Variations in the use of do-not-resuscitate orders in ICUS. Findings from a national study

Practice and Predictors of Do-Not-Resuscitate Orders in a Tertiary-Care Intensive Care Unit in Saudi Arabia

Introduction

The objective of this study was to describe Do-Not-Resuscitate (DNR) practices in a tertiary-care intensive care unit (ICU) in Saudi Arabia, and determine the predictors and outcomes of patients who had DNR orders.

Methods

This retrospective cohort study was based on a prospectively collected database for a medical-surgicalIntensive CareDepartment in a tertiary-care center in Riyadh, Saudi Arabia (1999-2017). We compared patients who had DNR orders during the ICU stay with those with "full code." The primary outcome was hospital mortality. The secondary outcomes included ICU mortality, tracheostomy, duration of mechanical ventilation, and length of stay in the ICU and hospital.

Results

Among 24790 patients admitted to the ICU over the 19-year study period, 3217 (13%) had DNR orders during the ICU stay. Compared to patients with "full code," patients with DNR orders were older (median 67 years [Q1, Q3: 55, 76] versus 57 years [Q1, Q3: 33, 71], p < 0.0001), were more likely to be females (43% versus 38%, p < 0.0001), had worse premorbid functional status (WHO performance status scores 4-5: 606[18.9%] versus 1894[8.8%], p < 0.0001), higher prevalence of comorbid conditions, and higher APACHE II score (median 28 [Q1, Q3: 23, 34] versus 19 [Q1, Q3: 13, 25], p < 0.0001) and were more likely to be mechanically ventilated (83% versus 55%, p < 0.0001). Patients had DNR orders were more likely to die in the ICU (67.8% versus 8.5%, p < 0.0001) and hospital (82.4% versus 18.1%, p < 0.0001). On multivariable logistic regression analysis, the following were associated with an increased likelihood of DNR status: increasing age (odds ratio (OR) 1.01, 95% confidence interval (CI) 1.01-1.02), higher APACHE II score (OR 1.09, 95% CI 1.08-1.10), and worse WHO performance status score. Patients admitted in recent years (2012-2017 versus 2002-2005) were less likely to have DNR orders (OR 0.35, 95% CI 0.32-0.39, p < 0.0001). Patients with DNR orders had higher ICU mortality, more tracheostomies, longer duration of mechanical ventilation and length of ICU stay compared to patients with with "full code" but they had shorter length of hospital stay.

Conclusion

In a tertiary-care hospital in Saudi Arabia, 13% of critically ill patients had DNR orders during ICU stay. This study identified several predictors of DNR orders, including the severity of illness and poor premorbid functional status.

Palliative Medicine and End of Life Care Between Races in an Academic Intensive Care Unit

Background: Although palliative medicine (PM) is more commonly being integrated into the intensive care unit (ICU), research on racial disparities in this area is lacking. Our objectives were to (a) identify racial disparities in utilization of PM consultation for patients who received ICU care and (b) determine if there were differences in the use of code status or PM consultation over time based on race. Materials and Methods: Retrospective analysis of 571 patients, 18 years and above, at a tertiary care institution who received ICU care and died during their hospital stay. We analyzed two timeframes, 2008-2009 and 2018-2019. Univariate analysis was utilized to evaluate baseline characteristics. A multivariate logistic regression model and interaction P values were employed to assess for differential use of PM consultation, do not resuscitate (DNR) orders, and comfort care (CC) orders between races in aggregate and for changes over time. Results: There was a notable increase in Black/African-American (AA) (54% to 61%) and Hispanic/Latino (2% to 3%) patients over time in our population. Compared to White patients, we found no differences between PM consultation and CC orders. There was a lower probability of DNR orders for Black/AA (adjusted odds ratio [aOR] 0.569; P = .049; confidence interval [CI]: 0.324-0.997) and other/unknown/multiracial patients (aOR: 0.389; P = .273; CI: 0.169-0.900). Comparing our earlier time period to the later time period, we found an increased usage of PM for all patients. Interaction P values suggest there were no differences between races regarding PM, DNR, and CC orders. Conclusions: PM use has increased over time at our institution. Contrary to the previous literature, there were no differences in the frequency of utilization of PM consultation between races. Further analysis to evaluate the usage of PM in the ICU setting in varying populations and geographic locations is warranted.

Incidence and Outcomes of Cardiopulmonary Resuscitation in ICUs: Retrospective Cohort Analysis

OBJECTIVES

We aim to describe incidence and outcomes of cardiopulmonary resuscitation (CPR) efforts and their outcomes in ICUs and their changes over time.

DESIGN

Retrospective cohort analysis.

SETTING

Patient data documented in the Austrian Center for Documentation and Quality Assurance in Intensive Care database.

PATIENTS

Adult patients (age ≥ 18 yr) admitted to Austrian ICUs between 2005 and 2019.

INTERVENTIONS

None.

MEASUREMENTS ANDN MAIN RESULTS

Information on CPR was deduced from the Therapeutic Intervention Scoring System. End points were overall occurrence rate of CPR in the ICU and CPR for unexpected cardiac arrest after the first day of ICU stay as well as survival to discharge from the ICU and the hospital. Incidence and outcomes of ICU-CPR were compared between 2005 and 2009, 2010 and 2014, and 2015 and 2019 using chi-square test. A total of 525,518 first admissions and readmissions to ICU of 494,555 individual patients were included; of these, 72,585 patients (14.7%) died in hospital. ICU-CPR was performed in 20,668 (3.9%) admissions at least once; first events occurred on the first day of ICU admission in 15,266 cases (73.9%). ICU-CPR was first performed later during ICU stay in 5,402 admissions (1.0%). The incidence of ICU-CPR decreased slightly from 4.4% between 2005 and 2009, 3.9% between 2010 and 2014, and 3.7% between 2015 and 2019 (p < 0.001). A total of 7,078 (34.5%) of 20,499 patients who received ICU-CPR survived until hospital discharge. Survival rates varied slightly over the observation period; 59,164 (12.0%) of all patients died during hospital stay without ever receiving CPR in the ICU.

CONCLUSIONS

The incidence of ICU-CPR is approximately 40 in 1,000 admissions overall and approximately 10 in 1,000 admissions after the day of ICU admission. Short-term survival is approximately four out of 10 patients who receive ICU-CPR.

Epidemiologic Trends of Adoption of Do-Not-Resuscitate Status After Pediatric In-Hospital Cardiac Arrest

OBJECTIVES

To evaluate the prevalence of do-not-resuscitate status, assess the epidemiologic trends of do-not-resuscitate status, and assess the factors associated with do-not-resuscitate status in children after in-hospital cardiac arrest using large, multi-institutional data.

DESIGN

Generalized estimating equations logistic regression model was used to evaluate the trends of do-not-resuscitate status and evaluate the factors associated with do-not-resuscitate status after cardiac arrest.

SETTING

American Heart Association's Get With the Guidelines-Resuscitation Registry.

PATIENTS

Children (< 18 yr old) with an index in-hospital cardiac arrest and greater than or equal to 1 minute of documented chest compressions were included (2006-2015). Patients with no return of spontaneous circulation after cardiac arrest were excluded.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

In total, 8,062 patients qualified for inclusion. Of these, 1,160 patients (14.4%) adopted do-not-resuscitate status after cardiac arrest. We found low rates of survival to hospital discharge among children with do-not-resuscitate status (do-not-resuscitate vs no do-not-resuscitate: 6.0% vs 69.7%). Our study found that rates of do-not-resuscitate status after cardiac arrest are highest in children with Hispanic ethnicity (16.4%), white race (15.0%), and treatment at institutions with larger PICUs (> 50 PICU beds: 17.8%) and at institutions located in North Central (17.6%) and South Atlantic/Puerto Rico (17.1%) regions of the United States. Do-not-resuscitate status was more common among patients with more preexisting conditions, longer duration of cardiac arrest, greater than 1 cardiac arrest, and among patients requiring extracorporeal cardiopulmonary resuscitation. We also found that trends of do-not-resuscitate status after cardiac arrest in children are decreasing in recent years (2013-2015: 13.8%), compared with previous years (2006-2009: 16.0%).

CONCLUSIONS

Patient-, hospital-, and regional-level factors are associated with do-not-resuscitate status after pediatric cardiac arrest. As cardiac arrest might be a signal of terminal chronic illness, a timely discussion of do-not-resuscitate status after cardiac arrest might help families prioritize quality of end-of-life care.

Accurate and interpretable intensive care risk adjustment for fused clinical data with generalized additive models

Risk adjustment models for intensive care outcomes have yet to realize the full potential of data unlocked by the increasing adoption of EHRs. In particular, they fail to fully leverage the information present in longitudinal, structured clinical data - including laboratory test results and vital signs - nor can they infer patient state from unstructured clinical narratives without lengthy manual abstraction. A fully electronic ICU risk model fusing these two types of data sources may yield improved accuracy and more personalized risk estimates, and in obviating manual abstraction, could also be used for real-time decision-making. As a first step towards fully "electronic" ICU models based on fused data, we present results of generalized additive modeling applied to a sample of over 36,000 ICU patients. Our approach outperforms those based on the SAPS and OASIS systems (A UC: 0.908 vs. 0.794 and 0.874), and appears to yield more granular and easily visualized risk estimates.

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

Importance

Critically ill patients often receive high-intensity life sustaining treatments (LST) in the intensive care unit (ICU), although they can be ineffective and eventually undesired. Determining the risk factors associated with reversals in LST goals can improve patient and provider appreciation for the natural history and epidemiology of critical care and inform decision making around the (continued) use of LSTs.

Methods

This is a single institution retrospective cohort study of patients receiving life sustaining treatment in an academic tertiary hospital from 2009 to 2013. Deidentified patient electronic medical record data was collected via the clinical data warehouse to study the outcomes of treatment limiting Comfort Care and do-not-resuscitate (DNR) orders. Extended multivariable Cox regression models were used to estimate the association of patient and clinical factors with subsequent treatment limiting orders.

Results

10,157 patients received life-sustaining treatment while initially Full Code (allowing all resuscitative measures). Of these, 770 (8.0%) transitioned to Comfort Care (with discontinuation of any life-sustaining treatments) while 1,669 (16%) patients received new DNR orders that reflect preferences to limit further life-sustaining treatment options. Patients who were older (Hazard Ratio(HR) 1.37 [95% CI 1.28–1.47] per decade), with cerebrovascular disease (HR 2.18 [95% CI 1.69–2.81]), treated by the Medical ICU (HR 1.92 [95% CI 1.49–2.49]) and Hematology-Oncology (HR 1.87 [95% CI 1.27–2.74]) services, receiving vasoactive infusions (HR 1.76 [95% CI 1.28, 2.43]) or continuous renal replacement (HR 1.83 [95% CI 1.34, 2.48]) were more likely to transition to Comfort Care. Any new DNR orders were more likely for patients who were older (HR 1.43 [95% CI 1.38–1.48] per decade), female (HR 1.30 [95% CI 1.17–1.44]), with cerebrovascular disease (HR 1.45 [95% CI 1.25–1.67]) or metastatic solid cancers (HR 1.92 [95% CI 1.48–2.49]), or treated by Medical ICU (HR 1.63 [95% CI 1.42–1.86]), Hematology-Oncology (HR 1.63 [95% CI 1.33–1.98]) and Cardiac Care Unit-Heart Failure (HR 1.41 [95% CI 1.15–1.72]).

Conclusion

Decisions to reverse or limit treatment goals occurs after more than 1 in 13 trials of LST, and is associated with older female patients, receiving non-ventilator forms of LST, cerebrovascular disease, and treatment by certain medical specialty services.

The Natural History of Changes in Preferences for Life-Sustaining Treatments and Implications for Inpatient Mortality in Younger and Older Hospitalized Adults

OBJECTIVES

To compare changes in preferences for life-sustaining treatments (LSTs) and subsequent mortality of younger and older inpatients.

DESIGN

Retrospective cohort study.

SETTING

Kaiser Permanente Northern California (KPNC).

PARTICIPANTS

Individuals hospitalized at 21 KPNC hospitals between 2008 and 2012 (N = 227,525).

MEASUREMENTS

Participants were divided according to age (<65, 65-84, ≥85). The effect of age on adding new and reversing prior LST limitations was evaluated. Survival to inpatient discharge was compared according to age group after adding new LST limitations.

RESULTS

At admission, 18,254 (54.2%) of those aged 85 and older, 18,349 (20.8%) of those aged 65 to 84, and 3,258 (3.1%) of those younger than 65 had requested that the use of LST be limited. Of the 187,664 participants who initially did not request limitations on the use of LST, 15,932 (8.5%) had new LST limitations added; of the 39,861 admitted with LST limitations, 3,017 (7.6%) had these reversed. New limitations were more likely to be seen in older participants (aged 65-84, odds ratio (OR) = 2.27, 95% confidence interval (CI) = 2.16-2.39; aged ≥85, OR = 6.43, 95% CI = 6.05-6.84), and reversals of prior limitations were less likely to be seen in older individuals (aged 65-84, OR = 0.73, 95% CI = 0.65-0.83; aged ≥85, OR = 0.46, 95% CI = 0.41-0.53) than in those younger than 65. Survival rates to inpatient discharge were 71.7% of subjects aged 85 and older who added new limitations, 57.2% of those aged 65 to 84, and 43.4% of those younger than 65 (P < .001).

CONCLUSION

Changes in preferences for LSTs were common in hospitalized individuals. Age was an important determinant of likelihood of adding new or reversing prior LST limitations. Of subjects who added LST limitations, those who were older were more likely than those who were younger to survive to hospital discharge.

The epidemiology of do-not-resuscitate orders in patients with trauma: a community level one trauma center observational experience

Background

Do-Not-Resuscitate (DNR) orders in patients with traumatic injury are insufficiently described. The objective is to describe the epidemiology and outcomes of DNR orders in trauma patients.

Methods

We included all adults with trauma to a community Level I Trauma Center over 6 years (2008–2013). We used chi-square, Wilcoxon rank-sum, and multivariate stepwise logistic regression tests to characterize DNR (established in-house vs. pre-existing), describe predictors of establishing an in-house DNR, timing of an in-house DNR (early [within 1 day] vs late), and outcomes (death, ICU stay, major complications).

Results

Included were 10,053 patients with trauma, of which 1523 had a DNR order in place (15%); 715 (7%) had a pre-existing DNR and 808 (8%) had a DNR established in-house. Increases were observed over time in both the proportions of patients with DNRs established in-house (p = 0.008) and age ≥65 (p < 0.001). Over 90% of patients with an in-house DNR were ≥65 years. The following covariates were independently associated with establishing a DNR in-house: age ≥65, severe neurologic deficit (GCS 3–8), fall mechanism of injury, ED tachycardia, female gender, and comorbidities (p < 0.05 for all). Age ≥65, female gender, non-surgical service admission and transfers-in were associated with a DNR established early (p < 0.05 for all). As expected, mortality was greater in patients with DNR than those without (22% vs. 1%), as was the development of a major complication (8% vs. 5%), while ICU admission was similar (19% vs. 17%). Poor outcomes were greatest in patients with DNR orders executed later in the hospital stay.

Conclusions

Our analysis of a broad cohort of patients with traumatic injury establishes the relationship between DNR and patient characteristics and outcomes. At 15%, DNR orders are prevalent in our general trauma population, particularly in patients ≥65 years, and are placed early after arrival. Established prognostic factors, including age and physiologic severity, were determinants for in-house DNR orders. These data may improve physician predictions of outcomes with DNR and help inform patient preferences, particularly in an environment with increasing use of DNR and increasing age of patients with trauma.

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-015-0094-2) contains supplementary material, which is available to authorized users.

Variation in decisions to forgo life-sustaining therapies in US ICUs

BACKGROUND

The magnitude and implication of variation in end-of-life decision-making among ICUs in the United States is unknown.

METHODS

We reviewed data on decisions to forgo life-sustaining therapy (DFLSTs) in 269,002 patients admitted to 153 ICUs in the United States between 2001 and 2009. We used fixed-effects logistic regression to create a multivariable model for DFLST and then calculated adjusted rates of DFLST for each ICU.

RESULTS

Patient factors associated with increased odds of DFLST included advanced age, female sex, white race, and poor baseline functional status (all P < .001). However, associations with several of these factors varied among ICUs (eg, black race had an OR for DFLST from 0.18 to 2.55 across ICUs). The ICU staffing model was also found to be associated with DFLST, with an open ICU staffing model associated with an increased odds of a DFLST (OR = 1.19). The predicted probability of DFLST varied approximately sixfold among ICUs after adjustment for the fixed patient and ICU effects and was directly correlated with the standardized mortality ratios of ICUs (r = 0.53, 0.41-0.68).

CONCLUSION

Although patient factors explain much of the variability in DFLST practices, significant effects of ICU culture and practice influence end-of-life decision-making. The observation that an ICU's risk-adjusted propensity to withdraw life support is directly associated with its standardized mortality ratio suggests problems with using the latter as a quality measure.

End-of-life treatment preferences: a key to reducing ethnic/racial disparities in advance care planning?

BACKGROUND

The objective of this study was to identify targets for interventions to reduce end-of-life care disparities among patients with advanced cancer. To do this, the authors evaluated the degree to which end-of-life care values and preferences are associated with advance care planning within racial/ethnic minority groups.

METHODS

The Coping with Cancer study recruited patients with advanced cancer from outpatient clinics in 5 states from 2002 to 2008. Then, the rates of 1 type of advance care planning-do-not-resuscitate (DNR) orders-reported at baseline interviews by 606 patients were investigated. Bivariate tests determined associations among DNR order completion, religious values, and treatment preferences within racial/ethnic groups.

RESULTS

Non-Latino white patients were significantly more likely to have a DNR order (45%) than black (25%) and Latino (20%) patients (P<.001). A preference against specific life-prolonging treatment (eg, chemotherapy, ventilation) was the only factor significantly associated with higher DNR order likelihood in each group, with non-Latino white patients more likely than Latino or black patients to express preferences against life-prolonging care (eg, 26% of non-Latino white patients, 46% of black patients, and 41% of Latino patients wanted a feeding tube if it would extend life for 1 more day; P<.001).

CONCLUSIONS

Preferences against life-prolonging care differ dramatically by race/ethnicity, but they have a uniform significant association with DNR order completion rates across racial/ethnic groups of patients with advanced cancer. Advance care planning interventions that target preferences associated with DNR orders across racial/ethnic groups may reach a broad patient population and reduce end-of-life care disparities.

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.

DNR directives are established early in mechanically ventilated intensive care unit patients

PURPOSE

Setting treatment goals in the intensive care unit (ICU) often involves resuscitation decisions. Our objective was to study the rate of establishing do-not-resuscitate (DNR) directives, determinants, and outcomes of those directives for mechanically ventilated patients.

METHODS

In a multicentre observational study, we included consecutive adults with no DNR directives within 24 hr of ICU admission who were mechanically ventilated for at least 48 hr. We identified the rate with which DNR directives were established, and factors associated with these directives.

RESULTS

Among 765 patients, DNR directives were established for 231 (30.2%) patients; 143 (62.1%) of these were established within the first week. Factors independently associated with a DNR directive were: patient age [> or = 75 yr (hazard ratio [HR] 2.3, 95% confidence interval 1.5-3.4], 65 to 74 yr (HR 1.8, 1.2-2.7), 50 to 64 yr (HR 1.4, 1.0-2.2) relative to < 50 yr); medical rather than surgical diagnosis (HR 1.8, 1.3-2.5); multiple organ dysfunction score (HR 1.7 for each five-point increment, 1.4-2.0); physician prediction of ICU survival [< 10% (HR 15.0, 6.7-33.6)], 10 to 40% [(HR 5.0, 2.3-11.2), 41 to 60% (HR 4.0, 1.8-9.0) relative to > 90%]; and physician perception of patient preference to limit life support (no advanced life support [(HR 5.8, 3.6-9.4) or partial advanced life support (HR 3.2, 2.2-4.6) compared to full measures].

CONCLUSION

One third of mechanically ventilated patients had DNR directives established early during their ICU stay after the first 24 hr of admission. The strongest predictors of DNR directives were physician prediction of low probability of survival, physician perception of patient preference to limit life support, organ dysfunction, medical diagnosis and age.

Comparison of APACHE III, APACHE IV, SAPS 3, and MPM0III and influence of resuscitation status on model performance

BACKGROUND

There are few comparisons among the most recent versions of the major adult ICU prognostic systems (APACHE [Acute Physiology and Chronic Health Evaluation] IV, Simplified Acute Physiology Score [SAPS] 3, Mortality Probability Model [MPM]0III). Only MPM0III includes resuscitation status as a predictor.

METHODS

We assessed the discrimination, calibration, and overall performance of the models in 2,596 patients in three ICUs at our tertiary referral center in 2006. For APACHE and SAPS, the analyses were repeated with and without inclusion of resuscitation status as a predictor variable.

RESULTS

Of the 2,596 patients studied, 283 (10.9%) died before hospital discharge. The areas under the curve (95% CI) of the models for prediction of hospital mortality were 0.868 (0.854-0.880), 0.861 (0.847-0.874), 0.801 (0.785-0.816), and 0.721 (0.704-0.738) for APACHE III, APACHE IV, SAPS 3, and MPM0III, respectively. The Hosmer-Lemeshow statistics for the models were 33.7, 31.0, 36.6, and 21.8 for APACHE III, APACHE IV, SAPS 3, and MPM0III, respectively. Each of the Hosmer-Lemeshow statistics generated P values < .05, indicating poor calibration. Brier scores for the models were 0.0771, 0.0749, 0.0890, and 0.0932, respectively. There were no significant differences between the discriminative ability or the calibration of APACHE or SAPS with and without “do not resuscitate” status.

CONCLUSIONS

APACHE III and IV had similar discriminatory capability and both were better than SAPS 3, which was better than MPM0III. The calibrations of the models studied were poor. Overall, models with more predictor variables performed better than those with fewer. The addition of resuscitation status did not improve APACHE III or IV or SAPS 3 prediction.

Palliative care need and management in the acute hospital setting: a census of one New Zealand Hospital

Background

Improving palliative care management in acute hospital settings has been identified as a priority internationally. The aim of this study was to establish the proportion of inpatients within one acute hospital in New Zealand who meet prognostic criteria for palliative care need and explore key aspects of their management.

Methods

A prospective survey of adult hospital inpatients (n = 501) was undertaken. Case notes were examined for evidence that the patient might be in their last year of life according to Gold Standards Framework (GSF) prognostic indicator criteria. For patients who met GSF criteria, clinical and socio-demographic information were recorded.

Results

Ninety-nine inpatients met GSF criteria, representing 19.8% of the total census population. The patients’ average age was 70 years; 47% had a primary diagnosis of cancer. Two thirds had died within 6 months of their admission. Seventy-eight of the 99 cases demonstrated evidence that a palliative approach to care had been adopted; however documentation of discussion about goals of care was very limited and only one patient had evidence of an advance care plan.

Conclusion

One fifth of hospital inpatients met criteria for palliative care need, the majority of whom were aged >70 years. Whilst over three quarters were concluded to be receiving care in line with a palliative care approach, very little documented evidence of discussion with patients and families regarding end of life issues was evident. Future research needs to explore how best to support ‘generalist’ palliative care providers in initiating, and appropriately recording, such discussions.

[Impact of age on mortality in patients with acute traumatic spinal cord injury requiring intensive care]

OBJECTIVE

To evaluate the impact of age (<or≥65 ans) on hospital mortality in traumatic spinal cord injury requiring intensive care.

DESIGN

Retrospective, monocenter.

PATIENTS AND METHODS

A total of 131 patients greater or equal to 15 years (<65 years, n=109 and ≥65 years, n=22) was analyzed (cervical, n=71; thoracolumbar, n=60), over a 10 years period (1998-2008). The hospital and long-term mortality were studied. The risks factors of death were searched by a uni- and multivariate analysis. Intensive care unit (ICU) discharge and long-term neurological recovery, and long-term functional independence measure (FIM) were assessed.

RESULTS

Hospital mortality was increased in patients greater or equal to 65 years (41% vs 6%, P<0.001) and long term mortality was not different between the two groups (31% vs 12%, P=0.150). The risks factors of death were age (HR=3.44; IC 95%: 1.53-7.72, P=0.028), previous coronary disease (HR=3.64; IC 95%: 1.25-10.65; P=0.018) and fall injury (HR=2.40; IC 95%: 1.15-5.00, P=0.020). Among survivors, incompletes forms (Frankel B, C, D, E) were significantly more frequent in older patients at ICU discharge and long term follow up. At long term, FIM was similar in the two groups except a better sphincter control in patient greater or equal to 65 years.

CONCLUSION

Mortality rate of older people (≥65 years) were greater than those in younger people, mainly caused by an increased hospital mortality. Among survivors, the neurological recovery was better in patients' greater or equal to 65 years, and was associated with a functional status at least comparable than in the youngest patients.

The influence of race/ethnicity and socioeconomic status on end-of-life care in the ICU

BACKGROUND

There is conflicting evidence about the influence of race/ethnicity on the use of intensive care at the end of life, and little is known about the influence of socioeconomic status.

METHODS

We examined patients who died in the ICU in 15 hospitals. Race/ethnicity was assessed as white and nonwhite. Socioeconomic status included patient education, health insurance, and income by zip code. To explore differences in end-of-life care, we examined the use of (1) advance directives, (2) life-sustaining therapies, (3) symptom management, (4) communication, and (5) support services.

RESULTS

Medical charts were abstracted for 3,138/3,400 patients of whom 2,479 (79%) were white and 659 (21%) were nonwhite (or Hispanic). In logistic regressions adjusted for patient demographics, socioeconomic factors, and site, nonwhite patients were less likely to have living wills (OR, 0.41; 95% CI, 0.32-0.54) and more likely to die with full support (OR, 1.59; 95% CI, 1.30-1.94). In documentation of family conferences, nonwhite patients were more likely to have documentation that prognosis was discussed (OR, 1.47; 95% CI, 1.21-1.77) and that physicians recommended withdrawal of life support (OR, 1.57; 95% CI, 1.11-2.21). Nonwhite patients also were more likely to have discord documented among family members or with clinicians (OR, 1.49; 95% CI, 1.04-2.15). Socioeconomic status did not modify these associations and was not a consistent predictor of end-of-life care.

CONCLUSIONS

We found numerous racial/ethnic differences in end-of-life care in the ICU that were not influenced by socioeconomic status. These differences could be due to treatment preferences, disparities, or both. Improving ICU end-of-life care for all patients and families will require a better understanding of these issues.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT00685893; URL: www.clinicaltrials.gov.

Demographic and clinical determinants of having do not resuscitate orders in the intensive care unit of a comprehensive cancer center

To understand the needs of patients and family members as physicians communicate their expectations about patients admitted to the intensive care unit (ICU), we evaluated the demographic and clinical determinants of having a Do Not Resuscitate (DNR) order for adults with cancer. Patients included were admitted from June 16, 2008-August 16, 2008, to the ICU in a comprehensive cancer center. We conducted a prospective chart review and collected data on patient demographics, length of stay, advance directives, clinical characteristics, and DNR orders. A total of 362 patients met the inclusion criteria; only 15.2% had DNR orders before ICU discharge. In the multivariate analysis, we found that medical admission was an independent predictor of having a DNR order during the ICU stay (odds ratio = 3.65; 95% confidence interval, 1.44-9.28); we also found a significant two-way interaction between race/ethnicity and type of admission (medical vs. surgical) with having a DNR order (p = .04). Although medical admissions were associated with significantly more DNR orders than were surgical admissions, we observed that the subgroup of non-white patients admitted for medical reasons was significantly less likely to have DNR orders. This finding could reflect different preferences for aggressive care by race/ethnicity in patients with cancer, and deserves further investigation.

Survey of do-not-resuscitate orders in surgical intensive care units

BACKGROUND/PURPOSE

End-of-life decisions are always difficult and complex, especially in the surgical setting. This study examines the epidemiology of do-not-resuscitate (DNR) orders, and the clinical factors influencing DNR consent. The impact of DNR on treatment and resource use in the surgical intensive-care unit (ICU) is also assessed.

METHODS

This retrospective observational study was performed at National Taiwan University Hospital, a tertiary medical center in Taipei. A total of 14,698 patients were admitted to the surgical ICUs between January 2003 and December 2006. Of these, 13,825 (94.1%) survived to ICU discharge and 873 (5.9%) died. Of those that died, 278 (1.9% of total patients) went home to die due to terminal stage illness and 595 (4.0 % of total patients) died in the ICU. All mortality patients were included in this study.

RESULTS

Yearly DNR rates were all above 65%. The average interval from ICU admission to DNR consent remained stable at 11-13 days, but the interval from DNR consent to death increased over the study period, from 2.0 to 3.5 days. Discussion over DNR was mainly initiated by intensivists. Multivariate logistic regression analysis found that older age (odds ratio, 1.010; p = 0.017) was significantly associated with DNR consent. DNR patients had longer ICU stays, lower fraction of inspired oxygen, and less inotropic infusion, dialysis, transfusion, laboratory examination, and chest radiography, but more use of sedative drugs, analgesics, and nutrition support at the time of death. After DNR, the use of advanced antibiotics, chest radiography, laboratory examination, and transfusion decreased. Inotropic infusion, however, continued to significantly increase.

CONCLUSION

Although DNR was common in our surgical ICU patients, this request was signed late in the ICU course, when therapeutic options had been exhausted. Early initiation of DNR discussion should be promoted to improve end-of-life care and reduce futile treatments in the ICU.

Preliminary report of the integration of a palliative care team into an intensive care unit

Nearly half of Americans who die in hospitals spend time in the intensive care unit (ICU) in the last 3 days of life. Minority patients who die in the ICU are less likely to formalize advance directives and surviving family members report lower satisfaction with the provision of information and sensitivity to their cultural traditions at the end-of-life. This is a descriptive report of a convenience sample of 157 consecutive patients served by a palliative care team which was integrated into the operations of an ICU at Montefiore Medical Center in the Bronx, New York, from August 2005 until August 2007. The team included an advance practice nurse (APN) and social worker. A separate case-control study was conducted comparing the length of hospital stay for persons who died in the ICU during the final 6 months of the project, prior to and post-palliative care consultation for 22 patients at the hospital campus where the project team was located versus 24 patients at the other campus. Pharmaco-economic data were evaluated for 22 persons who died with and 43 who died without a palliative care consultation at the intervention campus ICU to evaluate whether the project intervention was associated with an increase in the use of pain medications or alterations in the use of potentially non-beneficial life-prolonging treatments in persons dying in the ICU. Data was abstracted from the medical record with a standardized chart abstraction instrument by an unblinded research assistant. Interviews were conducted with a sample of family members and ICU nurses rating the quality of end-of-life care in the ICU with the Quality of Dying and Death in the ICU instrument (ICUQODD), and a family focus group was also conducted. Forty percent of patients were Caucasian, 35% were African American or Afro-Caribbean, 22% Hispanic and 3% were Asian or other. Exploration of the patients' and families' needs identified significant spiritual needs in 62.4% of cases. Education on the death process was provided to 85% of families by the project team. Twenty-nine percent of patients were disconnected from mechanical ventilators following consultation with the Palliative Care Service (PCS), 15.9% of patients discontinued the use of inotropic support, 15.3% stopped artificial nutrition, 6.4% stopped dialysis and 2.5% discontinued artificial hydration. Recommendations on pain management were made for 51% of the project's patients and symptom management for 52% of patients. The project was associated with an increase in the rate of the formalization of advance directives. Thirty-three percent of the patients who received PCS consultations had 'do not resuscitate' orders in place prior to consultation and 83.4% had 'do not resuscitate' orders after the intervention. The project team referred 80 (51%) of the project patients to hospice and 55 (35%) patients were enrolled on hospice, primarily at the medical center. The mean time from admission to palliative care consultation at the project site was 2.8 days versus 15.5 days at the other campus (p = 0.0184). Median survival times from admission to the medical center were not significantly different when stratified by palliative care consultation status: 12 days for the control group (95% CI 8-18) and 13.5 days for the intervention group (95% CI 8-20). Median charges for the use of opioid medications were higher (p = 0.01) for the intervention group but lower for use of laboratory (p = 0.004) and radiology tests (p = 0.027). We conclude that the integration of palliative care experts into the operation of critical care units is of benefit to patients, families and critical care clinicians. Preliminary evidence suggest that such models may be associated with improved quality of life, higher rates of formalization of advance directives and utilization of hospices, as well as lower use of certain non-beneficial life-prolonging treatments for critically ill patients who are at the end of life.

Mortality probability model III and simplified acute physiology score II: assessing their value in predicting length of stay and comparison to APACHE IV

BACKGROUND

To develop and compare ICU length-of-stay (LOS) risk-adjustment models using three commonly used mortality or LOS prediction models.

METHODS

Between 2001 and 2004, we performed a retrospective, observational study of 11,295 ICU patients from 35 hospitals in the California Intensive Care Outcomes Project. We compared the accuracy of the following three LOS models: a recalibrated acute physiology and chronic health evaluation (APACHE) IV-LOS model; and models developed using risk factors in the mortality probability model III at zero hours (MPM(0)) and the simplified acute physiology score (SAPS) II mortality prediction model. We evaluated models by calculating the following: (1) grouped coefficients of determination; (2) differences between observed and predicted LOS across subgroups; and (3) intraclass correlations of observed/expected LOS ratios between models.

RESULTS

The grouped coefficients of determination were APACHE IV with coefficients recalibrated to the LOS values of the study cohort (APACHE IVrecal) [R(2) = 0.422], mortality probability model III at zero hours (MPM(0) III) [R(2) = 0.279], and simplified acute physiology score (SAPS II) [R(2) = 0.008]. For each decile of predicted ICU LOS, the mean predicted LOS vs the observed LOS was significantly different (p

CONCLUSIONS

APACHE IV and MPM(0) III were more accurate than SAPS II for the prediction of ICU LOS. APACHE IV is the most accurate and best calibrated model. Although it is less accurate, MPM(0) III may be a reasonable option if the data collection burden or the treatment effect bias is a consideration.

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MESH Headings

• APACHE
• Adolescent
• Adult
• Aged
• Aged, 80 and over
• California
• Critical Care
• Hospital Mortality
• Humans
• Length of Stay
• Middle Aged
• Models, Statistical
• Predictive Value of Tests
• Retrospective Studies
• Risk Assessment
• Severity of Illness Index
• Young Adult

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Grants

• L40 RR022168 NCRR NIH HHS
• R01 HS013919 AHRQ HHS
• R01 HS13919-01 AHRQ HHS

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Affiliation(s)

Eduard E Vasilevskis Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco, San Francisco, CA; Division of General Internal Medicine, University of California at San Francisco, San Francisco, CA; Division of Hospital Medicine, University of California at San Francisco, San Francisco, CA; Department of Medicine (General Internal Medicine and Public Health) [Dr. Vasilevskis], Vanderbilt University, Nashville, TN; Geriatric Research Education and Clinical Care, Tennessee Valley Healthcare System, Nashville, TN; Clinical Research Training Center of Excellence, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, TN.
Michael W Kuzniewicz Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco, San Francisco, CA; Division of Neonatology, University of California at San Francisco, San Francisco, CA
Brian A Cason Department of Anesthesiology and Perioperative Medicine, University of California at San Francisco, San Francisco, CA; Veterans Affairs Medical Center, San Francisco, CA
Rondall K Lane Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco, San Francisco, CA; Department of Anesthesiology and Perioperative Medicine, University of California at San Francisco, San Francisco, CA
Mitzi L Dean Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco, San Francisco, CA
Ted Clay Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco, San Francisco, CA
Deborah J Rennie Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco, San Francisco, CA
Eric Vittinghoff Department of Epidemiology and Biostatistics, University of California at San Francisco, San Francisco, CA
R Adams Dudley Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco, San Francisco, CA; Division of Pulmonary and Critical Care Medicine, University of California at San Francisco, San Francisco, CA

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Collaborators Collapse

[Effect of the do-not-resuscitate orders on the critical patient care plan]

BACKGROUND

Do-not-resuscitate (DNR) orders are physician orders that refer to not initiating cardiopulmonary resuscitation in a patient who is in cardiac or respiratory arrest. However, these orders often imply other treatment modifications.

AIMS

To analyze the effect that do-not-resuscitate orders have on the care plan of the critically ill patient; and to analyze if differences exist in the nursing workload (NEMS), before and after DNR prescription.

METHOD

This descriptive study analyzed the care plan of 50 critically ill adult patients, before and after an electronic DNR order.

RESULTS

After the DNR order was written the following variations were found: treatment was withdrawn in 30 patients; initiated in 6; both withdrawn and initiated in 12 patients; and there were no changes in their treatment in 2 patients. Specific modifications were: respiratory support: invasive mechanical ventilation was withdrawn in 7 patients, and non-invasive ventilation in 3, and the FiO(2) of the ventilator was reduced in 15 patients on the day of death; circulatory support: in 10 patients vasoconstrictor drugs were withdrawn and in one patient this therapy was initiated; inotropic drugs were withdrawn in 3 patients and initiated in 2 patients; extrarenal depuration hemofiltration was withdrawn in 4 patients and initiated in 2. The NEMS scores decreased on the patients after the order was written (36.20-34.62; p = 0.03).

CONCLUSIONS

Do-not-resuscitate orders have an effect on the care plan of the critically ill adult patient. Also, although the NEMS scores decrease after the order, the nursing workload remains the same due to an increase in the psychosocial intervention with patient and family.

Differences in hospital mortality among critically ill patients of Asian, Native Indian, and European descent

BACKGROUND

It is unclear whether race/ethnicity influences survival for acute critical illnesses. We compared hospital mortality among patients of Asian (originating from Asia or Southeast Asia), Native Indian, and European descent admitted to the ICU.

METHODS

Prospective cohort study of patients admitted to three ICUs (January 1999 to January 2006) in British Columbia, Canada. Multivariable analysis evaluated hospital mortality for each ethnic group, adjusting for age, sex, APACHE (acute physiology and chronic health evaluation) II score, hospital, median income, unemployment, and education. To account for differences in case mix, multivariable analysis was also restricted to those patients admitted for the five most common ICU admission diagnoses (sepsis, pneumonia, brain injury, COPD, and ARDS) and adjusted for these diagnoses.

RESULTS

Of 7,331 patients, 21% were Asian, 4% were Native Indian, and 75% were of European descent. Crude mortality was 33% for Asian, 30% for Native Indians, and 28% for patients of European descent. After adjusting for potential confounders, Native Indian descent was not associated with an increase in mortality compared to European descent. Asian descent was associated with a significantly higher mortality (odds ratio [OR], 1.22; 95% confidence interval [CI], 1.06 to 1.41; p = 0.005). After adjusting for case mix, this difference was no longer seen. For patients admitted for COPD exacerbation, Asian descent was associated with a substantial increase in mortality (OR, 4.5; 95% CI, 1.56 to 12.9; p = 0.005). There were no significant differences in mortality by race/ethnicity for patients who had any of the other common admitting diagnoses.

CONCLUSION

Patients of Asian and Native Indian descent with acute critical illness did not have an increased mortality after adjusting for differences in case mix.

Prospective analysis of life-sustaining therapy discussions in the surgical intensive care unit: a housestaff perspective

BACKGROUND

Prospective data addressing end-of-life care in the surgical ICU are lacking. We determined factors surrounding life-sustaining therapy discussions (LSTDs) in our surgical ICU as experienced by housestaff.

STUDY DESIGN

Housestaff were interviewed daily about the occurrence of an LSTD between themselves and either a patient or surrogate. Patients for whom at least one LSTD occurred were compared with patients for whom an LSTD never occurred. Housestaff also completed a standardized questionnaire that captured events surrounding each LSTD.

RESULTS

Eighty LSTDs occurred among 50 patients. Lack of decision-making capacity (p = 0.04), age (p = 0.02), and acuity (p = 0.01) predicted independently the occurrence of an LSTD. Housestaff were significantly more likely to both report recent clinical deterioration (p < 0.01) and to assign a worse prognosis (p < 0.01) to patients for whom an LSTD occurred. Housestaff initiated the majority of LSTDs (70.0%) and usually did so because of clinical deterioration (60.7%); patient surrogates were most commonly believed to initiate LSTDs because of lack of improvement (60.1%). In no instance did a patient initiate an LSTD. For 39 of 50 patients (78.0%), changes in end-of-life care plans were eventually enacted as proposed originally. Housestaff reported that the likelihood of enactment depended on both the preexisting end-of-life care plan and the proposed change in end-of-life care plan.

CONCLUSIONS

Age, acuity, and lack of decision-making capacity were the most important factors involved in the initiation of an LSTD. Housestaff reported that they initiated LSTDs for different reasons and proposed different end-of-life care plans relative to both patients and their surrogates. These disparities can contribute to failed enactment of proposed changes in end-of-life care plans.

Using the medical record to evaluate the quality of end-of-life care in the intensive care unit

RATIONALE

We investigated whether proposed "quality markers" within the medical record are associated with family assessment of the quality of dying and death in the intensive care unit (ICU).

OBJECTIVE

To identify chart-based markers that could be used as measures for improving the quality of end-of-life care.

DESIGN

A multicenter study conducting standardized chart abstraction and surveying families of patients who died in the ICU or within 24 hrs of being transferred from an ICU.

SETTING

ICUs at ten hospitals in the northwest United States.

PATIENTS

Overall, 356 patients who died in the ICU or within 24 hrs of transfer from an ICU.

MEASUREMENTS

The 22-item family assessed Quality of Dying and Death (QODD-22) questionnaire and a single item rating of the overall quality of dying and death (QODD-1).

ANALYSIS

The associations of chart-based quality markers with QODD scores were tested using Mann-Whitney U tests, Kruskal-Wallis tests, or Spearman's rank-correlation coefficients as appropriate.

RESULTS

Higher QODD-22 scores were associated with documentation of a living will (p = .03), absence of cardiopulmonary resuscitation performed in the last hour of life (p = .01), withdrawal of tube feeding (p = .04), family presence at time of death (p = .02), and discussion of the patient's wish to withdraw life support during a family conference (p < .001). Additional correlates with a higher QODD-1 score included use of standardized comfort care orders and occurrence of a family conference (p < or = .05).

CONCLUSIONS

We identified chart-based variables associated with higher QODD scores. These QODD scores could serve as targets for measuring and improving the quality of end-of-life care in the ICU.

Interhospital transfer of critically ill patients: demographic and outcomes comparison with nontransferred intensive care unit patients

PURPOSE

We examined the association between access to intensive care services and mortality in a cohort of critically ill patients.

MATERIALS AND METHODS

We conducted an observational study involving 6298 consecutive admissions to the intensive care units (ICUs) of a tertiary care hospital. Data including demographics, admission source, and outcomes were collected on all patients. Admission source was classified as "transfer" for patients admitted to the ICU from other hospitals, "ER" for patients admitted from the emergency room, and "ward" for patients admitted from non-ICU inpatient wards.

RESULTS

Transfer patients had higher crude ICU and hospital mortality rates compared with emergency room admissions (crude odds ratio [OR], 1.51; 95% confidence interval [CI], 1.32-1.75). After adjusting for age, sex, diagnosis, comorbidities, and acute physiology scores, the difference in ICU mortality remained significant (OR, 1.30; 95% CI, 1.09-1.56); however, hospital mortality did not (OR, 1.19; 95% CI, 1.00-1.41). Compared with ward patients, transfer from other hospitals was associated with lower hospital mortality after adjusting for severity of illness and other case-mix variables (OR, 0.81; 95% CI, 0.68-0.95).

CONCLUSIONS

We found some evidence to suggest that differential access to intensive care services impacts mortality within this case mix of patients. These findings may have implications for current efforts to centralize and regionalize critical care services.

Variation in the rates of do not resuscitate orders after major trauma and the impact of intensive care unit environment

BACKGROUND

There is an increased emphasis on benchmarking of trauma mortality outcomes as a measure of quality. Differences in approaches to end-of-life care or perceptions of salvageability might account for some of the variability in outcomes across centers. We postulated that these differences in perceptions or practice might lead to significant variation in the use of do not resuscitate (DNR) orders and sought to identify institutional characteristics associated with their use.

METHODS

Patients surviving >24 hours and admitted to an intensive care unit (ICU) in one of 68 centers across the United States were identified from a large prospective cohort study of severely injured patients. Independent predictors of a DNR order at both the patient and institutional level were identified using multivariate hierarchical modeling stratified by age <55 or >/=55.

RESULTS

Of 6,765 patients, 7% had a DNR order, of whom 88% died. The proportion of patients in each center with a DNR order ranged from 0% to 57%. Independent patient-level predictors associated with a DNR order were increasing age, preinjury comorbidity burden, severe injury, and organ failure. Institutional predictors of DNR orders differed by age. Care in an open ICU was associated with a DNR order (odds ratio, 1.7; 95% confidence interval, 1.0-3.0) in the elderly, whereas care in a combined medical-surgical ICU (vs. surgical or trauma ICU) was associated with greater likelihood (odds ratio, 2.0; 95% confidence interval, 1.1-4.1) of a DNR order in the young.

CONCLUSIONS

DNR orders are relatively common in seriously injured trauma patients, and there is significant variability in their use across centers. Given the institutional characteristics independently associated with DNR status, it is likely that both differences in the ethos of end-of-life care and perceptions of salvageability affect decision making.

Forgoing life sustaining treatments: differences and similarities between North America and Europe

BACKGROUND

As evidence exist that severe neurological damage or prolonged death after inappropriate CPR could occur, restraints and indications for CPR were perceived as necessary. The objective of this review is to examine policies and attitudes towards end-of-life decisions in Europe and North America and to outline differences and similarities.

METHODS

A bibliographic database search from 1990 to 2006 was performed using the following terms: do-not-resuscitate orders, end-of-life decisions, withholding/withdrawal of life-sustaining treatments, medical futility and advanced directives. Eighty-eight articles, out of 305 examined, were analyzed and their data systematically reported and compared where possible. They consisted of studies, questionnaires and surveys answering the following questions: percentage of deaths of critical patients preceded by do-not-resuscitate orders, factors affecting the decision for do-not-resuscitate orders, people involved in this decision (patient, surrogates and medical staff) and how it was performed.

RESULTS

There is an evident gap between the North American use of standard and formal procedures compared with Europe. Second, they diverge in the role acknowledged to surrogates in the decisional process, as in Europe, restraints and reserves to accept surrogates as decision makers seem still strong and a paternalistic approach at the end-of-life is still present.

CONCLUSION

Incidentally, despite the predictable differences between Europe and North America, concerns do exist about the actual extent of autonomy wished by patients and surrogates. It is important to highlight these findings, as the paternalistic attitude, too often negatively depicted, could be, according to the best medical practice, justified and more welcomed in some instances.

Communication and end-of-life care in the intensive care unit: patient, family, and clinician outcomes

Even though good communication among clinicians, patients, and family members is identified as the most important factor in end-of-life care in ICUs, it is the least accomplished. According to accumulated evidence, communication about end-of-life decisions in ICUs is difficult and flawed. Poor communication leaves clinicians and family members stressed and dissatisfied, as well as patients' wishes neglected. Conflict and anger both among clinicians and between clinicians and family members also result. Physicians and nurses lack communication skills, an essential element to achieve better outcomes at end of life. There is an emerging evidence base that proactive, multidisciplinary strategies such as formal and informal family meetings, daily team consensus procedures, palliative care team case finding, and ethics consultation improve communication about end-of-life decisions. Evidence suggests that improving end-of-life communication in ICUs can improve the quality of care by resulting in earlier transition to palliative care for patients who ultimately do not survive and by increasing family and clinician satisfaction. Both larger, randomized controlled trials and mixed methods designs are needed in future work. In addition, research to improve clinician communication skills and to assess the effects of organizational and unit context and culture on end-of-life outcomes is essential.

Should Do-Not-Resuscitate Status be Included as a Mortality Risk Adjustor?

BACKGROUND

The practice of ordering "Do-Not-Resuscitate" (DNR) varies across hospitals. No research has explored how the DNR variation would affect cross-institutional performance reporting when DNR status is used as a risk adjustor.

OBJECTIVE

We sought to assess the impact of DNR variation on performance reporting.

RESEARCH DESIGN

We used retrospective clinical data abstracted from chart review for our analysis.

SUBJECTS

We studied a total of 184,057 adult patients admitted to 149 Pennsylvania acute-care hospitals in 2001 for ischemic stroke, hemorrhagic stroke, pneumonia, acute myocardial infarction, congestive heart failure, and sepsis.

MEASURES

DNR rate and DNR mortality rate per patient at the hospital level was assessed. DNR also was used as an additional covariate to predict mortality in logistic regression models. Change of rank and outlier-status at the hospital level based on adjusted mortality determined by multivariable logistic models with or without DNR was used to assess the impact of DNR on performance reporting.

RESULTS

Large variations in DNR rates (1-37%) and DNR mortality rates (8-60%) existed across hospitals. There was a significant negative correlation between DNR rates and DNR mortality rates (r = -0.66, P < 0.0001). Adding DNR as a covariate resulted in a systematic shift in performance rank (r = 0.88, P < 0.0001) and change in statistical outlier-status (n = 33), which favored hospitals with higher DNR rates.

CONCLUSION

Using locally defined DNR as an additional covariate potentially introduces systematic bias in performance reporting. A more uniform definition and application of DNR is needed if it is to be included as a risk adjustor.

Quality of Dying and Death in Two Medical ICUs

OBJECTIVE

We compared perceptions of the quality of dying and death in the ICU across nurses, resident physicians, attending physicians, and family members. The aim was to obtain a surrogate assessment of the quality of the dying process and examine differences in the perceptions of different types of raters.

DESIGN

Cross-sectional survey of family members and ICU clinicians conducted following the death of enrolled patients.

SETTING

Two medical ICUs at academic tertiary care medical centers.

PATIENTS

Patients dying in the ICU (n = 68).

MEASUREMENTS AND RESULTS

The previously validated Quality of Dying and Death (QODD) instrument was modified for use in the ICU. Within 48 h of the time of death, the nurse, resident, and attending physician caring for the patient were asked to complete the QODD. One month following the death, a designated family member was contacted and the QODD was administered on the telephone. Family members and attending physicians gave the most favorable ratings of death, while nurses and residents provided less favorable ratings. Significant differences between these groups were notable (p < 0.01) on items related to patient autonomy: maintaining dignity, being touched by loved ones, and the overall quality of death.

CONCLUSIONS

The perception of dying and death in the ICU varies considerably between nurses, attending physicians, resident physicians, and family members. Further studies are needed to explain these differences and determine the utility of the ICU QODD instrument for assessing and improving the quality of end-of-life care in the ICU.

Adjustment for do-not-resuscitate orders reverses the apparent in-hospital mortality advantage for minorities

PURPOSE

The use of do-not-resuscitate (DNR) orders may differ by sex or ethnicity, and DNR status may be associated with outcomes for hospitalized patients. Thus, we sought to determine whether differences in rates of DNR by sex and ethnicity influenced differences in mortality.

SUBJECTS AND METHODS

We included all patients admitted to nonfederal California hospitals in 1999 with stroke, congestive heart failure, pneumonia, chronic obstructive pulmonary disease, chronic renal failure, angina, or diabetes mellitus. Rates of physician orders for DNR written within 24 hours of hospital admission and in-hospital mortality were compared between sexes and ethnicities after adjustment for age, admission source and diagnosis, payment type, and comorbidity scores in multivariable logistic regression models.

RESULTS

Of 327890 patients included, 25196 (7.7%) had DNR orders. In adjusted models, women were more likely to have DNR orders than men (odds ratio [OR] 1.19; 95% confidence interval 1.16-1.23; P <0.001) and non-Hispanic whites were more likely to have DNR orders than other ethnicities (OR 1.75; 1.69-1.82; P <0.001). Overall, 13549 (4.1%) patients died in the hospital. Risk of death was greater in those with a DNR order (OR 7.0; 6.7-7.3; P <0.001). Non-Hispanic whites appeared to have a greater risk of in-hospital death in adjusted models (OR 1.09; 1.04-1.12; P <0.001) when DNR status was ignored; however, the risk of death appeared to be lower in non-Hispanic whites in the complete model with DNR included (OR 0.94; 0.90-0.99; P = 0.01). A survival advantage for women was also more apparent after including DNR status in the adjusted model.

CONCLUSIONS

Women and non-Hispanic whites are more likely to have DNR orders. DNR status affected the measurement of sex-ethnic differences in mortality risk.

Physicians' attitudes towards 'do-not-resuscitate' orders for the elderly: a survey in Saudi Arabia

To study physicians' attitudes towards do-not-resuscitate orders (DNR) in the elderly and analyze the responses to some of the factors that may influence the resuscitation decisions, a self-completed questionnaire was administered to physicians in the departments of Medicine and Critical Care in three cities in Saudi Arabia. Physicians were asked whether they would recommend DNR for two hypothetical cases, one elderly and previously functional and another younger patient suffering from severe dementia. They were asked also to grade the importance of a number of factors that may have some influence on the resuscitation decisions. A total of 249 physicians participated in the study (a response rate of 79%). Only 16% of physicians indicated they would recommend DNR for the previously healthy elderly as opposed to 61% for the patient with dementia (P<0.001). When considering DNR orders, physicians ranked dignity of the patient, religious and legal concerns highly, and cared least about expenses of the medical care. In conclusion, most physicians assigned more importance to the functional status of the patient than the biological age. When considering DNR, physicians in Saudi Arabia shared with their counterparts in the West many features, notably caring about dignity of the patient, but were also concerned about the religious and the legal stand. This may be related to the absence of clear local policies and guidelines.

Evaluating the performance of an institution using an intensive care unit benchmark

OBJECTIVES

To describe the performances of selected intensive care units (ICUs) in a single institution using the Acute Physiology and Chronic Health Evaluation (APACHE) III benchmark and to propose interventions that may improve performance.

PATIENTS AND METHODS

In this retrospective study, we analyzed APACHE III data from critically ill patients admitted to ICUs at the Mayo Clinic in Rochester, Minn, between October 1994 and December 2003. We retrieved ICU performance measures based on first ICU day APACHE III values. Standardized ratios were defined as ratios of measured to predicted values. The primary performance measure was the standardized mortality ratio, and secondary performance measures were length of stay (LOS) ratios, low-risk monitor ICU admission rates, and ICU readmission rates. We calculated 95% confidence intervals (CIs) for each performance, graded as good, average, or poor.

RESULTS

Among 46,381 patients admitted during the study period, 57.5% were in surgical ICUs, 24.8% in a medical ICU, and 17.7% in a surgical-medical ICU. Low-risk monitoring accounted for 37.2% of admissions. Hospital standardized mortality ratios (95% CI) were 0.95 (0.90-0.99), 0.86 (0.81-0.91), and 0.70 (0.66-0.74) for medical, multispecialty, and surgical ICUs, respectively. Hospital LOS ratios (95% CI) were 0.83 (0.81-0.85), 0.91 (0.88-0.93), and 0.99 (0.97-1.00) for medical, multispecialty, and surgical ICUs, respectively. The ICU readmission rate for each ICU was higher than the 6.7% reported in the medical literature. Performances were good in mortality, average to good in LOS, average in low-risk admission, and poor in ICU readmission.

CONCLUSIONS

A national benchmarking database can highlight the strengths and weaknesses of ICUs. The performances of ICUs in a single institution may differ; therefore, the performance of each unit should be evaluated individually.

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

There is a major deficiency in the end-of-life care offered to patients dying in the intensive care unit (ICU).

HYPOTHESIS

Hospitalized dying patients had informed discussions on end-of-life and palliative care options before admission to ICU.

PATIENTS AND METHODS

A descriptive non-interventional study was performed at a teaching hospital to examine if patients who died in hospital had informed discussions on end-of-life care before admission to ICU. The impact of these discussions on subsequent patient care: aggressive therapy in the ICU, the quality of palliation, use of hospice care services and utilization of hospital resources were examined. Data were collected from medical records for all hospital deaths over 24 months.

RESULTS

Of 252 hospital deaths, 196 (78%) were treated and subsequently 165 (65%) died in the ICU. Patients treated either in the ICU or general hospital wards had similar frequency of ultimately or rapidly fatal pre-existing disease (47% versus 62%, P: ns) and readmission to hospital within one year before death (43% versus 57%, P, ns). The median age (10-90% percentile) was slightly younger for the ICU than hospital wards patients: 73 (45-85) versus 76 (55-91) years, P < 0.01. Of the 156 patients who were transferred to ICU from hospital wards: 136 (87%) were managed by house staff on teaching services and 20 (13%) were managed by attending staff hospitalists, P < 0.01. None of those transferred to the ICU who subsequently died had discussion of palliation or end-of-life care as an alternative treatment. Of those who died who were treated on general wards, 14 (25%) patients had discussion of palliation as an alternative treatment option before death. Do-not-resuscitate decisions were made in 48% of cases two days before death. Patients who were treated in the ICU had more invasive tests performed on them and were less likely to have adequate pain control or referral to hospice care services than on a general ward. Median hospital charge was much higher for patients who received ICU versus general ward care (33,252 dollars versus 8549 dollars, P < 0.001).

CONCLUSIONS

Patients who died in the ICU did not have informed discussions of end-of-life or palliative care as an alternative treatment option before admission. The quality of end-of-life care was disrupted for patients with fatal pre-existing chronic disease who were admitted to the ICU before death. Lack of clinical experience, knowledge and competency with end-of-life care influenced admission of patients to ICU regardless of poor prognosis. Decisions regarding the pursuit of aggressive therapy versus palliative care must be addressed with patients by physicians who are competent and experienced in end-of-life care as this will have a profound impact on both the quality of care delivered and effective use of limited hospital resources.

Do not attempt resuscitation decisions: the nursing role

This exploratory study examines the roles of practice nurses with regard to do not attempt resuscitation (DNAR) decisions. The British Medical Association (BMA) and the Royal College of Nursing (RCN) have published joint DNAR guidelines. One NHS trust responded by developing a local DNAR policy written for use in hospital and general practice. The study focuses on aspects of compliance with the policy and hence DNAR decision-making, in particular, the nurse's involvement in the decision-making process. The response rate to self-administered questionnaires to practice nurses was 52% (n = 45). Hospital nurses (n = 49) were selected for interview using a quota-sampling technique. Comparisons were made of the views of acute and community staff in their use of the DNAR policy. A clear finding is that hospital nurses wish for more autonomy in DNAR decision-making and improved methods of communicating with medical colleagues when decisions are made. Practice nurses are currently not involved in DNAR decisions. The appropriateness of developing policies for such complex issues as DNAR, when compliance remains low, questions their validity. This study raises awareness, and adds to the discussion for the need for a multidisciplinary approach to DNAR policy.

Do-not-resuscitate order after 25 years

BACKGROUND

In 1976, the first hospital policies on orders not to resuscitate were published in the medical literature. Since that time, the concept has continued to evolve and evoke much debate. Indeed, few initials in medicine today evoke as much symbolism or controversy as the Do-Not-Resuscitate (DNR) order.

OBJECTIVE

To review the development, implementation, and present standing of the DNR order.

DESIGN

Review article.

MAIN RESULTS

The DNR order concept brought an open decision-making framework to the resuscitation decision and did much to put appropriate restraint on the universal application of cardiopulmonary resuscitation for the dying patient. Yet, even today, many of the early concerns remain.

CONCLUSIONS

After 25 yrs of DNR orders, it remains reasonable to presume consent and attempt resuscitation for people who suffer an unexpected cardiopulmonary arrest or for whom resuscitation may have physiologic effect and for whom no information is available at the time as to their wishes (or those of their surrogate). However, it is not reasonable to continue to rely on such a presumption without promptly and actively seeking to clarify the patient's (or surrogate's) wishes. The DNR order, then, remains an inducement to seek the informed patient's directive.

Efficacy of CPR in a general, adult ICU

AIM

To investigate the initial cardiopulmonary resuscitation (CPR) success rate and long term survival in an Intensive care unit (ICU) population.

PATIENTS

All patients with cardiac arrest over a 2-year-period (1999-2000) in a general, adult ICU of a general hospital of Athens.

METHODS

Retrospective collection of clinical data concerning patients, CPR characteristics and survival rates.

RESULTS

We examined 111 ICU patients, aged 56.4+/-1.9 years (72 males). SAPS II score was 43.9+/-3.8. CPR was performed in 98.2% of the patients within 30 s. Initial restoration of cardiac function (RCF) and successful CPR rate was 100% while 24 h survival was 9.2%. Survivors at 24 h were younger, mainly males, with lower SAPS II score, mainly with pulmonary disease, ventricular fibrillation or ventricular tachycardia (8/10) and initial pupil reactivity (5/10). Four patients required more than one cycle of CPR. Survival to discharge was zero.

CONCLUSION

Although the initial successful CPR rate in ICU patients may be high, long term survival and hospital discharge is disappointing. Although ICU patients are better monitored and treated in a timely fashion, they are disadvantaged by chronic underlying diseases, severe current medical illnesses and multi organ dysfunction syndrome (MODS) leads to worst outcome after CPR compared with in-ward patients.

Health care rationing affecting older persons: rejected in principle but implemented in fact

Health care resources are finite and, therefore, need to be rationed among potential users. Over the past decade and a half in the United States, a variety of explicit, official rationing schemes have been proposed, including some in which chronological age would play a significant role. For ethical and political reasons, it is very unlikely that any age-based rationing schemes will be adopted explicitly and officially. However, various de facto forms of health care rationing are occurring at present. This article outlines the implications of payer behavior, physician practice patterns, the development of evidence-based clinical practice parameters or guidelines, and reliance on consumer choice of health plans as unofficial and generally unacknowledged mechanisms of health care rationing that may exert an important impact on the accessibility of health services for older persons.

Impact of a proactive approach to improve end-of-life care in a medical ICU

STUDY OBJECTIVES

To assess the impact of a proactive case finding approach to end-of-life care for critically ill patients experiencing global cerebral ischemia (GCI) after cardiopulmonary resuscitation and multiple organ system failure (MOSF) in comparison to historical control subjects.

DESIGN

Comparative study of retrospective and prospective cohorts.

SETTING

Medical ICU of a university hospital.

INTERVENTIONS

Patterns of end-of life care for patients with MOSF and GCI obtained through a retrospective chart review were compared to proactive case finding facilitated by the inpatient palliative care service. Interventions included identification of patient's advance directives or preferences about end-of life care, if any; assistance with discussion of the prognosis and treatment options with patients or their surrogates; and implementation of palliative care strategies when treatment goals changed to a focus on comfort measures.

RESULTS

Although our retrospective data demonstrated a high percentage of do-not-resuscitate decisions for the patients under investigation, a considerable time lag elapsed between identification of the poor prognosis and the establishment of end-of-life treatment goals (4.7 +/- 2.4 days and 3.5 +/- 0.5 days for patients with MOSF and GCI, respectively [mean +/- SE]). The proactive case finding approach decreased hospital length of stay (mean, 20.6 +/- 4.1 days vs 15.1 +/- 2.5 days and 8.6 +/- 1.6 days vs 4.7 +/- 0.6 days for MOSF and GCI patients, respectively; p = 0.063 and < 0.001, respectively). More importantly, a proactive palliative care intervention decreased the time between identification of the poor prognosis and the establishment of comfort care goals (7.3 +/- 2.9 days vs 2.2 +/- 0.8 days and 6.3 +/- 1.2 days vs 3.5 +/- 0.4 days for MOSF and GCI patients, respectively; p < 0.05 for both), decreased the time dying patients with MOSF remained in the ICU, and reduced the use of nonbeneficial resources, thus reducing the cost of care.

CONCLUSIONS

Proactive interventions from a palliative care consultant within this subset of patients decreased the use of nonbeneficial resources and avoided protracted dying.

A multicenter description of intermediate-care patients: comparison with ICU low-risk monitor patients

STUDY OBJECTIVES

To describe the characteristics and outcomes of patients admitted to intermediate-care areas (ICAs) and to compare them with those of ICU patients who receive monitoring only on day 1 and are at a low risk (i.e., < 10%) for receiving subsequent active life-supporting therapy (i.e., low-risk monitor patients).

DESIGN

Nonrandomized, retrospective, cohort study.

SETTING

Thirteen US teaching hospitals and 19 nonteaching hospitals.

PATIENTS

A consecutive sample of 8,971 patients at 37 ICAs and 5,116 low-risk (i.e., < 10%) monitor patients at 59 ICUs in 32 US hospitals.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

We recorded demographic and clinical characteristics, resource use, and outcomes for the ICA and ICU low-risk monitor patients. Patient data and outcomes for this study were collected concurrently or retrospectively. ICA and ICU low-risk monitor patients were similar in regard to gender, race, and frequency of comorbitities, but ICA patients were significantly (p < 0.001) older, had fewer physiologic abnormalities (mean acute physiology score, 16.7 vs 19.8, respectively), and were more frequently admitted due to nonoperative diagnoses. The mean length of stay for ICA patients was significantly longer (3.9 days) than for ICU low-risk monitor patients (2.6 days; p < 0.001). The hospital mortality rate was significantly higher for ICA patients (3.1%) compared to ICU low-risk monitor patients (2.3%; p = 0.002).

CONCLUSIONS

The clinical features of ICA patients are similar, but not identical to, those of less severely ill ICU monitor patients. Comparisons of hospital death rates and lengths of stay for these patients should be adjusted for characteristics that previously have been shown to influence these outcomes.

Economic influences on end-of-life care: empirical evidence and ethical speculation

Although very little actual evidence on the issue is available, much ethical speculation has been voiced about the probable impact of the current cost containment-oriented economic climate in the United States on decisions that are being made and implemented in the context of end-of-life medical care. This article, after noting that numerous factors besides money drive the behavior of various actors in the health care system, turns to the economic influences on care for dying patients. These influences, both real and imagined, may be manifested in the amount of de facto health care rationing by age that occurs, the prevalent fears of older persons regarding both overtreatment and undertreament, the financial expectations as well as disappointments emanating from the practice of advance medical planning, and the paucity of options from which many impoverished individuals must choose at the end of their lives. It is too early to judge specifically the impact of managed care on end-of-life decisions, but positive opportunities as well as perils may materialize.

Communication between the hospitalized older patient and physician

Much research has shown that how physicians communicate with patients can have profound influence on behavioral, psychosocial, and clinical outcomes of the encounter. Communication with older patients, however, is often compromised by some attributes of the aging process. Communication can also be affected by the setting in which it takes place, and the hospital presents some barriers not found in ambulatory sites. These concerns are often compounded in end-of-life decisions for older patients when discussed in hospital settings.