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Piers RD, Banner-Goodspeed V, Åkerman E, Kieslichova E, Meyfroidt G, Gerritsen RT, Uyttersprot E, Benoit DD. Outcomes in Patients Perceived as Receiving Excessive Care by ICU Physicians and Nurses: Differences Between Patients < 75 and ≥ 75 Years of Age? Chest 2023; 164:656-666. [PMID: 37062350 DOI: 10.1016/j.chest.2023.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/24/2023] [Accepted: 04/04/2023] [Indexed: 04/18/2023] Open
Abstract
BACKGROUND The benefit of the ICU for older patients is often debated. There is little knowledge on subjective impressions of excessive care in ICU nurses and physicians combined with objective patient data in real-life cases. RESEARCH QUESTION Is there a difference in treatment limitation decisions and 1-year outcomes in patients < 75 and ≥ 75 years of age, with and without concordant perceptions of excessive care by two or more ICU nurses and physicians? STUDY DESIGN AND METHODS This was a reanalysis of the prospective observational DISPROPRICUS study, performed in 56 ICUs. Nurses and physicians completed a daily questionnaire about the appropriateness of care for each of their patients during a 28-day period in 2014. We compared the cumulative incidence of patients with concordant perceptions of excessive care, treatment limitation decisions, and the proportion of patients attaining the combined end point (death, poor quality of life, or not being at home) at 1 year across age groups via Cox regression with propensity score weighting and Fisher exact tests. RESULTS Of 1,641 patients, 405 (25%) were ≥ 75 years of age. The cumulative incidence of concordant perceptions of excessive care was higher in older patients (13.6% vs 8.5%; P < .001). In patients with concordant perceptions of excessive care, we found no difference between age groups in risk of death (1-year mortality, 83% in both groups; P > .99; hazard ratio [HR] after weighting, 1.11; 95% CI, 0.74-1.65), treatment limitation decisions (33% vs 31%; HR after weighting, 1.11; 95% CI, 0.69-2.17), and reaching the combined end point at 1 year (90% vs 93%; P = .546). In patients without concordant perceptions of excessive care, we found a difference in risk of death (1-year mortality, 41% vs 30%; P < .001; HR after weighting, 1.38; 95% CI, 1.11-1.73) and treatment limitation decisions (11% vs 5%; P < .001; HR, 2.11; 95% CI, 1.37-3.27); however, treatment limitation decisions were mostly documented prior to ICU admission. The risk of reaching the combined end point was higher in the older adults (61.6% vs 52.8%; P < .001). INTERPRETATION Although the incidence of perceptions of excessive care is slightly higher in older patients, there is no difference in treatment limitation decisions and 1-year outcomes between older and younger patients once patients are identified by concordant perceptions of excessive care. Additionally, in patients without concordant perceptions, the outcomes are worse in the older adults, pleading against ageism in ICU nurses and physicians.
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Affiliation(s)
- Ruth D Piers
- Department of Geriatrics, Ghent University Hospital, Ghent, Belgium.
| | - Valerie Banner-Goodspeed
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Eva Åkerman
- Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Stockholm, Sweden; General Intensive Care Unit, Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Eva Kieslichova
- Department of Anesthesiology, Resuscitation and Intensive Care, Institute for Clinical and Experimental Medicine, Prague, Czech Republic; First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Geert Meyfroidt
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | | | - Emma Uyttersprot
- Department of Applied Mathematics and Computer Sciences, Ghent University, Ghent, Belgium
| | - Dominique D Benoit
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
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Jönsson N, Pettersson N, Asplund P, Bremer A, Lehtipalo S, Hessulf F. Factors associated with treatment limitations in two Swedish intensive care units: Prevalence and patient involvement. Acta Anaesthesiol Scand 2023; 67:339-346. [PMID: 36534119 DOI: 10.1111/aas.14185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 12/01/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022]
Abstract
The aim was to study the prevalence, documentation, and patient involvement in treatment limitations (TLs) in two Swedish intensive care units (ICUs). All patients admitted to the ICUs of two Swedish regional hospitals in 2019 were screened for inclusion. Exclusion criteria included postanesthesia care <24 h. Patients were identified using the Swedish Intensive Care Registry (SIR) and data were extracted from SIR and hospital charts. Uni- and multivariable logistic analysis was performed to investigate associations with the presence of TLs. A total of 3090 patients were admitted to the two ICUs in 2019. After exclusion, 1019 patients were included in the study. 45.5% were women and the mean age was 62.9 years. 26.5% of the patients had one or several TLs. Age (OR 1.04 per one year increase 95% confidence interval (CI) 1.02-1.05), SAPS3-score (OR 1.08 per one unit increase 95% CI 1.06-1.09) and ICU length of stay (OR 1.11 per one day increase 95% CI 1.05-1.17) were independently associated with an increased likelihood of receiving a TL. 17% of the patients were involved in the decision-making process and in >30% of cases neither the patient nor next-of-kin were informed. Women were to a larger extent involved in the decision process than men (24.5 vs. 12.5% p < .05). When the intensivist documented why a TL was established, patient autonomy was four times more commonly stated as the motivation for the TL among women compared to men (15.5% vs. 3.8% p < .05). TLs were common in two Swedish ICUs but a substantial number of patients and next-of-kin were not involved in the decision-making process or informed of the decision. Women were more often than men engaged in the decision to establish a TL.
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Affiliation(s)
- Nino Jönsson
- Department of Anesthesiology and Intensive Care Medicine, Halland Hospital Halmstad, Halmstad, Sweden
| | - Niklas Pettersson
- Department of Anesthesiology and Intensive Care Medicine, Halland Hospital Halmstad, Halmstad, Sweden
| | - Peter Asplund
- Department of Anesthesiology and Intensive Care Medicine, Halland Hospital Halmstad, Halmstad, Sweden
| | - Anders Bremer
- Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden.,Centre of Interprofessional Collaboration within Emergency care (CICE), Linnaeus University, Växjö, Sweden.,Department of Ambulance Service, Region Kalmar County, Kalmar, Sweden
| | - Stefan Lehtipalo
- Department of Anesthesiology and Intensive Care Medicine, Halland Hospital Halmstad, Halmstad, Sweden
| | - Fredrik Hessulf
- Department of Anesthesiology and Intensive Care Medicine, Halland Hospital Halmstad, Halmstad, Sweden.,Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Molecular and Clinical Medicine, Institution of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Mehlis K, Bierwirth E, Laryionava K, Mumm F, Heussner P, Winkler EC. Late decisions about treatment limitation in patients with cancer: empirical analysis of end-of-life practices in a haematology and oncology unit at a German university hospital. ESMO Open 2020; 5:e000950. [PMID: 33109628 PMCID: PMC7592262 DOI: 10.1136/esmoopen-2020-000950] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/15/2020] [Accepted: 09/16/2020] [Indexed: 12/25/2022] Open
Abstract
Background Decisions to limit treatment (DLTs) are important to protect patients from overtreatment but constitute one of the most ethically challenging situations in oncology practice. In the Ethics Policy for Advance Care Planning and Limiting Treatment study (EPAL), we examined how often DLT preceded a patient’s death and how early they were determined before (T1) and after (T2) the implementation of an intrainstitutional ethics policy on DLT. Methods This prospective quantitative study recruited 1.134 patients with haematological/oncological neoplasia in a period of 2×6 months at the University Hospital of Munich, Germany. Information on admissions, discharges, diagnosis, age, DLT, date and place of death, and time span between the initial determination of a DLT and the death of a patient was recorded using a standardised form. Results Overall, for 21% (n=236) of the 1.134 patients, a DLT was made. After implementation of the policy, the proportion decreased (26% T1/16% T2). However, the decisions were more comprehensive, including more often the combination of ‘Do not resuscitate’ and ‘no intense care unit’ (44% T1/64% T2). The median time between the determination of a DLT and the patient’s death was similarly short with 6 days at a regular ward (each T1/T2) and 10.5/9 (T1/T2) days at a palliative care unit. For patients with solid tumours, the DLTs were made earlier at both regular and palliative care units than for the deceased with haematological neoplasia. Conclusion Our results show that an ethics policy on DLT could sensitise for treatment limitations in terms of frequency and extension but had no significant impact on timing of DLT. Since patients with haematological malignancies tend to undergo intensive therapy more often during their last days than patients with solid tumours, special attention needs to be paid to this group. To support timely discussions, we recommend the concept of advance care planning.
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Affiliation(s)
- Katja Mehlis
- Medical Oncology, National Center for Tumor Diseases Heidelberg, Heidelberg, Germany.
| | - Elena Bierwirth
- Institut für physikalische und rehabilitative Medizin, Klinikum Ingolstadt GmbH, Ingolstadt, Germany
| | - Katsiaryna Laryionava
- Medical Oncology, National Center for Tumor Diseases Heidelberg, Heidelberg, Germany
| | - Friederike Mumm
- Department of Medicine III, University Hospital Munich, Munich, Germany
| | - Pia Heussner
- Zentrum Innere Medizin, Klinikum Garmisch-Partenkirchen GmbH, Garmisch-Partenkirchen, Germany
| | - Eva C Winkler
- Medical Oncology, National Center for Tumor Diseases Heidelberg, Heidelberg, Germany
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van der Zee EN, Epker JL, Bakker J, Benoit DD, Kompanje EJO. Treatment Limitation Decisions in Critically Ill Patients With a Malignancy on the Intensive Care Unit. J Intensive Care Med 2020; 36:42-50. [PMID: 32787659 PMCID: PMC7705645 DOI: 10.1177/0885066620948453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Background: Treatment limitation decisions (TLDs) on the ICU can be challenging, especially in patients with a malignancy. Up-to-date literature regarding TLDs in critically ill patients with a malignancy admitted to the ICU is scarce. The aim was to compare the incidence of written TLDs between patients with an active malignancy, patients with a malignancy in their medical history (complete remission, CR) and patients without a malignancy admitted unplanned to the ICU. Methods: We conducted a retrospective cohort study in a large university hospital in the Netherlands. We identified all unplanned admissions to the ICU in 2017 and categorized the patients in 3 groups: patients with an active malignancy (study population), with CR and without a malignancy. A TLD was defined as a written instruction not to perform life-saving treatments, such as CPR in case of cardiac arrest. A multivariate binary logistic regression analysis was used to identify whether having a malignancy was associated with TLDs. Results: Of the 1046 unplanned admissions, 125 patients (12%) had an active malignancy and 76 (7.3%) patients had CR. The incidence of written TLDs in these subgroups were 37 (29.6%) and 20 (26.3%). Age (OR 1.03; 95% CI 1.01 -1.04), SOFA score at ICU admission (OR 1.11; 95% CI 1.05 -1.18) and having an active malignancy (OR 1.75; 95% CI 1.04-2.96) compared to no malignancy were independently associated with written TLDs. SOFA scores on the day of the TLD were not significantly different in patients with and without a malignancy. Conclusions: This study shows that the presence of an underlying malignancy is independently associated with written TLDs during ICU stay. Patients with CR were not at risk of more written TLDs. Whether this higher incidence of TLDs in patients with a malignancy is justified, is at least questionable and should be evaluated in future research.
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Affiliation(s)
- Esther N van der Zee
- Department of Intensive Care, 6993Erasmus MC-University Medical Center Rotterdam, the Netherlands
| | - Jelle L Epker
- Department of Intensive Care, 6993Erasmus MC-University Medical Center Rotterdam, the Netherlands
| | - Jan Bakker
- Department of Intensive Care, 6993Erasmus MC-University Medical Center Rotterdam, the Netherlands.,Department of Pulmonology and Critical Care, New York University NYU Langone Medical Center, New York, NY, USA.,Department of Pulmonology and Critical Care, Columbia University Medical Center, New York, NY, USA.,Department of Intensive Care, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Dominique D Benoit
- Department of Intensive Care, 60200Ghent University Hospital, Ghent, Belgium
| | - Erwin J O Kompanje
- Department of Intensive Care, 6993Erasmus MC-University Medical Center Rotterdam, the Netherlands
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Audigé M, Gillam L, Stark Z. Treatment limitation and advance planning: Hospital-wide audit of paediatric death. J Paediatr Child Health 2020; 56:893-899. [PMID: 31898378 DOI: 10.1111/jpc.14771] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 12/14/2019] [Accepted: 12/19/2019] [Indexed: 11/30/2022]
Abstract
AIM To examine paediatric deaths following withdrawal or withholding of medical treatment (WWMT) from a hospital-wide perspective and identify changes over a 10 year period. METHODS A retrospective review of medical records was conducted for all paediatric inpatient deaths at the Royal Children's Hospital, Melbourne from April 2015 to April 2016, and results were compared to 2007 data from our centre. χ2 tests were used for comparisons. RESULTS A total of 101 deaths occurred in the inpatient setting in 2015-2016. Most deaths followed WWMT (88/101, 87%) and occurred in children with pre-existing chronic conditions (85/101, 85%). There was a shift to earlier discussions with parents regarding WWMT compared to 10 years prior. Cases where discussions began prior to the last admission increased from 4 to 19% (P = 0.004). There was increased paediatric palliative care (PPC) involvement (10 vs. 37%, P < 0.001), and a slightly greater proportion of children died outside of intensive care (16 vs. 22%, P = 0.25). In 2015-2016, subgroup analysis showed that children who died as inpatients but outside of intensive care were 76% more likely to have PPC involved than those who died in intensive care (P < 0.001). Their families were 51% more likely to have discussed WWMT with medical staff before the last admission (P < 0.001). CONCLUSIONS The last decade has seen an increase in PPC involvement and advance discussions around WWMT at our centre. Both of these are associated with death outside of intensive care.
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Affiliation(s)
- Manon Audigé
- Children's Bioethics Centre, Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, The Royal Children's Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Lynn Gillam
- Children's Bioethics Centre, Royal Children's Hospital, Melbourne, Victoria, Australia.,Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Zornitza Stark
- Department of Paediatrics, The Royal Children's Hospital, The University of Melbourne, Melbourne, Victoria, Australia.,Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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Laryionava K, Mehlis K, Bierwirth E, Mumm F, Hiddemann W, Heußner P, Winkler EC. Development and Evaluation of an Ethical Guideline for Decisions to Limit Life-Prolonging Treatment in Advanced Cancer: Protocol for a Monocentric Mixed-Method Interventional Study. JMIR Res Protoc 2018; 7:e157. [PMID: 29907553 PMCID: PMC6026302 DOI: 10.2196/resprot.9698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 03/26/2018] [Accepted: 04/03/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Many patients with advanced cancer receive chemotherapy close to death and are referred too late to palliative or hospice care, and therefore die under therapy or in intensive care units. Oncologists still have difficulties in involving patients appropriately in decisions about limiting tumor-specific or life-prolonging treatment. OBJECTIVE The aim of this Ethics Policy for Advanced Care Planning and Limiting Treatment Study is to develop an ethical guideline for end-of-life decisions and to evaluate the impact of this guideline on clinical practice regarding the following target goals: reduction of decisional conflicts, improvement of documentation transparency and traceability, reduction of distress of the caregiver team, and better knowledge and consideration of patients' preferences. METHODS This is a protocol for a pre-post interventional study that analyzes the clinical practice on treatment limitation before and after the guideline implementation. An embedded researcher design with a mixed-method approach encompassing both qualitative and quantitative methods is used. The study consists of three stages: (1) the preinterventional phase, (2) the intervention (development and implementation of the guideline), and 3) the postinterventional phase (evaluation of the guideline's impact on clinical practice). We evaluate the process of decision-making related to limiting treatment from different perspectives of oncologists, nurses, and patients; comparing them to each other will allow us to develop the guideline based on the interests of all parties. RESULTS The first preintervention data of the project have already been published, which detailed a qualitative study with oncologists and oncology nurses (n=29), where different approaches to initiation of end-of-life discussions were ethically weighted. A framework for oncologists was elaborated, and the study favored an anticipatory approach of preparing patients for forgoing therapy throughout the course of disease. Another preimplementational study of current decision-making practice (n=567 patients documented) demonstrated that decisions to limit treatment preceded the death of many cancer patients (62/76, 82% of deceased patients). However, such decisions were usually made in the last week of life, which was relatively late. CONCLUSIONS The intervention will be evaluated with respect to the following endpoints: better knowledge and consideration of patients' treatment wishes; reduction of decisional conflicts; improvement of documentation transparency and traceability; and reduction of the psychological and moral distress of a caregiver team. REGISTERED REPORT IDENTIFIER RR1-10.2196/9698.
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Affiliation(s)
- Katsiaryna Laryionava
- National Center for Tumor Diseases, Department of Medical Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Katja Mehlis
- National Center for Tumor Diseases, Department of Medical Oncology, Heidelberg University Hospital, Heidelberg, Germany
| | - Elena Bierwirth
- Interdisciplinary Center of Psycho-Oncology, University Hospital Grosshadern, Ludwig-Maximilians University, Munich, Germany.,Department of Medicine III, University Hospital Grosshadern, Ludwig-Maximilians University, Munich, Germany
| | - Friederike Mumm
- Interdisciplinary Center of Psycho-Oncology, University Hospital Grosshadern, Ludwig-Maximilians University, Munich, Germany.,Department of Medicine III, University Hospital Grosshadern, Ludwig-Maximilians University, Munich, Germany
| | - Wolfgang Hiddemann
- Department of Medicine III, University Hospital Grosshadern, Ludwig-Maximilians University, Munich, Germany
| | - Pia Heußner
- Interdisciplinary Center of Psycho-Oncology, University Hospital Grosshadern, Ludwig-Maximilians University, Munich, Germany.,Department of Medicine III, University Hospital Grosshadern, Ludwig-Maximilians University, Munich, Germany
| | - Eva C Winkler
- National Center for Tumor Diseases, Department of Medical Oncology, Heidelberg University Hospital, Heidelberg, Germany
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Abstract
Appropriate treatment limitations towards the end of life to reduce unwanted burdens require ethical clarity that is supported by appropriate legislation. The lack of knowledge of enabling legal provisions, physicians feel vulnerable to legal misinterpretation of treatment limiting decisions. In India the lack of societal awareness, inadequate exploration of the gray areas of bio-ethics and unambiguous legal position relating to terminal illness have resulted in poor quality end of life care. Much of the perceived vulnerability by the physician is attributable to insufficient knowledge and understanding of existing constitutional and legal position in India. While we await informed legal and legislative opinion, this paper highlights possible legal liabilities arising from treatment limitation decisions with available defense. It is hoped that such clarity would lead to more confident ethical decisions and improved end of life care for patients.
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Affiliation(s)
- R K Mani
- Department of Critical Care, Pulmonology and Sleep Medicine, Nayati Healthcare and Research Pvt. Ltd, DLF Corporate Park, Gurgaon, Haryana, India
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