Decision-making regarding withdrawal of life-sustaining treatment and the role of intensivists in the intensive care unit: a single-center study

Palliative Care in the Intensive Care Unit: An Integrative Review of Intensive Care Unit Health Care Professionals' Views and Experiences

BACKGROUND

It has become more common for patients with long-term diseases or receiving aggressive cancer treatments to need intensive care. Research about palliative care in the intensive care unit (ICU) largely focuses on decision-making in relation to end-of-life care and organ donation. Few studies examine the current evidence about how palliative care in its wider conceptualization is understood by intensive care health care professionals.

OBJECTIVES

To synthesize the literature on ICU health care professionals' experiences and views of providing palliative care in the ICU.

METHODS

This was an integrative review where data were assessed and analyzed using Whittemore and Knafl's approach.

RESULTS

Four themes were identified in the synthesis: the meaning of palliative care, relationships with families, multidisciplinary working, and preparation for providing palliative care.

DISCUSSION

Our findings suggest there is variation in how palliative care in the ICU is conceptualized and interpreted. Intensive care unit professionals need enhanced competencies and training to develop their confidence in providing palliative care and improve role clarity. Such training should focus on serious illness conversations with patients/families and interdisciplinary teamwork. Integration of palliative consultants into the ICU could be further developed.

Ethical Decision-Making Regarding Life Sustaining Treatment in End-Of-Life Care: A Scoping Review of the Similarities and Differences Between Two Viewpoints

Decisions on life-sustaining treatment depend on evaluating fundamental ethical principles regarding taking human life. This study aimed to compare the Islamic standpoint with secular views on ethical decision-making in end-of-life care. We conducted a scoping review to analyze and compare articles published in 2000-2022, regarding ethical criteria for withdrawing life-prolonging treatments in dying patients, and the final decision-maker in such cases. The main difference between the two viewpoints, however, lies in the perspective that in Islam to save human life is of utmost importance, and therefore the criteria for treatment benefits, indications, and goals should all be evaluated in the light of this profound Islamic concept. The most significant similarity discovered between the two standpoints was that a terminal patient's wish not to prolong the process of dying should be respected, and the physician's opinion in determining the benefit or futility of treatment is of utmost importance. Comparison of Islamic and Secular perspectives about ethical decision-making in end-of-life care regarding life sustaining treatment indicates that benefits of treatments for patients, and healthcare goals are among the major factors in decision-making according to both viewpoints, and patients, their families, physicians, and the medical team are all involved in making the final decision.

Changes in Pediatric End-of-Life Process After the Enforcement of the Act on Life-Sustaining Treatment Decisions-The Experience of a Single Children's Hospital

Background: The Act on Life-Sustaining Treatment (LST) for patients at the end of life (the Korean LST Decision Act), implemented in the Republic of Korea in February 2018, has led to changes in the end-of-life decision-making (EOLDM) process in children. This study aimed to investigate changes in pediatric EOLDM process and LST practices since the Korean LST Decision Act. Methods: This retrospective cohort study included 107 patients who died at Kyungpook National University Children's Hospital from January 2015 to December 2020. Patients were divided into two groups: pre-law (January 2015-January 2018, n = 55) and post-law (February 2018-December 2020, n = 52). We analyzed medical records for EOLDM process, patient characteristics, intensive care unit (ICU) admission, documentation types, and LST withholding or withdrawal decisions. Results: After the Korean LST Decision Act, the median total hospitalization duration decreased significantly (14 days [IQR, 3-80] vs. 6 days [IQR, 2-18], p = 0.020), as did the median ICU length of stay (3 days [IQR 1-33] vs. 2.5 days [IQR 1-10.3], p = 0.002). The time from admission to end-of-life decision documentation was significantly shorter in group 2 (6 days [IQR 1-31] vs. 4 days [IQR 1-9], p = 0.027). The use of physician orders for life-sustaining treatment (POLST) documents increased (0% to 33.3%), while do-not-resuscitate (DNR) orders decreased (85.3% to 16.7%). Notably, LST withdrawal decisions increased from 0% to 27.8% (p = 0.001) in the post-legislation period. Conclusions: The Korean LST Decisions Act has led to significant changes in the EOLDM process for terminally ill children, including earlier decision-making, increased use of POLST documents, more frequent LST withdrawal decisions, and shorter hospital and ICU stays. These findings suggest a shift towards more structured and timely end-of-life care discussions in pediatric settings.

Comparison of factors influencing the decision to withdraw life-sustaining treatment in intensive care unit patients after implementation of the Life-Sustaining Treatment Act in Korea

BACKGROUND

The decision to discontinue intensive care unit (ICU) treatment during the end-oflife stage has recently become a significant concern in Korea, with an observed increase in life-sustaining treatment (LST) withdrawal. There is a growing demand for evidence-based support for patients, families, and clinicians in making LST decisions. This study aimed to identify factors influencing LST decisions in ICU inpatients and to analyze their impact on healthcare utilization.

METHODS

We retrospectively reviewed medical records of ICU patients with neurological disorders, infectious disorders, or cancer who were treated at a single university hospital between January 1, 2019 and July 7, 2021. Factors influencing the decision to withdraw LST were compared between those who withdrew LST and those who did not.

RESULTS

Among 54,699 hospital admissions, LST was withdrawn in 550 cases (1%). Cancer was the most common diagnosis, followed by pneumonia and cerebral infarction. Among ICU inpatients, LST was withdrawn from 215 (withdrawal group). The withdrawal group was older (78 vs. 75 years, P=0.002), had longer total hospital stays (16 vs. 11 days, P<0.001), and higher ICU readmission rates than the control group. There were no significant differences in the healthcare costs of ICU stay between the two groups. Most LST decisions (86%) were made by family.

CONCLUSIONS

The decisions to withdraw LST of ICU inpatients were influenced by age, readmission, and disease category. ICU costs were similar between the withdrawal and control groups. Further research is needed to tailor LST decisions in the ICU.

Characteristics and outcomes of patients with do-not-resuscitate and physician orders for life-sustaining treatment in a medical intensive care unit: a retrospective cohort study

BACKGROUND

In the intensive care unit (ICU), we may encounter patients who have completed a Do-Not-Resuscitate (DNR) or a Physician Orders to Stop Life-Sustaining Treatment (POLST) document. However, the characteristics of ICU patients who choose DNR/POLST are not well understood.

METHODS

We retrospectively analyzed the electronic medical records of 577 patients admitted to a medical ICU from October 2019 to November 2020, focusing on the characteristics of patients according to whether they completed DNR/POLST documents. Patients were categorized into DNR/POLST group and no DNR/POLST group according to whether they completed DNR/POLST documents, and logistic regression analysis was used to evaluate factors influencing DNR/POLST document completion.

RESULTS

A total of 577 patients were admitted to the ICU. Of these, 211 patients (36.6%) had DNR or POLST records. DNR and/or POLST were completed prior to ICU admission in 48 (22.7%) patients. The DNR/POLST group was older (72.9 ± 13.5 vs. 67.6 ± 13.8 years, p < 0.001) and had higher Acute Physiology and Chronic Health Evaluation (APACHE) II score (26.1 ± 9.2 vs. 20.3 ± 7.7, p < 0.001) and clinical frailty scale (5.1 ± 1.4 vs. 4.4 ± 1.4, p < 0.001) than the other groups. Solid tumors, hematologic malignancies, and chronic lung disease were the most common comorbidities in the DNR/POLST groups. The DNR/POLST group had higher ICU and in-hospital mortality and more invasive treatments (arterial line, central line, renal replacement therapy, invasive mechanical ventilation) than the other groups. Body mass index, APAHCE II score, hematologic malignancy, DNR/POLST were factors associated with in-hospital mortality.

CONCLUSIONS

Among ICU patients, 36.6% had DNR or POLST orders and received more invasive treatments. This is contrary to the common belief that DNR/POLST patients would receive less invasive treatment and underscores the need to better understand and include end-of-life care as an important ongoing aspect of patient care, along with communication with patients and families.

Comparison of the end-of-life decisions of patients with hospital-acquired pneumonia after the enforcement of the life-sustaining treatment decision act in Korea

BACKGROUND

Although the Life-Sustaining Treatment (LST) Decision Act was enforced in 2018 in Korea, data on whether it is well established in actual clinical settings are limited. Hospital-acquired pneumonia (HAP) is a common nosocomial infection with high mortality. However, there are limited data on the end-of-life (EOL) decision of patients with HAP. Therefore, we aimed to examine clinical characteristics and outcomes according to the EOL decision for patients with HAP.

METHODS

This multicenter study enrolled patients with HAP at 16 referral hospitals retrospectively from January to December 2019. EOL decisions included do-not-resuscitate (DNR), withholding of LST, and withdrawal of LST. Descriptive and Kaplan-Meier curve analyses for survival were performed.

RESULTS

Of 1,131 patients with HAP, 283 deceased patients with EOL decisions (105 cases of DNR, 108 cases of withholding of LST, and 70 cases of withdrawal of LST) were analyzed. The median age was 74 (IQR 63-81) years. The prevalence of solid malignant tumors was high (32.4% vs. 46.3% vs. 54.3%, P = 0.011), and the ICU admission rate was lower (42.9% vs. 35.2% vs. 24.3%, P = 0.042) in the withdrawal group. The prevalence of multidrug-resistant pathogens, impaired consciousness, and cough was significantly lower in the withdrawal group. Kaplan-Meier curve analysis revealed that 30-day and 60-day survival rates were higher in the withdrawal group than in the DNR and withholding groups (log-rank P = 0.021 and 0.018). The survival of the withdrawal group was markedly decreased after 40 days; thus, the withdrawal decision was made around this time. Among patients aged below 80 years, the rates of EOL decisions were not different (P = 0.430); however, mong patients aged over 80 years, the rate of withdrawal was significantly lower than that of DNR and withholding (P = 0.001).

CONCLUSIONS

After the LST Decision Act was enforced in Korea, a DNR order was still common in EOL decisions. Baseline characteristics and outcomes were similar between the DNR and withholding groups; however, differences were observed in the withdrawal group. Withdrawal decisions seemed to be made at the late stage of dying. Therefore, advance care planning for patients with HAP is needed.

Effect of end-of-life care education on perceived self-efficacy of the pediatric respiratory therapist

Background

End-of-life care (EoLC) is difficult for respiratory therapists (RTs), causing struggles with providing EoLC and grief during and after the death.

Objective

The objective of the study was to determine if EoLC education can increase RTs' perception of knowledge of EoLC, respiratory therapy as a valuable EoLC service, comfort providing EoLC, and knowledge of ways to deal with grief.

Methods

One hundred and thirty pediatric RTs completed a 1 h EoLC education session. Afterwards, a single-centre descriptive survey was administered to the 60 volunteers out of the 130 attendees. To determine RTs' self-rated change in knowledge of EoLC, perception of respiratory therapy as a valuable EoLC service, comfort with EoLC, and knowledge of ways to cope with grief. Statistical analysis included percent change.

Results

Overall, 96% of surveyed RTs agree they had an increase in knowledge, perception of RT services, comfort with providing care, and coping. Only 4% felt that this course had little benefit overall but still perceived value in RT EoLC and increased knowledge of long- and short-term ways to deal with grief.

Conclusion

Education on EoLC practices increased pediatric RTs' perception of knowledge, perceived value of respiratory therapy in EoLC, comfort with EoLC, and knowledge of coping resources.

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

BACKGROUND

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

METHODS

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

CONCLUSION

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

Factors Influencing the Initiative Behavior of Intensive Care Unit Nurses toward End-of-Life Decision Making: A Cross-Sectional Study

Background: Although the importance of intensive care unit (ICU) nurse initiative in end-of-life (EOL) decision making has been confirmed, there are few studies on the nurses' initiative in EOL situations. Objectives: To explore the role and mechanism of facilitators/barriers and perceived stress on the behavior of ICU nurses that initiate EOL decision making (i.e., initiative behavior). Design: This research adopted a cross-sectional descriptive design. Setting/Participants: A questionnaire composed of demographics, facilitators/barriers scale, perceived stress scale, and initiative behavior for EOL decision-making scale was used for registered ICU nurses in five tertiary general hospitals in Zhejiang Province, China. Results: The average score of the EOL decision initiative behavior was 5.54 on a range of 2-10. The results of correlation analysis indicated that the facilitators promote the initiative behavior, whereas the barriers interfere with initiative behavior. Facilitators/barriers in the EOL decision-making process significantly predicted the initiative behavior of ICU nurses in decision making (β = 0.698, p < 0.001). Facilitators/barriers had a significant indirect effect on the initiative behavior of ICU nurses through perceived stress. The 95% confidence interval was (-0.327 to -0.031), and the mediating effect of perceived stress accounted for 6.31% of the total effect. Conclusion: In the EOL context, the decision initiative of ICU nurses was at a medium level. Medical managers should implement intervention strategies based on the path that affects the initiative behavior of ICU nurses to reduce barriers and stress level in the decision-making process. That is, they should improve inter-team collaboration, nurse-patient communication, clarity of role responsibilities, and emotional support in dying situations to increase initiative and participation of ICU nurses in decision making.

Changes in the incidence of cardiopulmonary resuscitation before and after implementation of the Life-Sustaining Treatment Decisions Act

Background

Methods

Results

Conclusions

The Future Direction of the Organ Donation System After Legislation of the Life-Sustaining Treatment Decision Act

Background

The transplant community is seeking ways to encourage organ donation after cardiac arrest to solve the problem of the insufficiency of organs available for the increasing number of people awaiting transplantation. This study aimed to determine whether the life-sustaining treatment (LST) decision system, implemented in Korea on February 4, 2018, can address the shortage of organ donations.

Material/Methods

We retrospectively analyzed the medical records of the 442 patients who had filled out forms for the LST decision at Ewha Womans University Mokdong Hospital from April 2018 to December 2019, and classified the eligibility of organ and tissue donation according to the Korean Organ Donation Agency criteria.

Results

We included 442 patients in this study. Among them, 238 (53.8%) were men, and 204 (46.2%) were women. The average age of the patients was 71.8 years (the youngest and oldest were aged 23 years and 103 years, respectively). Of these, 110 patients (24.9%) decided on their own to discontinue LST, whereas 332 (75.1%) decided to discontinue with their family’s consent. This study demonstrated that 50% of patients who were not brain-dead and discontinued LST were eligible for organ donation. However, the patients and caregivers were not aware of this option because the current law does not allow the discussion of such donations.

Conclusions

A discussion regarding donation after circulatory death is recommended to solve the problem of insufficient organ donation.

Analysis of high-intensity care in intensive care units and its cost at the end of life among older people in South Korea between 2016 and 2019: a cross-sectional study of the health insurance review and assessment service national patient sample database

OBJECTIVES

To provide useful information for clinicians and policy makers to prepare guidelines for adequate use of medical resources during end-of-life period by analysing the intensive care use and related costs at the end of life in South Korea.

DESIGN

Cross-sectional, retrospective, observational study.

SETTING

Tertiary hospitals in South Korea.

PARTICIPANTS

We analysed claim data and patient information from the Health Insurance Review and Assessment Service national dataset. This dataset included 19 119 older adults aged 65 years or above who received high-intensity care at least once and died in the intensive care unit in South Korea between 2016 and 2019. High-intensity care was defined as one of the following treatments or procedures: cardiopulmonary resuscitation, mechanical ventilation, extra-corporeal membrane oxygenation, haemodialysis, transfusion, chemotherapy and vasopressors.

PRIMARY AND SECONDARY OUTCOME MEASURES

Usage and cost of high-intensity care.

RESULTS

The most commonly used high-intensity care was transfusion (68.9%), mechanical ventilation (50.6%) and haemodialysis (35.7%) during the study period. The annual cost of high-intensity care at the end of life increased steadily from 2016 to 2019. There existed differences by age, gender, length of hospital stays and primary cause of death in use of high-intensity care and associated costs.

CONCLUSION

Findings indicate that invasive and device-dependent high-intensity care is frequently provided at the end of life among older adults, which could potentially place an economic burden on patients and their families. In Korea's ageing society, increased rates of chronic illness are expected to significantly burden those who lack the financial resources to provide end-of-life care. Therefore, guidelines for the use of high-intensity care are required to ensure affordable end-of-life care.