Recovery Potential in Patients Who Died After Withdrawal of Life-Sustaining Treatment: A TRACK-TBI Propensity Score Analysis

Among patients with severe traumatic brain injury (TBI), there is high prognostic uncertainty but growing evidence that recovery of independence is possible. Nevertheless, families are often asked to make decisions about withdrawal of life-sustaining treatment (WLST) within days of injury. The range of potential outcomes for patients who died after WLST (WLST+) is unknown, posing a challenge for prognostic modeling and clinical counseling. We investigated the potential for survival and recovery of independence after acute TBI in patients who died after WLST. We used Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) data and propensity score matching to pair participants with WLST+ to those with a similar probability of WLST (based on demographic and clinical characteristics), but for whom life-sustaining treatment was not withdrawn (WLST-). To optimize matching, we divided the WLST- cohort into tiers (Tier 1 = 0-11%, Tier 2 = 11-27%, Tier 3 = 27-70% WLST propensity). We estimated the level of recovery that could be expected in WLST+ participants by evaluating 3-, 6-, and 12-month Glasgow Outcome Scale-Extended (GOSE) and Disability Rating Scale outcomes in matched WLST- participants. Of 90 WLST+ participants (80% male, mean [standard deviation; SD] age = 59.2 [17.9] years, median [IQR] days to WLST = 5.4 [2.2, 11.7]), 80 could be matched to WLST- participants. Of 56 WLST- participants who were followed at 6 months, 31 (55%) died. Among survivors in the overall sample and survivors in Tiers 1 and 2, more than 30% recovered at least partial independence (GOSE ≥4). In Tier 3, recovery to GOSE ≥4 occurred at 12 months, but not 6 months, post-injury. These results suggest a substantial proportion of patients with TBI and WLST may have survived and achieved at least partial independence. However, death or severe disability is a common outcome when the probability of WLST is high. While further validation is needed, our findings support a more cautious clinical approach to WLST and more complete reporting on WLST in TBI studies.

Observations from Optimizing an Electronic Order Set for Withdrawal of Life-Sustaining Treatment

Background: Withdrawal of life-sustaining treatment (WLST) is a process with unique pressure for all involved. The use of an electronic order set can facilitate best care. Objective: To assess utilization of a WLST order set and time to inpatient death before and after optimization. Design: A retrospective chart review for 12-month periods before and after enhancements to a WLST order set. Setting/Subjects: Multicenter study within an American, not-for-profit health care system of inpatient decedents July 2017-June 2018 and April 2021-March 2022 with orders placed via WLST order set. Measurements: Co-primary outcomes included order set utilization and time from activation of orders to patient death. Descriptive post hoc analyses featured demographics, palliative consultation, ordering clinician type/specialty, and COVID-19. Results: A total of 1949 patients had orders placed via the WLST order set and died in-hospital. Compared with the 2017-2018 period, use increased 35.8% in 2021-2022. Time to death after release of orders was significantly longer for the 2021-2022 group (4.4 vs. 3.7 hours). Demographic details included nurse practitioners (39%) as most frequent WLST order set utilizer and palliative consultation in 46% of terminal hospitalizations. Among decedents with consultation, palliative clinicians were the WLST order set utilizer for 47% of cases (i.e., 21% of all WLST order set utilizations). The median time to death was significantly longer when orders were placed by a palliative clinician (4.5 hours) compared with nonpalliative specialists (3.9 hours). COVID-19 was a hospital diagnosis for 29% of decedents in the 2021-2022 group. Conclusions: In the emotionally and cognitively intense process that is WLST, an order set provides a modifiable panel of defaults. Our experience highlights the power in guiding primary palliative care for WLST in the hospital setting and suggests that advanced practice providers and nonpalliative clinicians, as primary utilizers, be integral in the design of a WLST order set.

Critical care nurses' role in the decision-making process of withdrawal of life-sustaining treatment: A qualitative systematic review

AIM

To synthesise the qualitative evidence regarding the role of critical care nurses in the decision-making process of withdrawing life-sustaining treatment in critically ill adults.

DESIGN

Qualitative systematic review.

REVIEW METHODS

This qualitative systematic review employed the guidelines of Bettany-Saltikov and McSherry. The review was reported according to the ENTREQ checklist. Pairs of authors independently assessed eligibility, appraised methodological quality and extracted data. Data were synthesised using thematic synthesis.

DATA SOURCES

CINAHL, MEDLINE and EMBASE were searched for studies published between January 2001 and November 2021.

RESULTS

Twenty-three studies were included. Three analytical themes were synthesised: performing ethical decision-making to safeguard patients' needs rights, and wishes; tailoring a supporting role to guide the family's decision-making process; and taking on the role of the middleman by performing coordination.

CONCLUSION

The role of the critical care nurses in the decision-making process in withdrawal of life-sustaining treatment requires experience and the development of the clinical perspective of critical care nurses.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Enhanced knowledge of the decision-making process of withdrawing life-sustaining treatment can prepare critical care nurses to be more equipped to master this role and enhance their ability to handle the emotional and moral stress associated with this part of the critical care unit.

IMPACT

The literature reveals the complex and challenging role of critical care nurses during the decision-making process of withdrawing life-sustaining treatment. Critical care nurses perform ethical decision-making to safeguard patients' concerns, guide the family's decision-making process and take on the role of the middleman. The findings have implications for critical nurses working in critical care units in hospitals and for educators and students in training in critical care nursing.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution was included.

Ethical Healthcare Attitudes of Japanese Citizens and Physicians: Patient-Centered or Family-Centered?

BACKGROUND

In current Western medical ethics, patient-centered medicine is considered the norm. However, the cultural background of collectivism in East Asia often leads to family-centered decision-making. In Japan, prior studies have reported that family-centered decision-making is more likely to be preferred in situations of disease notification and end-of-life decision-making. Nonetheless, there has been a recent shift from collectivism to individualism due to changes in the social structure. Various personal factors have also been reported to influence moral decision-making. Therefore, this study examined whether the current trend in attitudes of healthcare decision-making in Japan is family-centered or patient-centered among the general public and physicians. In addition, the personal factors that influence this tendency were examined.

METHODS

Three vignettes on disease notification and two vignettes on decision-making during end-of-life care were created, and 457 members of the public and 284 physicians were asked about their attitudes (behavioral intentions) regarding these vignettes.

RESULTS

Approximately, 95% of physicians were patient-centered in explaining the patient's severe medical condition. However, approximately 80% of physicians emphasized the wishes of the family over patient wishes when making life-sustaining decisions. Nearly half the general public emphasized the patient's wishes in the explanation of a severe medical condition and in life-sustaining decisions. In both the public and physician groups, personal factors, particularly the presence or absence of a disease under treatment and prior caregiving experience, influenced ethical attitudes toward medical treatment decisions.

CONCLUSIONS

In relatively low-conflict situations, such as the announcement of a patient's medical condition, physicians tended to be patient-centered, while they tended to be family-centered in situations of strong conflict in withholding life-sustaining treatment. The fact that personal factors influenced the family-centered response in situations of strong conflict highlights the importance of not only acquiring knowledge of medical ethics but also learning to fairly apply this knowledge in practice.

The theoretical and practical arguments against the unilateral withdrawal of life-sustaining treatment during crisis standards of care: Does the Knobe effect apply to unilateral withdrawal?

Some argue that it is ethically justifiable to unilaterally withdraw life-sustaining treatment during crisis standards of care without the patient's consent in order to reallocate it to another patient with a better chance of survival. This justification has been supported by two lines of argument: the equivalence thesis and the rule of the double effect. We argue that there are theoretical issues with the first and practical ones with the second, as supported by an experiment aimed at exploring whether the Knobe effect, which affects the folk concept of intention, applies to situations of unilateral withdrawal. Fifty-two critical care physicians from one university were asked to ascribe intention in two hypothetical scenarios A and B in which outcomes differ-the patient from whom life-sustaining treatment is withdrawn dies in scenario A but survives in scenario B-but the intention, to save the other patient regardless of the outcome of the other, is the same. The survey was administered via a web-based survey and all answers were anonymous. A paired proportion test was used to compare responses to both questions. All 52 surveyed individuals responded in scenario A and 30 (57.7%) ascribed intention when outcomes were unfavorable, whereas 50 responded in scenario B and 8 (16%) ascribed intention when outcomes were favorable, a difference that was statistically significant (p < 0.001). There are theoretical and practical issues with the arguments proposed to justify the unilateral withdrawal of life-sustaining treatment based on the equivalence thesis and the rule of double effect.

Clinician Ethical Perspectives on Extracorporeal Membrane Oxygenation in Practice

PURPOSE

Extracorporeal membrane oxygenation (ECMO) is an expensive and scarce life sustaining treatment provided to certain critically ill patients. Little is known about the informed consent process for ECMO or clinician viewpoints on ethical complexities related to ECMO in practice.

METHODS

We sent a cross-sectional survey to all departments providing ECMO within 7 United States hospitals in January 2021. One clinician from each department completed the 42-item survey representing their department.

RESULTS

Fourteen departments within 7 hospitals responded (response rate 78%, N = 14/18). The mean time spent consenting patients or surrogate decision-makers for ECMO varied, from 7.5 minutes (95% CI 5-10) for unstable patients to 20 minutes (95% CI 15-30) for stable patients (p = 0.0001). Few clinician respondents (29%) report patients or surrogate decision-makers always possess informed consent for ECMO. Most departments (92%) have absolute exclusion criteria for ECMO such as older age (43%, cutoffs ranging from 60-75 years), active malignancy (36%), and elevated body mass index (29%). A significant minority of departments (29%) do not always offer the option to withdraw ECMO to patients or surrogate decision-makers. For patients who cannot be liberated from ECMO and are ineligible for heart or lung transplant, 36% of departments would recommend the patient be removed from ECMO and 64% would continue ECMO support.

CONCLUSION

Adequate informed consent for ECMO is a major ethical challenge, and the content of these discussions varies. Use of categorical exclusion criteria and withdrawal of ECMO if a patient cannot be liberated from it differ among departments and institutions.

Reasons for physician-related variability in end-of-life decision-making in intensive care

BACKGROUND

There is increasing evidence that the individual physician is the main factor influencing variability in end-of-life decision-making in intensive care units. End-of-life decisions are complex and should be adapted to each patient. Physician-related variability is problematic as it may result in unequal assessments that affect patient outcomes. The primary aim of this study was to investigate factors contributing to physician-related variability in end-of-life decision-making.

METHOD

This is a qualitative substudy of a previously conducted study. In-depth thematic analysis of semistructured interviews with 19 critical care specialists from five different Swedish intensive care units was performed. Interviews took place between 1 February 2017 and 31 May 2017.

RESULTS

Factors influencing physician-related variability consisted of different assessment of patient preferences, as well as intensivists' personality and values. Personality was expressed mainly through pace and determination in the decision-making process. Personal prejudices appeared in decisions, but few respondents had personally witnessed this. Avoidance of criticism and conflicts as well as individual strategies for emotional coping were other factors that influenced physician-related variability. Many respondents feared criticism for making their assessments, and the challenging nature of end-of-life decision-making lead to avoidance as well as emotional stress.

CONCLUSION

Variability in end-of-life decision-making is an important topic that needs further investigation. It is imperative that such variability be acknowledged and addressed in a more formal and transparent manner. The ethical issues faced by intensivists have recently been compounded by the devastating impact of the COVID-19 pandemic, demonstrating in profound terms the importance of the topic.

Determining the impact of timing and of clinical factors during end-of-life decision-making in potential controlled donation after circulatory death donors

Controlled donation after circulatory death (cDCD) occurs after a decision to withdraw life-sustaining treatment and subsequent family approach and approval for donation. We currently lack data on factors that impact the decision-making process on withdraw life-sustaining treatment and whether time from admission to family approach, influences family consent rates. Such insights could be important in improving the clinical practice of potential cDCD donors. In a prospective multicenter observational study, we evaluated the impact of timing and of the clinical factors during the end-of-life decision-making process in potential cDCD donors. Characteristics and medication use of 409 potential cDCD donors admitted to the intensive care units (ICUs) were assessed. End-of-life decision-making was made after a mean time of 97 hours after ICU admission and mostly during the day. Intracranial hemorrhage or ischemic stroke and a high APACHE IV score were associated with a short decision-making process. Preserved brainstem reflexes, high Glasgow Coma Scale scores, or cerebral infections were associated with longer time to decision-making. Our data also suggest that the organ donation request could be made shortly after the decision to stop active treatment and consent rates were not influenced by daytime or nighttime or by the duration of the ICU stay.

Prediction Model for Timing of Death in Potential Donors After Circulatory Death (DCD III): Protocol for a Multicenter Prospective Observational Cohort Study

Background

Controlled donation after circulatory death (cDCD) is a major source of organs for transplantation. A potential cDCD donor poses considerable challenges in terms of identification of those dying within the predefined time frame of warm ischemia after withdrawal of life-sustaining treatment (WLST) to circulatory arrest. Several attempts have been made to develop models predicting the time between treatment withdrawal and circulatory arrest. This time window determines whether organ donation can occur and influences the quality of the donated organs. However, the selected patients used for these models were not always restricted to potential cDCD donors (eg, patients with cancer or severe infections were also included). This severely limits the generalizability of those data.

Objective

The objectives of this study are the following: (1) to develop a model predicting time to death within 60 minutes in potential cDCD patients; (2) to validate and update previous prediction models on time to death after WLST; (3) to determine timing and patient characteristics that are associated with prognostication and the decision-making process that leads to initiating end-of-life care; (4) to evaluate the impact of timing of family approach on organ donation approval; and (5) to assess the influence of variation in WLST processes on postmortem organ donor potential and actual postmortem organ donors.

Methods

In this multicenter observational prospective cohort study, all patients admitted to the intensive care unit of 3 university hospitals and 3 teaching hospitals who met the criteria of the cDCD protocol as defined by the Dutch Transplant Foundation were included. The target of enrolment was set to 400 patients. Previously developed models will be refitted in our data set. To further update previous prediction models, we will apply least absolute shrinkage and selection operator (LASSO) as a tool for efficient variable selection to develop the multivariable logistic regression model.

Results

This protocol was funded in August 2014 by the Dutch Transplant Foundation. We expect to have the results of this study in July 2020. Patient enrolment was completed in July 2018 and data collection was completed in April 2020.

Conclusions

This study will provide a robust multimodal prediction model, based on clinical and physiological parameters, that can predict time to circulatory arrest in cDCD donors. In addition, it will add valuable insight in the process of WLST in cDCD donors and will fill an important knowledge gap in this essential field of health care.

Trial Registration

ClinicalTrials.gov NCT04123275; https://clinicaltrials.gov/ct2/show/NCT04123275

International Registered Report Identifier (IRRID)

DERR1-10.2196/16733

Prediction of potential for organ donation after circulatory death in neurocritical patients

BACKGROUND

The success or failure of donation after circulatory death depends largely on the functional warm ischemia time, which is closely related to the duration between withdrawal of life-sustaining treatment and circulatory arrest. However, a reliable predictive model for the duration is absent. We aimed to compare the performance of the Chinese Donation after Circulatory Death Nomogram (C-DCD-Nomogram) and 3 other tools in a cohort of potential donors.

METHODS

In this prospective, multicenter, observational study, data were obtained from 219 consecutive neurocritical patients in China. The patients were followed until circulatory death after withdrawal of life-sustaining treatment.

RESULTS

The C-DCD-Nomogram performed well in predicting patient death within 30, 60, 120 and 240 minutes after withdrawal of life-sustaining treatment with c-statistics of 0.87, 0.88, 0.86 and 0.95, respectively. The DCD-N score was a poor predictor of death within 30, 60 and 240 minutes, with c-statistics of 0.63, 0.69 and 0.59, respectively, although it was able to predict patient death within 120 minutes, with a c-statistic of 0.73. Neither the University of Wisconsin DCD evaluation tool (UWDCD) nor the United Network for Organ Sharing (UNOS) criteria was able to predict patient death within 30, 60, 120 and 240 minutes after withdrawal of life-sustaining treatment (UWDCD tool: 0.48, 0.45, 0.49 and 0.57; UNOS criteria: 0.50, 0.53, 0.51 and 0.63).

CONCLUSION

The C-DCD-Nomogram is superior to the other 3 tools for predicting death within a limited duration after withdrawal of life-sustaining treatment in Chinese neurocritical patients. Thus, it appears to be a reliable tool identifying potential donors after circulatory death.

Clinical characteristics and temporal profile of recovery in patients with favorable outcomes at 6 months after severe traumatic brain injury

OBJECTIVE Early withdrawal of life-sustaining treatment due to expected poor prognosis is responsible for the majority of in-house deaths in severe traumatic brain injury (TBI). With increased focus on the decision and timing of withdrawal of care in patients with severe TBI, data on early neurological recovery in patients with a favorable outcome is needed to guide physicians and families. METHODS The authors reviewed prospectively collected data obtained in 1241 patients with head injury who were treated between 1986 and 2012. Patients with severe TBI, motor Glasgow Coma Scale (mGCS) score < 6 on admission, and those who had favorable outcomes (Glasgow Outcome Scale [GOS] score of 4 or 5, indicating moderate disability or good recovery) at 6 months were selected. Baseline demographic, clinical, and imaging data were analyzed. The time from injury to the first record of following commands (mGCS score of 6) after injury was recorded. The temporal profile of GOS scores from discharge to 6 months after the injury was also assessed. RESULTS The authors studied 218 patients (183 male and 35 female) with a mean age of 28.9 ± 11.2 years. The majority of patients were able to follow commands (mGCS score of 6) within the 1st week after injury (71.4%), with the highest percentage of patients in this group recovering on Day 1 (28.6%). Recovery to the point of following commands beyond 2 weeks after the injury was seen in 14.8% of patients, who experienced significantly longer durations of intracranial pressure monitoring (p = 0.001) and neuromuscular blockade (p < 0.001). In comparison with patients with moderate disability, patients with good recovery had a higher initial GCS score (p = 0.01), lower incidence of anisocoria at admission (p = 0.048), and a shorter ICU stay (p < 0.001) and total hospital stay (p < 0.001). There was considerable improvement in GOS scores from discharge to follow-up at 6 months. CONCLUSIONS Up to 15% of patients with a favorable outcome after severe TBI may begin to follow commands beyond 2 weeks after the injury. These data caution against early withdrawal of life-sustaining treatment in patients with severe TBI.

Comparing withdrawal and non-withdrawal of life-sustaining treatment among patients who died from stroke

BACKGROUND

In severe stroke, a decision to withdraw life-sustaining treatment is sometimes made in cooperation with the family. The aim of this study was to study the time from withdrawing life-sustaining treatment to death in patients with severe ischemic or hemorrhagic stroke.

METHODS

In total, 2,506 patients with stroke admitted to Haukeland University Hospital between 2006 and 2011 were prospectively registered in the Bergen NORSTROKE database. Risk factors, stroke severity, etiology, and blood analyses were registered. Retrospectively, the patients' records were examined to determine the number of days from withdrawing all life-sustaining treatment to death in patients who died from severe stroke during the hospital stay.

RESULTS

Life-sustaining treatment was withheld in 50 patients with severe stroke. Median time to death after withdrawing life-sustaining treatment was 4 days, and a quarter lived at least 1 week (range =1-11 days). Cox regression analyses showed that short time from withdrawing life-sustaining treatment to death was associated with high age (Hazard ratio [HR] =1.05, P=0.07), male sex (HR =2.9, P=0.01), high C-reactive protein on admission (HR =1.01, P=0.001), and hemorrhagic stroke (versus ischemic stroke, HR =1.5, P=0.03).

CONCLUSION

One week after withdrawing life-sustaining treatment, a quarter of our patients with severe stroke remained alive. Short time to death was associated with high age, male sex, hemorrhagic stroke, and high C-reactive protein on admittance.

When life-sustaining treatment is withdrawn and the patient doesn't die

One of the most difficult decisions that doctors and parents must make is the decision to withdraw life-sustaining treatment. Doctors find it easier to withdraw treatments in situations where withdrawal will be rapidly fatal rather than in situations in which treatment withdrawal will lead to a prolonged dying process. Mechanical ventilation is usually such a treatment. Withdrawal of ventilation generally leads to the patient's rapid demise. Doctors may tell parents that death will occur quickly after a ventilator is withdrawn. But what happens when the doctors are wrong and a patient survives without life support? What should doctors do next? We present a case in which that happened and asked 3 experts to comment on the case. Stefan Kutzsche is a senior consultant in neonatology at Oslo University Hospital Ulleval in Norway. John Colin Partridge is a neonatologist and professor of pediatrics at University of California, San Francisco. Steven R. Leuthner is a neonatologist and professor of pediatrics and bioethics at the Medical College of Wisconsin. They each recommend slightly different approaches to this dilemma.