End-of-life care preferences of patients enrolled in cardiovascular rehabilitation programs

Barriers to the composition and implementation of advance directives in oncology: a literature review

The advance directive (AD) is an important resource in oncology and all areas of medicine directly involved in the care of palliative patients. It provides people with the right to have their living wills honoured when they cannot respond by themselves. Despite their importance, ADs are still underused in most countries due to multiple factors. The objective of this review is to better categorise the barriers and difficulties that could impair the composition and implementation of ADs, allowing direct efforts against these obstacles. After the literature review, we believe that there would be five steps in the trajectory of an AD (discussion, composition, registration, access and implementation) and that all those steps can be affected by factors involving the health systems and professionals, the patient themselves and relatives or caregivers.

The Role of Palliative Care in the Cardiac Intensive Care Unit

In the last few years, important changes have occurred in the clinical and epidemiological characteristics of patients that were admitted to cardiac intensive care units (CICU). Care has shifted from acute coronary syndrome patients towards elderly patients, with a high prevalence of non-ischemic cardiovascular diseases and a high burden of non-cardiovascular comorbid conditions: both increase the susceptibility of patients to developing life-threatening critical conditions. These conditions are associated with a significant symptom burden and mortality rate and an increased length of stay. In this context, palliative care programs, including withholding/withdrawing life support treatments or the deactivation of implanted cardiac devices, are frequently needed, according to the specific guidelines of scientific societies. However, the implementation of these recommendations in clinical practice is still inconsistent. In this review, we analyze the reasons for this gap and the main cultural changes that are required to improve the care of patients with advanced illness.

Palliative care and end-of-life care for polypathological patients

Patients with advanced chronic diseases receive fragmented care, which entails high resource consumption and a poor quality of life. Uncertainty in the prognosis and scarce investigation into the importance of symptomatic control in this patient group hinders a proper therapeutic approach. Palliative care teams optimise the use of resources through comprehensive patient care, the optimization of the patient's environment, communication, the preparation of early care plans and the creation of coordinated healthcare circuits, which improve the quality of the patient's care in advanced stages of the disease. In the end-of-life phase, the therapeutic approach is focused on symptomatic control, selecting treatments according to the cause, comorbidities and the patient's wishes. To control refractory symptoms, palliative sedation is considered an indispensable option.

Palliative Care and Cardiovascular Disease and Stroke: A Policy Statement From the American Heart Association/American Stroke Association

The mission of the American Heart Association/American Stroke Association includes increasing access to high-quality, evidence-based care that improves patient outcomes such as health-related quality of life and is consistent with the patients’ values, preferences, and goals. Awareness of and access to palliative care interventions align with the American Heart Association/American Stroke Association mission. The purposes of this policy statement are to provide background on the importance of palliative care as it pertains to patients with advanced cardiovascular disease and stroke and their families and to make recommendations for policy decisions. Palliative care, defined as patient- and family-centered care that optimizes health-related quality of life by anticipating, preventing, and treating suffering, should be integrated into the care of all patients with advanced cardiovascular disease and stroke early in the disease trajectory. Palliative care focuses on communication, shared decision making about treatment options, advance care planning, and attention to physical, emotional, spiritual, and psychological distress with inclusion of the patient’s family and care system. Our policy recommendations address the following: reimbursement for comprehensive delivery of palliative care services for patients with advanced cardiovascular disease and stroke; strong payer-provider relationships that involve data sharing to identify patients in need of palliative care, identification of better care and payment models, and establishment of quality standards and outcome measurements; healthcare system policies for the provision of comprehensive palliative care services during hospitalization, including goals of care, treatment decisions, needs of family caregivers, and transition to other care settings; and health professional education in palliative care as part of licensure requirements.

Nurses’ and Physicians’ Opinions on Aggressiveness of Treatment for General Ward Patients

The aim of this study was to evaluate agreement between nurses’ and physicians’ opinions regarding aggressiveness of treatment and to investigate and compare the rationales on which their opinions were based. Structured interviews regarding 714 patients were performed on seven general wards of a university hospital. The data gathered were then subjected to qualitative and quantitative analyses. There was 86% agreement between nurses’ and physicians’ opinions regarding full or limited treatment when the answers given as ‘uncertain’ were excluded. Agreement was less (77%) for patients with a life expectancy of less than one year. Disagreements were not associated with professional status because the physicians considered limiting life-sustaining treatment as often as the nurses. A broad spectrum of rationales was given but the results focus mostly on those for full treatment. The nurses and the physicians had similar bases for their opinions. For the majority of the patients, medical rationales were used, but age and quality of life were also expressed as important determinants. When considering full treatment, nurses used quality-of-life rationales for significantly more patients than the physicians. Respect for patients’ wishes had a minor influence.

Advance Directives among Elderly Veterans

The goal of this study was to identify various sociodemographic and clinical variables related to the completion of advance directives among 281 elderly male veterans recruited from the acute medical inpatient unit of a Veterans Affairs Medical Center. Results found the rates of advance directives to be higher among elderly male veterans compared to other populations (44% had either a durable power of attorney or a living will, 34.2% had a living will, and 35.2% had a durable power of attorney). In addition, individuals who completed an advance directive were significantly more likely to be Caucasian than non-Caucasian. Other than race, there were other important factors including religiosity, desire for life-saving treatment, social support, and depressive symptoms that were related to the completion of advance directives among elderly veterans. Such factors seem consistent with the research literature on nonveteran populations.

Hospital mortality in postoperative critically ill patients older than 80 years. Can we predict it at an early stage?

OBJECTIVES

To determine the incidence of in-hospital mortality throughout the post-surgical period of patients aged 80 or over who were admitted to the post-surgical critical care unit, as well as to assess the predictive capacity of those variables existing in the first 48hours on the in-hospital mortality.

MATERIAL AND METHODS

An observational retrospective cohort study conducted on postsurgical patients up to 80years old who were admitted to the unit between June 2011 and December 2013. Univariate and multivariate binary logistic regression was used to determine the association between mortality and the independent variables.

RESULTS

Of the 186 patients included, 9 (4.8%) died in the critical care unit, and 22 (11.8%) died in wards during hospital admission, giving a hospital mortality of 31 (16.7%). Among the 78 patients (42%) that underwent acute surgery, and the 108 who underwent elective surgery, there was a mortality rate of 19 (10.2%) and 12 (6.5%), respectively. As regards the variables analysed during the first 48hours of admission that showed to be hospital mortality risk factor were the need for mechanical ventilation over 48h, with an OR: 7.146 (95%CI: 1.563-32.664, P=.011) and the degree of the severity score on the APACHE II scale in the first 24hours, with an OR: 1.102 (95%CI: 1.005-1.208, P=.039).

CONCLUSION

The incidence of hospital mortality in very old patients found in our study is comparable to that reported by other authors. Patients who need mechanical ventilation over 48h, and with higher scores in the APACHE II scale could be at a higher risk of in-hospital mortality.

Diretivas antecipadas de vontade aos doentes terminais: revisão integrativa

RESUMOObjetivo:caracterizar a produção científica nacional e internacional sobre as diretivas antecipadas de vontade aplicadas ao doente terminal.Método:a revisão integrativa, incluindo os artigos publicados no Portal Capes, SCIELO, LILACS, MEDLINE, Revista de Bioética e Bioethikos, a partir dos descritores: Diretivas antecipadas, Testamentos quanto à vida, Advance Directives, Living Will e Terminally Ill totalizando 44 artigos submetidos à análise de conteúdo.Resultados:emergiram três categorias: Estudantes e profi ssionais frente às diretivas antecipadas de vontade: percepções, opiniões e condutas; Receptividade dos pacientes às diretivas antecipadas de vontade; A família diante das diretivas antecipadas de vontade.Conclusão:evidenciou-se a relevância do tema como garantidor do respeito à dignidade e à autonomia do doente, bem como para a redução dos conflitos éticos enfrentados pelos familiares e profi ssionais da saúde frente aos cuidados em fi nal de vida.

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.

Older Adults Making End of Life Decisions: An Application of Roy's Adaptation Model

Purpose. The purpose of this study was to identify variables that influenced completion of advanced directives in the context of adaptation from national data in older adults. Knowledge gained from this study would help us identify factors that might influence end of life discussions and shed light on strategies on effective communication on advance care planning. Design and Method. A model-testing design and path analysis were used to examine secondary data from 938 participants. Items were extracted from the data set to correspond to variables for this study. Scales were constructed and reliabilities were tested. Results. The final path model showed that physical impairment, self-rated health, continuing to work, and family structure had direct and indirect effects on completion of advanced directives. Five percent of the variance was accounted for by the path analysis. Conclusion. The variance accounted for by the model was small. This could have been due to the use of secondary data and limitations imposed for measurement. However, health care providers and families should explore patient's perception of self-health as well as their family and work situation in order to strategize a motivational discussion on advance directive or end of life care planning.

Ethical challenges in advanced heart failure

PURPOSE OF REVIEW

Advanced heart failure (AHF) is an increasingly important field. Both the population of AHF patients and the therapeutic and diagnostic interventions available are expanding, creating a host of difficult ethical challenges. This article discusses these important issues and proposes an approach to caring for AHF patients.

RECENT FINDINGS

Recent guidelines and clinical trials describe the benefits of costly and invasive therapies for AHF, such as ventricular assist devices and cardiac resynchronization therapy which prolong life and improve symptoms but may create burdens and conflict over deactivation at the end of life. Prognostication, informed consent, and early involvement of palliative care are central to addressing the decision-making challenges raised by these devices. Societal concerns such as cost-effectiveness and distributive justice will play an increasingly important role in the dissemination of these devices.

SUMMARY

More research, increased end-of-life education, emphasis on advance directives, a more comprehensive informed consent process, and a true multidisciplinary approach are needed to provide optimal care for patients with AHF.

Link between decisions regarding resuscitation and preferences for quality over length of life with heart failure

AIMS

Survival preferences, ascertained from time-trade-off utilities, have not been studied in heart failure patients who designate a 'do not resuscitate' (DNR) status. Therefore, the aim of this study was to determine the association of heart failure patients' resuscitation preferences with survival preferences and mortality in the ESCAPE trial.

METHODS AND RESULTS

We analysed the association of resuscitation orders at 1 month with time-trade-off utilities and 6-month mortality. There were 26 and 349 patients with a DNR order and Full Code order, respectively. DNR patients were older, had more coronary artery disease, hypertension, renal impairment, and poorer exercise capacity than Full Code patients. DNR patients also experienced longer hospitalization and higher 6-month mortality. In multivariate analysis, DNR preference was associated with 10-fold higher odds of willingness to trade survival time (lower time-trade-off utility) in favour of improved quality of life [odds ratio 10.33, 95% confidence interval (CI) 1.65-64.80]. DNR preference was the best predictor of mortality (χ(2) 26.12, P < 0.0001, hazard ratio 6.88, 95% CI 3.28-14.41), despite adjustment for known predictors including brain natriuretic peptide.

CONCLUSIONS

Heart failure patients' requests to forego resuscitation may signify more than simply 'what-if' directives for emergency care. DNR decisions may reflect preferences for intervention to enhance quality rather than prolong survival, which is particularly important as these patients have high early mortality.

End-of-life care conversations with heart failure patients: a systematic literature review and narrative synthesis

BACKGROUND

Current models of end-of-life care (EOLC) have been largely developed for cancer and may not meet the needs of heart failure patients.

AIM

To review the literature concerning conversations about EOLC between patients with heart failure and healthcare professionals, with respect to the prevalence of conversations; patients' and practitioners' preferences for their timing and content; and the facilitators and blockers to conversations.

DESIGN OF STUDY

Systematic literature review and narrative synthesis.

METHOD

Searches of Medline, PsycINFO and CINAHL databases from January 1987 to April 2010 were conducted, with citation and journal hand searches. Studies of adult patients with heart failure and/or their health professionals concerning discussions of EOLC were included: discussion and opinion pieces were excluded. Extracted data were analysed using NVivo, with a narrative synthesis of emergent themes.

RESULTS

Conversations focus largely on disease management; EOLC is rarely discussed. Some patients would welcome such conversations, but many do not realise the seriousness of their condition or do not wish to discuss end-of-life issues. Clinicians are unsure how to discuss the uncertain prognosis and risk of sudden death; fearing causing premature alarm and destroying hope, they wait for cues from patients before raising EOLC issues. Consequently, the conversations rarely take place.

CONCLUSION

Prognostic uncertainty and high risk of sudden death lead to EOLC conversations being commonly avoided. The implications for policy and practice are discussed: such conversations can be supportive if expressed as 'hoping for the best but preparing for the worst'.

Nurses' conceptions of decision making concerning life-sustaining treatment

The aim of this study was to describe nurses' conceptions of decision making with regard to life-sustaining treatment for dialysis patients. Semistructured interviews were conducted with 13 nurses caring for such patients at three hospitals. The interview material was subjected to qualitative content analysis. The nurses saw decision making as being characterized by uncertainty and by lack of communication and collaboration among all concerned. They described different ways of handling decision making, as well as insufficiency of physician-nurse collaboration, lack of confidence in physicians, hindrances to patient participation, and ambivalence about the role of patients' next of kin. Future research should test models for facilitating communication and decision making so that decisions will emerge from collaboration of all concerned. Nurses' role in decision making also needs to be discussed.

Predicting neurological outcome following cardiac arrest

Because a large number of patients will suffer cardiac arrest each year, physicians must place attention on improving care for patients in the post-resuscitative setting. Part of this effort requires setting realistic goals based on patients' potential for recovery. Recovery from cardiac arrest often depends on the extent of anoxic brain injury, and for this reason primary teams consult neurologists to offer insight into potential for awakening from post-arrest coma. In doing so, neurologists inform a decision with legal, social and ethical implications. Though inapplicable without preparation at the time of cardiac arrest, the four principles of medical ethics have a direct impact on decision making during the post-resuscitative period. A review of the literature reveals that physical examination, electrophysiology, radiology, and biochemical markers can prove useful in estimating a patient's chances for neurological recovery from cardiac arrest. These factors most reliably predict poor outcome, but do so with high specificity. However, the role of the neurology consultant must change to include guidance on strategies of neuroprotection. Aggressive efforts directed towards neuroprotection may change predictions for outcomes after cardiac arrest in the future.

Advance directives in the cardiac care unit

BACKGROUND

Despite effective therapies, mortality for many cardiovascular diseases remains higher than for many cancers and is difficult to predict. Guidelines recommend discussing advance directives (AD), including living wills and durable powers of attorney, with heart failure patients. The Patient Self-Determination Act mandates such discussions with all hospitalized patients. Little data are available on AD prevalence in patients with serious cardiac disease.

METHODS

Patients admitted to a cardiac care unit (CCU) were surveyed regarding demographics, medical history, prevalence of AD, and interest in obtaining more information about AD. Histories of life-threatening cardiac diagnoses were tabulated. Prevalence of AD and interest in obtaining more information about AD were obtained via chart review from patients on an oncology (ONC) floor at the same hospital.

RESULTS

One hundred twelve CCU (average age 58 +/- 16 years, 47 women) and 105 ONC (average age 58 +/- 14 years, 32 women) patients were enrolled. Prevalence of AD was not different between CCU and ONC patients (26% vs 31%, P = .37). Among CCU patients with prior hospitalizations but no AD, 21 of 64 did not recall being asked about AD. Cardiac care unit patients with heart failure and pulmonary hypertension were more likely to report being asked about AD in the past (39 of 54, P = .03 and 7 of 9, P = .008, respectively), but only heart failure patients were more likely to want more information about AD (P = .005). Of patients without AD, 83% from CCU and 18% from ONC wanted more information on AD (P < .001).

CONCLUSIONS

Prevalence of AD in the CCU was low, and many patients did not recall prior AD discussions. The CCU patients without AD were more likely to want information about AD than the ONC patients. A renewed emphasis on AD discussions with cardiovascular patients is needed and would be welcomed. Advance directives should be emphasized in cardiovascular training programs.

Advanced chronic obstructive pulmonary disease: innovative approaches to palliation

By the year 2020, chronic obstructive pulmonary disease (COPD) will be the third leading cause of death globally. While there have been consistent calls for increased palliative care involvement in the care of patients with advanced COPD, these calls should be based on empirical evidence that such an approach improves the symptom burden and poor quality of life associated with advanced COPD. Rather than reviewing the traditional treatments of airflow obstruction and palliative measures familiar to the palliative care community, we will focus on some novel approaches to the management of patients with advanced COPD from the perspective of clinicians involved in end of life care provision and research. By combining the clinical and research skills of pulmonologists and palliative medicine specialists we can advance the care of patients with this progressive and incurable disease.

Improving end-of-life care for patients with chronic heart failure: "Let's hope it'll get better, when I know in my heart of hearts it won't"

BACKGROUND

Although chronic heart failure (CHF) has a high mortality rate and symptom burden, and clinical guidance stipulates palliative care intervention, there is a lack of evidence to guide clinical practice for patients approaching the end of life.

AIMS

(1) To formulate guidance and recommendations for improving end-of-life care in CHF; (2) to generate data on patients' and carers' preferences regarding future treatment modalities, and to investigate communication between staff, patients and carers on end-of-life issues.

DESIGN

Semistructured qualitative interviews were conducted with 20 patients with CHF (New York Heart Association functional classification III-IV), 11 family carers, 6 palliative care clinicians and 6 cardiology clinicians.

SETTING

A tertiary hospital in London, UK.

RESULTS

Patients and families reported a wide range of end-of-life care preferences. None had discussed these with their clinicians, and none was aware of choices or alternatives in future care modalities, such as adopting a palliative approach. Patients and carers live with fear and anxiety, and are uninformed about the implications of their diagnosis. Cardiac staff confirmed that they rarely raise such issues with patients. Disease- and specialism-specific barriers to improving end-of-life care were identified.

CONCLUSIONS

The novel, integrated data presented here provide three recommendations for improving care in line with policy directives: sensitive provision of information and discussion of end-of-life issues with patients and families; mutual education of cardiology and palliative care staff; and mutually agreed palliative care referral criteria and care pathways for patients with CHF.

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.

[Knowledge of the disease and the advance directives in patients with HIV infection]

BACKGROUND AND OBJECTIVE

Advanced directives documents (ADD), allow respect and know patient's intentions in health matters, when they are not able by themselves, for decision making. The aim of this study is making a valoration of the knowledgment of this documents in human immunodeficiency virus (HIV) infected patients, as well as their own knowledgment about this patology and possible complications.

PATIENTS AND METHOD

HIV infected patients controlled in 2 centers (Hospital de Mataró and Hospital de Granollers). Plained interview as a questinonary, that permits evaluate: own knowledge of the patology, received medical information level of satisfaction, patient s medical decision making involving desire, aptitudes in front of different hypothetical health status, and ADD knowledge. Factors associated to both knowledges (patology and ADD) are also evaluated.

RESULTS

74.3% of the interviewed patients, showed a good patology knowledge. This result was associated with: youth, less functional level according to Karnofsky's scale, subjective perception on severity, previous admission at an intensive care unit, chronic hepatopathy, and previous parenteral drugs addiction. In the same way was associated with the negative to depend of mechanical ventilation or another people, and not being uncomfortable talking about this subjects. ADD's knowledge was relationated with the fact of being female (42.0% vs 26.8%; p = 0.024), higher academic formation (55.1% vs 25.5%; p < 0.001) and belief that medical decision making must be done by themselves (78.3% vs 53.6%; p = 0.002).

CONCLUSIONS

Patology understanding and its complications, may be considered optimal in HIV population. One third of this group, has a good knowledge of ADDs, and is directly relationated with female sex, academic level, and clinical decisions making implication by the patients.

End-of-life issues in elderly patients with acute coronary syndrome: the role of the cardiovascular nurse

End-of-life care and cardiovascular disease are concepts that do not have the same synergy as end-of-life care and cancer. Cardiovascular care is predominantly perceived by patients and practitioners as a curative discipline. However, with the aging of the population and the prevalence of cardiovascular heart disease, it will continue to be the leading cause of death for adults in the United States. Clinical treatment options and issues surrounding end-of-life care need to be addressed with elderly patients and their families. The purpose of this article is to discuss the role of the cardiovascular nurse in the care of the elderly patient with acute coronary syndrome.

End-of-life preferences in elderly patients admitted for heart failure

BACKGROUND

Heart failure is increasing in prevalence and incidence, with considerable mortality among the elderly.

AIM

To determine preferences concerning cardiopulmonary-resuscitation (CPR) and end-of-life care in elderly patients hospitalized for heart failure.

DESIGN

Prospective interview-based survey.

METHODS

Patients >64 years old admitted for acute heart failure were interviewed to address their preferences regarding end-of-life care and cardio-pulmonary resuscitation (CPR) when facing the last stages of their disease.

RESULTS

We interviewed 80 patients (mean age 79 years; 58% women). Thirty-two (40%) expressed a wish not to have CPR. Only two had previously discussed their CPR preferences with their physicians. When recovery from the illness was considered unlikely, 40 (50%) participants preferred to receive treatment at home, 32 (40%) preferred in-hospital management, and 8 (10%) were unsure. Thirty-three patients (41%) expressed a desire for spiritual support, 38 (48%) said not and the remaining 9 (11%) were indifferent.

DISCUSSION

Advance planning of end-of-life procedures and doctor-patient communication regarding these items remains poor and must be improved.

Clinician predictions of intensive care unit mortality*

OBJECTIVE

Predicting outcomes for critically ill patients is an important aspect of discussions with families in the intensive care unit. Our objective was to evaluate clinical intensive care unit survival predictions and their consequences for mechanically ventilated patients.

DESIGN

Prospective cohort study.

SETTING

Fifteen tertiary care centers.

PATIENTS

Consecutive mechanically ventilated patients > or = 18 yrs of age with expected intensive care unit stay > or = 72 hrs.

INTERVENTIONS

We recorded baseline characteristics at intensive care unit admission. Daily we measured multiple organ dysfunction score (MODS), use of advanced life support, patient preferences for life support, and intensivist and bedside intensive care unit nurse estimated probability of intensive care unit survival.

MEASUREMENTS AND MAIN RESULTS

The 851 patients were aged 61.2 (+/- 17.6, mean + SD) yrs with an Acute Physiology and Chronic Health Evaluation (APACHE) II score of 21.7 (+/- 8.6). Three hundred and four patients (35.7%) died in the intensive care unit, and 341 (40.1%) were assessed by a physician at least once to have a < 10% intensive care unit survival probability. Independent predictors of intensive care unit mortality were baseline APACHE II score (hazard ratio, 1.16; 95% confidence interval, 1.08-1.24, for a 5-point increase) and daily factors such as MODS (hazard ratio, 2.50; 95% confidence interval, 2.06-3.04, for a 5-point increase), use of inotropes or vasopressors (hazard ratio, 2.14; 95% confidence interval, 1.66-2.77), dialysis (hazard ratio, 0.51; 95% confidence interval, 0.35-0.75), patient preference to limit life support (hazard ratio, 10.22; 95% confidence interval, 7.38-14.16), and physician but not nurse prediction of < 10% survival. The impact of physician estimates of < 10% intensive care unit survival was greater for patients without vs. those with preferences to limit life support (p < .001) and for patients with less vs. more severe organ dysfunction (p < .001). Mechanical ventilation, inotropes or vasopressors, and dialysis were withdrawn more often when physicians predicted < 10% probability of intensive care unit survival (all ps < .001).

CONCLUSIONS

Physician estimates of intensive care unit survival < 10% are associated with subsequent life support limitation and more powerfully predict intensive care unit mortality than illness severity, evolving or resolving organ dysfunction, and use of inotropes or vasopressors.

Discussing life-sustaining treatments: An overview and communications guide for primary care physicians

Physicians must be skilled communicators with patients, families, and multidisciplinary health care teams to meet ethical decision-making challenges arising in end-stage disease care. We offer practical suggestions for collaborative communication in the "perfect storm" of contemporary critical care settings.

Intensive care decision making in the seriously ill and elderly*

OBJECTIVE

To determine the influence of self-reported preadmission quality of life, hypothetical quality of life and mortality prognosis, and length and intensity of intensive care on decision making in the seriously ill and elderly.

DESIGN

Prospective cohort study.

SETTING

Medical university.

SUBJECTS

Adult inpatients with chronic illness and an estimated 50% 6-month mortality along with patients > or =80 yrs old with an acute illness.

INTERVENTIONS

Patients were presented with two scenarios: a) mechanical ventilation for 14 days; and 2) mechanical ventilation for 1 month with tracheostomy and feeding tube placement. A modified time trade-off was used to vary survival and quality of life over plausible ranges. Patients could consent to intensive care or choose care directed at comfort measures.

MEASUREMENTS AND MAIN RESULTS

Fifty patients were interviewed. As projected intensive care unit mortality rate or postintensive care unit quality of life decreased, patients were less likely to consent to intensive care. Postintensive care quality of life was as important to patients as intensive care survival estimates. However, prehospitalization quality of life did not significantly influence decision making regarding life-extending treatment. When progressing from the acute intensive care scenario to chronic mechanical ventilation with associated interventions, patients demanded a significant increase in survival and quality of life. Neither race nor previous intensive care unit admission was associated with consent to intensive care.

CONCLUSIONS

There is wide variation in preference for aggressive care that does not appear to be influenced by prehospitalization quality of life. However, predicted quality of life appears to be as important as estimates of intensive care unit survival in decision making. When confronted with extended mechanical ventilation and associated care, a significant proportion of patients would accept this care only for an improved prognosis. Length and intensity of intensive care should be incorporated into discussions regarding intensive care.

End-of-life decisions in Swedish ICUs. How do physicians from the admitting department reason?

OBJECTIVE

To study how physicians from the admitting department reason during the decision-making process to forego life-sustaining treatment of patients in intensive care units (ICUs).

DESIGN

Qualitative interview that applies a phenomenological approach.

SETTING

Two ICUs at one secondary and one tertiary referral hospital in Sweden.

PARTICIPANTS

Seventeen admitting-department physicians who have participated in decisions to forego life-sustaining treatment.

RESULTS

The decision-making process as it appeared from the physicians' experiences was complex, and different approaches to the process were observed. A pattern of five phases in the process emerged in the interviews. The physicians described the process principally as a medical one, with few ethical reflections. Decision-making was mostly done in collaboration with other physicians. Patients, family and nurses did not seem to play a significant role in the process.

CONCLUSION

This study describes how physicians reasoned when confronted with real patient situations in which decisions to forego life-sustaining treatment were mainly based on medical--not ethical--considerations.

End-of-life care in patients with lung cancer

Evidence-based practice guidelines for end-of-life care for patients with lung cancer have been previously available only from the British health-care system. Currently in this setting, there has been increasing concern in attaining control of the physical, psychological, social, and spiritual distress of the patient and family. This American College of Chest Physicians'-sponsored multidisciplinary panel has generated recommendations for improving quality of life after examining the English-language literature for answers to some of the most important questions in end-of-life care. Communication between the doctor, patient, and family is central to the active total care of patients with disease that is not responsive to curative treatment. The advance care directive, which has been slowly evolving and is presently limited in application and often circumstantially ineffective, better protects patient autonomy. The problem-solving capability of the hospital ethics committee has been poorly utilized, often due to a lack of understanding of its composition and function. Cost considerations and a sense of futility have confused caregivers as to the potentially important role of the critical care specialist in this scenario. Symptomatic and supportive care provided in a timely and consistent fashion in the hospice environment, which treats the patient and family at home, has been increasingly used, and at this time is the best model for end-of-life care in the United States.

Awareness and use of advance directives in the spinal cord injured population

STUDY DESIGN

Research was conducted through the use of semi-structured patient interviews. Subjects were recruited through the Saskatchewan branch of the Canadian Paraplegic Association (CPA) and through the clinical practice of the primary investigator. A total of twenty-one patients were interviewed. A qualitative outcome analysis was performed on information collected.

OBJECTIVES

Advance directives (or living wills) serve to communicate the wishes of individuals in the event that they should no longer be capable of making those wishes known. This can include directives on issues such as resuscitation status and withdrawal or withholding of care. The goal of this study was to determine the present level of knowledge and interest of spinal cord injured (SCI) patients on the topic of advance directives, and to determine what specific issues they felt need to be addressed in such a document in this population.

SETTING

The study was performed in Saskatoon, Saskatchewan, Canada. Although design and analysis were done in a tertiary care centre, the interviews themselves were conducted in the homes of the participants.

RESULTS AND CONCLUSION

The results show that spinal cord injured patients have some knowledge of what is involved in the preparation of an advance directive and that they feel these documents are important. A relatively small percentage have completed their own written directives but a large percentage planned to do so after completing this survey. There is some disagreement about when after the injury the topic should first be discussed. Information about medical conditions which are more likely to arise following a SCI should be included in an SCI-specific document. A template for an SCI-specific living will (the SCIAD) is provided.

Effects of advance care education in cardiovascular rehabilitation programs: a prospective randomized study

PURPOSE

To determine the effect of advance care education provided to patients enrolled in cardiovascular rehabilitation (CVR) programs and assess patients' acceptance of the educational program.

METHODS

In a multicenter, prospective, randomized study, the authors administered two questionnaires 6 months apart to 284 patients enrolled in 14 CVR programs in 11 states. An educational group (99 subjects) participated in educational programs related to advance care planning and received advance directive forms after completing the first questionnaires; 185 subjects served as controls. Primary outcomes were completion of patient-physician discussions of end-of-life issues and patient confidence that their end-of-life wishes were understood by their physicians. Secondary outcomes were completion of formal advance directives and patient acceptance of the educational program.

RESULTS

Both the educational and control groups demonstrated a larger proportion of patients at the end of the study, compared with the amount at the beginning of the study, who had completed living wills, durable powers of attorney for healthcare, and discussions with their physicians about advance directives and life support care. These outcomes were not observed more commonly after the educational intervention. Neither groups gained confidence, however, that their physicians understood their end-of-life wishes. Only 8.6% of patients had a negative response to the educational program.

CONCLUSIONS

Advance care education is well received by patients enrolled in CVR programs. Enrollment in CVR promotes advance care planning to a small but measurable degree CVR rehabilitation programs appear to be acceptable sites for advance care planning but further research is needed to develop effective educational interventions.