Reversals and limitations on high-intensity, life-sustaining treatments

European Society of Intensive Care Medicine guidelines on end of life and palliative care in the intensive care unit

The European Society of Intensive Care Medicine (ESICM) has developed evidence-based recommendations and expert opinions about end-of-life (EoL) and palliative care for critically ill adults to optimize patient-centered care, improving outcomes of relatives, and supporting intensive care unit (ICU) staff in delivering compassionate and effective EoL and palliative care. An international multi-disciplinary panel of clinical experts, a methodologist, and representatives of patients and families examined key domains, including variability across countries, decision-making, palliative-care integration, communication, family-centered care, and conflict management. Eight evidence-based recommendations (6 of low level of evidence and 2 of high level of evidence) and 19 expert opinions were presented. EoL legislation and the importance of respecting the autonomy and preferences of patients were given close attention. Differences in EoL care depending on country income and healthcare provision were considered. Structured EoL decision-making strategies are recommended to improve outcomes of patients and relatives, as well as staff satisfaction and mental health. Early integration of palliative care and the use of standardized tools for symptom assessment are suggested for patients at high risk of dying. Communication training for ICU staff and printed communication aids for families are advocated to improve outcomes and satisfaction. Methods for enhancing family-centeredness of care include structured family conferences and culturally sensitive interventions. Conflict-management protocols and strategies to prevent burnout among healthcare professionals are also considered. The work done to develop these guidelines highlights many areas requiring further research.

The attitudes about life-sustaining treatment among cardiac surgery ICU patients and their families

Purpose

To investigate the attitudes among cardiac surgery ICU patients and their families regarding life-sustaining treatment.

Methods

A total of 172 pairs of patients in the cardiac surgery ICU of Nanjing First Hospital and their family members were enrolled in this study that examined their attitudes toward life-sustaining treatment using a willingness to care for life-sustaining treatment questionnaire. The consistency of the attitudes of patients and family members toward life-sustaining treatment was analyzed by the chi-square test with a paired design.

Results

The most popular life-sustaining treatment for cardiac ICU patients was noninvasive mechanical ventilation (79.1%); the most unpopular was intra-aortic balloon counterpulsation (48.3%). Most patients and their families had not considered electric defibrillation (65.7%), but most understood and were willing to permit cardiopulmonary resuscitation (76.2%). Few family members agreed that patients should receive a pacemaker (25.0%). The consistency of life support attitudes of patients and their families ranged from 12.8% to 60.5% for procedures both would agree to, 1.2% to 19.8% for procedures they were unwilling to permit, and 0.6% to 39.0% for procedures they had not considered. Kappa values ranged from 0.218 to 0.597 (P < 0.05), with general consistency.

Conclusion

Cardiac surgery ICU patients families are generally consistent in their attitudes toward life-sustaining treatment, and family members' choices are not representative of patients' wishes.

stratamatch: Prognostic Score Stratification Using a Pilot Design

In a block-randomized controlled trial, individuals are subdivided by prognostically important baseline characteristics (e.g., age group, sex, or smoking status), prior to randomization. This step reduces the heterogeneity between the treatment groups with respect to the baseline factors most important to determining the outcome, thus enabling more precise estimation of treatment effect. The stratamatch package extends this approach to the observational setting by implementing functions to separate an observational data set into strata and interrogate the quality of different stratification schemes. Once an acceptable stratification is found, treated and control individuals can be matched by propensity score within strata, thereby recapitulating the block-randomized trial design for the observational study. The stratification scheme implemented by stratamatch applies a "pilot design" approach (Aikens, Greaves, and Baiocchi 2019) to estimate a quantity called the prognostic score (Hansen 2008), which is used to divide individuals into strata. The potential benefits of such an approach are twofold. First, stratifying the data enables more computationally efficient matching of large data sets. Second, methodological studies suggest that using a prognostic score to inform the matching process increases the precision of the effect estimate and reduces sensitivity to bias from unmeasured confounding factors (Aikens et al. 2019; Leacy and Stuart 2014; Antonelli, Cefalu, Palmer, and Agniel 2018). A common mistake is to believe reserving more data for the analysis phase of a study is always better. Instead, the stratamatch approach suggests how clever use of data in the design phase of large studies can lead to major benefits in the robustness of the study conclusions.

"Has Anything Changed Since Then?": A Framework to Incorporate Prior Goals-of-Care Conversations Into Decision-Making for Acutely Ill Patients

When assuming care for a seriously ill hospitalized patient, we should find documentation of previous decisions about goals of care so that our conversation takes advantage of previous discussions and reduces decision-making burden on the patient, particularly when the patient is clinically declining and time is short. This article presents a framework to help clinicians incorporate prior goals of care conversations into decision-making for an acutely ill patient. When there is strong evidence that a previous decision still applies, clinicians should, after a brief check-in about the previous decision with the patient, then present a plan consistent with their previous decision as a default option, to which they can opt out. If there is less evidence of the basis for a previous decision, clinicians should explore the thinking behind the decision and, if there is clarity about patient preferences, propose a treatment plan. If there is conflict or uncertainty about the patient's preferences, clinicians should engage in a more comprehensive goals-of-care conversation, which involves exploring the patient's understanding of their illness, patient values, and reasonable treatment options, before offering a plan. By giving the patient the ability to opt out of a previous decision they made about goals of care, rather than another choice, we make it more likely that they will receive care consistent with their known wishes.

Life-Sustaining Treatment in End-Stage Liver Disease Patients: Patients' Decisions and Results

Purpose

In 2018, the Act on Decisions on Life-Sustaining Treatment for Patients in Hospice and Palliative Care or at the End of Life was implemented and the scope of official recognition for terminally ill patients was expanded. The purpose of this study was to investigate the decisions made by patients with end-stage liver disease about their life-sustaining treatment in a clinical setting.

Methods

The subjects of this study were patients with endstage liver disease hospitalized at a tertiary hospital in Seoul, Korea who wrote physician orders for life-sustaining treatment (POLST). Data collection was done using patients' electronic medical records, and a retrospective analysis of POLST was conducted.

Results

Among 101 patients, 18.8% were female and 81.2% were male, and their mean age was 61.8 (±10.61) years. Sixty-three patients (62.4%) wrote their POLST by themselves. Three patients withdrew the POLST, of whom two did so for liver transplantation, and one did so for chemotherapy.

Conclusion

This study shows that sufficient consideration of liver transplantation is needed for end-stage liver disease patients before making decisions on life-sustaining treatment. The self-determination of patients must be respected and effective guidelines are urgently needed.

[Reversals in Decisions about Life-Sustaining Treatment and Associated Factors among Older Patients with Terminal Stage of Cardiopulmonary Disease]

PURPOSE

The purpose of this study was to investigate the frequency, patterns, and factors of reversals in decisions about life-sustaining treatment (LST) among older patients with terminal-stage chronic cardiopulmonary disease.

METHODS

This was a retrospective correlational descriptive study based on medical chart review. De-identified patient electronic medical record data were collected from 124 deceased older patients with terminal-stage cardiopulmonary disease who had made reversals of LST decisions in an academic tertiary hospital in 2015. Data were extracted about the reversed LST decisions, LST treatments applied before death, and patients' demographic and clinical factors. Multivariate logistic regression analysis was used to identify the factors associated with the reversal to higher intensity of LST treatment.

RESULTS

The use of inotropic agents was the most frequently reversed LST treatment, followed by cardiopulmonary resuscitation, intubation, ventilator therapy, and hemodialysis. Inconsistency between the last LST decisions and actual treatments occurred most often in hemodialysis. One-third of the reversals in LST decisions were made toward higher intensity of LST treatment. Patients who had lung diseases (vs. heart diseases); were single, divorced, or bereaved (vs. married); and had an acquaintance as a primary decision maker (vs. the patients themselves) were significantly more likely to reverse the LST decisions to higher intensity of LST treatment.

CONCLUSION

This study demonstrated the complex and turmoil situation of the LST decision-making process among older patients with terminal-stage cardiopulmonary disease and suggests the importance of support for patients and families in their LST decision-making process.