies might promote a more effective use of ICU resources.

METHODS

Using semi-structured interviews, we surveyed 14 physician directors, 16 nurse managers and 14 respiratory therapists from 16 ICUs across Ontario. We analyzed the transcripts using a modified grounded-theory approach.

RESULTS

From the interviews, we generated a working definition of medically futile care to mean the use of considerable resources without a reasonable hope that the patient would recover to a state of relative independence or be interactive with his or her environment. Respondents felt that futile care was provided because of family demands, a lack of timely or skilled communication, or a lack of consensus among the treating team. Respondents said they were able to resolve cases of futile care most effectively by improving communication and by allowing time for families to accept the reality of the situation. Respondents felt that further efforts to limit futile care should focus on educating the public and health care professionals about the role of the ICU and about alternatives such as palliative care; mandating early and skilled discussion of resuscitation status; establishing guidelines for admission to the ICU; and providing legal and ethical support for physicians who encounter difficulties. There was a broad consistency in responses among all disciplines.

INTERPRETATION

ICU physicians, nurses and respiratory therapists have similar and well-formed opinions about how to define and resolve medically futile care and where to focus future efforts to limit the impact of futile care in the ICU.

The relationship between moral distress and perception of futile care in the critical care unit

PURPOSE

Study the relationship between moral distress (MD) and futile care in the critical care unit (CCU).

SUBJECTS AND METHODS

A cross-sectional survey consisting of 38 clinical situations associated with MD related to 6 categories: physician practice, nursing practice, institutional factors, futile care, deception and euthanasia was distributed to 100 nurses at a single CCU. The intensity and frequency of MD were scored with Likert scale: 0-lowest and 6-highest.

RESULTS

The survey was completed by 44 (44%) nurses. Median age was 33 years, 80% females. Median intensity of MD was high for the six categories and had no relationship with age, time in CCU or nursing practice. The encounter frequency of MD for futile care was the highest and was significantly related to age >33 years (p=0.03), time in CCU >4 years (p=0.04) and nursing practice >7 years (p=0.01).

CONCLUSION

MD associated with clinical situations representing futile care increased with time in CCU. Future interventions are required to minimize the exposure to futile care situations and develop mechanisms to mitigate the effects of MD in the CCU.

Management of patients with metastatic malignancy in the intensive care unit

Intensive care units serve to provide temporary physiologic support to patients with reversible organ failure. However, with increasing frequency, patients with end-stage and terminal illnesses are being admitted to the intensive care unit. Indeed, in the United States, a third of all patients with terminal metastatic malignancy are admitted to the intensive care unit, and 60% of all hospital deaths occur after such an admission. In many instances, admission to an intensive care unit serves only to transform death into a prolonged, painful, and undignified process. In patients with a terminal illness, the focus should be on measures that ensure comfort, and admission to an intensive care unit should generally be avoided. Intensivists, who are charged with making the best use of limited resources, should ultimately be the individuals who determine the appropriateness of admitting such patients to the intensive care unit.

Measuring the quality of dying and death: methodological considerations and recent findings

PURPOSE OF REVIEW

While the need to improve the quality of dying and death in critical settings has been well accepted, there is less agreement on which measures and criteria are best used to assess it. In this article, we present methodological considerations and recent findings that pertain to the measurement of the quality of dying and death.

RECENT FINDINGS

Research evaluating the quality of dying and death employs measures based on professionally determined criteria as well as measures relying on patient and family-centered standards. Professionally determined measures include assessments of resource consumption (e.g., length of stay, costs of care, technology utilization) and processes of care (e.g., do-not-resuscitate orders, family conferences). Studies of interventions designed to improve end-of-life care have shown positive changes in these outcomes. Patient and family-centered measures (e.g., quality of dying and death questionnaires, quality of end-of-life care questionnaires) have been used less often in intervention studies but, in descriptive studies, have shown important associations with factors related to a 'good death'.

SUMMARY

These findings suggest a need to integrate both types of measures in research on the quality of end-of-life experiences. This integration, with attention to important methodological issues, may represent a significant step toward improving patients' experiences at the end-of-life.

Case studies in medical futility

Technology has provided means to sustain life and provide care regardless of whether the treatment is appropriate and compassionate given the condition of the patient. This study presents two case histories, compiled from historical patient charts, staff notes and observations, that illustrate the variety of ethical issues involved and the role culture plays in the decision making process related to possible futile medical treatment. Ethical and cultural issues related to the cases are discussed and processes are presented that can help hospitals to avoid, or decrease the level of, medically futile care, and improve the cultural appropriateness of medical care and relationships with patients.

Reductionism and holism in coronary heart disease and cardiac nursing

Reductionism and holism are two contrasting philosophies which provide scientific knowledge of disease processes, health dynamics and care interventions. While reductionism focuses on specific and perhaps narrow concepts, it enhances our in-depth knowledge of key health issues. Holism focuses on understanding how all the significant factors affecting the particular health issue are involved, so a more informed decision can be made about health intervention. This article explores the contribution each makes to our understanding of coronary heart disease (CHD) and to the preparation of nurses working in cardiac nursing. It proposes that pre- and post-registration nursing curricula reflect both reductionist and holistic approaches and therefore cardiac nurses are suitably trained to manage reductionist as well as holistic care for clients with CHD.

Challenges to end of life care in the acute hospital setting

BACKGROUND

Research exploring patients' care and treatment preferences at the end of life (EOL) suggests they prefer comfort more than life-extension, wish to participate in decision-making, and wish to die at home. Despite these preferences, the place of death for many patients is the acute hospital, where EOL interventions are reported to be inappropriately invasive and aggressive.

AIM

This paper discusses the challenges to appropriate EOL care in acute hospitals in the UK, highlighting how this setting contributes to the patients' and families' care and treatment requirements being excluded from decision-making.

METHODS

Twenty-nine cancer nurse specialists from five hospitals participated in a grounded theory study, using observation and semi-structured interviews. Data were collected and analysed concurrently using the constant comparative method.

RESULTS

EOL interventions in the acute setting were driven by a preoccupation with treatment, routine practice and negative perceptions of palliative care. All these factors shaped clinical decision-making and prevented patients and their families from fully participating in clinical decision-making at the EOL.

Impact of a Palliative Care Service on In-Hospital Mortality in a Comprehensive Cancer Center

BACKGROUND

Palliative care services provide symptom control and psychosocial support for dying patients and their families. These services are not available in many cancer centers and tertiary hospitals. The purpose of this study was to review the impact of a palliative care program, established in 1999, on overall in-hospital mortality.

METHODS

We reviewed the M. D. Anderson Cancer Center computerized database to determine the total number of deaths and discharges and the place of death for each fiscal year from 1999 to 2004. The median length of stay for patients who died in different locations within the hospital was calculated. Annual palliative care consultations for patients who subsequently died in the hospital were retrieved. The annual mortality rate for the cancer center was calculated.

RESULTS

The overall in-hospital mortality rates were 3.6, 3.7, 3.6, 3.5, 3.6, and 3.7% of all discharges for the period 1999-2004 respectively (p > 0.2). The number of deaths in the medical intensive care unit (MICU) dropped from 252 in 671 (38%) in 1999 to 213 in 764 (28%) in 2004 (p < 0.0001). Involvement of the palliative care service in the care of patients dying in the hospital grew from 8 in 583 (1%) in 1999 to 264 in 764 (35%) in 2004 (p < 0.0001). The median length of hospital stay (MLOS) for patients who subsequently died in-hospital was significantly longer than that for patients who were discharged alive.

CONCLUSIONS

Increased involvement by the palliative care service in the care of decedent patients was associated with a decreased MICU mortality and no change in overall hospital mortality rate or inpatient length of hospital stay.