Background: Emergency Medical Services (EMS) are often involved in end-of-life circumstances, yet little is known about how EMS interfaces with advance directives to forego unwanted resuscitation (Do Not Attempt Resuscitation (DNAR)). We evaluated the frequency of these directives involved in out-of-hospital cardiac arrest (OHCA) and how they impact care.
Methods: We conducted a cohort investigation of adult, EMS-attended OHCA from January 1 to December 31, 2018 in King County, WA. DNAR status was ascertained from dispatch, EMS, and hospital records. Resuscitation was classified according to DNAR status: not initiated, initiated but ceased due to the DNAR, or full efforts.
Results: Of 3152 EMS-attended OHCA, 314 (9.9%) had a DNAR directive. DNAR was present more often among those for whom EMS did not attempt resuscitation compared to when EMS provided some resuscitation (13.2% [212/1611] vs 6.6% [101/1541], (p < 0.05).
Of those receiving resuscitation with a DNAR directive (n = 101), the DNAR was presented on average 6 min following EMS arrival. A total of 82% (n = 83) had EMS efforts ceased as a consequence of the DNAR while 18% (n = 18) received full efforts. Full-efforts compared to ceased-efforts were more likely to have a witnessed arrest (67% vs 36%), present with shockable rhythm (22% vs 6%), achieve spontaneous circulation by time of DNAR presentation (50% vs 4%), and have family contradict the DNAR (33% vs 0%) (p < 0.05 for each comparison).
Conclusions: Approximately 10% of EMS-attended OHCA involved DNAR. EMS typically fulfilled this end-of-life preference, though wishes were challenged by delayed directive presentation or contradictory family wishes.
Purpose: Visitor restrictions during the COVID-19 pandemic limit in-person family meetings for hospitalized patients. We aimed to evaluate the quantity of family meetings by telephone, video and in-person during the COVID-19 pandemic by manual chart review. Secondary outcomes included rate of change in patient goals of care between video and in-person meetings, the timing of family meetings, and variability in meetings by race and ethnicity.
Methods: A retrospective cohort study evaluated patients admitted to the intensive care unit at an urban academic hospital between March and June 2020. Patients lacking decision-making capacity and receiving a referral for a video meeting were included in this study.
Results: Most patients meeting inclusion criteria (N = 61/481, 13%) had COVID-19 pneumonia (n = 57/61, 93%). A total of 650 documented family meetings occurred. Few occurred in-person (n = 70/650, 11%) or discussed goals of care (n = 233/650, 36%). For meetings discussing goals of care, changes in patient goals of care occurred more often for in-person meetings rather than by video (36% vs. 11%, p = 0.0006). The average time to the first goals of care family meeting was 11.4 days from admission. More documented telephone meetings per admission were observed for White (10.5, SD 9.5) and Black/African-American (7.1, SD 6.6) patients compared to Hispanic or Latino patients (4.9, SD 4.9) (p = 0.02).
Conclusions: During this period of strict visitor restrictions, few family meetings occurred in-person. Statistically significant fewer changes in patient goals of care occurred following video meetings compared to in-person meetings, providing support limiting in-person meetings may affect patient care.
Ce récit documente comment des malades sont morts en FaceTime pendant l’épidémie de Covid. À partir d’une enquête de terrain que j’ai commencée en janvier 2020 dans le service de réanimation d’un hôpital de la côte Ouest des États-Unis, je raconte l’apparition de la Covid-19, la séparation des malades de leurs familles, la mort vécue sur l’écran des téléphones mobiles, ainsi que les différentes façons d’agir des soignants face à cette situation que, tous, s’accordèrent à trouver « horrible ».
BACKGROUND/OBJECTIVES: Experts have suggested that patients represented by professional guardians receive higher intensity end-of-life treatment than other patients, but there is little corresponding empirical data.
DESIGN: Retrospective cohort study.
SETTING AND PARTICIPANTS: Among veterans aged 65 and older who died from 2011 to 2013, we used Minimum Data Set assessments to identify those who were nursing home residents and had moderately severe or severe dementia. We applied methods developed in prior work to determine which of these veterans had professional guardians. Decedent veterans with professional guardians were matched to decedent veterans without guardians in a 1:4 ratio, according to age, sex, race, dementia severity, and nursing facility type (VA based vs non-VA).
MEASUREMENTS: Our primary outcome was intensive care unit (ICU) admission in the last 30 days of life. Secondary outcomes included mechanical ventilation and cardiopulmonary resuscitation in the last 30 days of life, feeding tube placement in the last 90 days of life, three or more nursing home-to-hospital transfers in the last 90 days of life, and in-hospital death.
RESULTS: ICU admission was more common among patients with professional guardians than matched controls (17.5% vs 13.7%), but the difference was not statistically significant (adjusted odds ratio = 1.33; 95% confidence interval = .89–1.99). There were no significant differences in receipt of any other treatment; nor was there a consistent pattern. Mechanical ventilation and cardiopulmonary resuscitation were more common among patients with professional guardians, and feeding tube placement, three or more end-of-life hospitalizations, and in-hospital death were more common among matched controls.
CONCLUSION: Rates of high-intensity treatment were similar whether or not a nursing home resident with dementia was represented by a professional guardian. This is in part because high-intensity treatment occurred more frequently than expected among patients without guardians.
OBJECTIVE: Our study aims to provide a paradigm when it is ethical to perform cardiopulmonary resuscitation (CPR) on patients during the COVID-19 pandemic.
SUMMARY BACKGROUND DATA: Hospitals around the nation are enacting systems to limit CPR in caring for COVID+ patients for a variety of legitimate reasons and based on concepts of medical futility and allocation of scarce resources. No ethical framework, however, has been proposed as a standard to guide care in this crucial matter.
METHODS: Our analysis begins with definitions of ethically relevant terms. We then cycle an illustrative clinical vignette through the mathematically permissible possibilities to account for all conceivable scenarios. Scenarios with ethical tension are examined.
RESULTS: Patients have the negative right to refuse care including CPR, but they do not have the positive right to demand it. Our detailed ethical analysis and recommendations support CPR if and only if 1) CPR is judged medically beneficial, and in line with the patient's and values and goals, 2) allocations or scarce resources follow a just and transparent triage system, and 3) providers are protected from contracting the disease.
CONCLUSIONS: CPR is an intervention like any other, with attendant risks and benefits and with responsibility for the utilization of limited resources. Our ethical analysis advocates for a systematic approach to codes that respects the important ethical considerations in caring for the critically ill and facilitates patient-centered, evidence-based, and fair treatment to all.
Aim: We validated the NUE rule, using three criteria (Non-shockable initial rhythm, Unwitnessed arrest, Eighty years or older) to predict futile resuscitation of patients with out-of-hospital cardiac arrest (OHCA).
Methods: We performed a retrospective cohort analysis of all recorded OHCA in Marion County, Indiana, from January 1, 2014 to December 31, 2019. We described patient, arrest, and emergency medical services (EMS) response characteristics, and assessed the performance of the NUE rule in identifying patients unlikely to survive to hospital discharge.
Results: From 2014 to 2019, EMS responded to 4370 patients who sustained OHCA. We excluded 329 (7.5%) patients with incomplete data. Median patient age was 62 years (IQR 49 - 73), 1599 (39.6%) patients were female, and 1728 (42.8%) arrests were witnessed. The NUE rule identified 290 (7.2%) arrests, of whom none survived to hospital discharge.
Conclusion: In external validation, the NUE rule (Non-shockable initial rhythm, Unwitnessed arrest, Eighty years or older) correctly identified 7.2% of OHCA patients unlikely to survive to hospital discharge. The NUE rule could be used in EMS protocols and policies to identify OHCA patients very unlikely to benefit from aggressive resuscitation.
CONTEXT: One fundamental way to honor patient autonomy is to establish and enact their wishes for end of life care. Limited research exists regarding adherence with code status.
OBJECTIVES: This study aimed to characterize cardiopulmonary resuscitation attempts discordant with documented code status at the time of death in the United States and to elucidate potential contributing factors.
METHODS: The Cerner APACHE outcomes database, which includes 237 U.S. hospitals that collect manually abstracted data from all critical care patients, was queried for adults admitted to intensive care units with a documented code status at the time of death from January 2008 to December 2016. The primary outcome was discordant cardiopulmonary resuscitation at death. Multivariable logistic regression models were used to identify patient-, and hospital-level associated factors after adjustment for age, hospital, and illness severity (APACHE III score).
RESULTS: A total of 21,537 patients from 56 hospitals were included. Of patients with a do-not-resuscitate code status, 149 (0.8%) received cardiopulmonary resuscitation at death and associated factors included: Black race, higher APACHE III score or treatment in small or non-teaching hospitals. Of patients with a full code status, 203 (9.0%) did not receive cardiopulmonary resuscitation at death and associated factors included: higher APACHE III score, primary neurologic or trauma diagnosis, or admission in a more recent year.
CONCLUSION: At the time of death, 1.6% of patients received or did not undergo cardiopulmonary resuscitation in a manner discordant with their documented code statuses. Race, and institutional factors were associated with discordant resuscitation, and addressing these disparities may promote concordant end-of-life care in all patients.
BACKGROUND: Cardiopulmonary resuscitation (CPR) is a medical emergency intervention aimed at ending a life-threatening cardiovascular arrest as quickly as possible. However, the medical ethics of starting CPR in patients who have incurable and terminal disease is a matter of controversy. This ethical dilemma affects cancer patients in particular, as they are often suffering from advanced disease in a palliative situation. Few data are as yet available concerning the prevalence of CPR in patients with terminal cancer.
METHODS: A population-based cross-sectional study was carried out on the basis of death certificates of two large cities in Germany evaluated for 2017. Medical data on resuscitation and cause of death were analyzed. Cancer patients with or without a palliative situation were identified, and the prevalence of resuscitation in these patients was determined. In addition, factors influencing resuscitation were calculated using binary multivariate regression.
RESULTS: A total of 8,496 persons died, 32.1% of whom [2,723] were cancer patients. A palliative situation was present in 80.9% of the cancer patients [2,202]. A total of 163 cancer patients and 1,006 individuals without cancer were resuscitated at the end of life, representing prevalences of 6.0% (95% CI, 5.1-6.9%) and 17.4% (95% CI, 16.4-18.4%), respectively. Cancer patients with a palliative disease status received CPR in 3.4% of cases (95% CI, 2.6-4.2%). More than half of the resuscitations were performed in hospital (57.7% of resuscitated persons and 68.7% of cancer patients). Sex, age, presence of a palliative situation, and care provided by a specialized outpatient palliative service were found to be independent influencing factors.
CONCLUSIONS: Six in 100 cancer patients, and slightly more than three in 100 cancer patients with a palliative disease status, undergo CPR at the end of their lives. Thus, the indication for resuscitation in advanced cancer patients is handled with care and responsibility in Germany.
Background: To characterize patients dying in a community hospital with or without attempting cardiopulmonary resuscitation (CPR) and to describe patient involvement in, documentation of, and compliance with decisions on resuscitation (Do-not-attempt-to-resuscitate orders; DNAR).
Methods: ll patients who died in Kalmar County Hospital during January 1, 2016 until December 31, 2016 were included. All information from the patients’ electronic chart was analysed.
Results: Of 660 patients (mean age 77.7 ± 12.1 years; range 21–101; median 79; 321 (48.6%) female), 30 (4.5%) were pronounced dead in the emergency department after out-of-hospital CPR. Of the remaining 630 patients a DNAR order had been documented in 558 patients (88.6%). Seventy had no DNAR order and 2 an explicit order to do CPR. In 43 of these 70 patients CPR was unsuccessfully attempted while the remaining 27 patients died without attempting CPR. In 2 of 558 (0.36%) patients CPR was attempted despite a DNAR order in place. In 412 patients (73.8%) the DNAR order had not been discussed with neither patient nor family/friends. Moreover, in 75 cases (13.4%) neither patient nor family/friends were even informed about the decision on code status.
Conclusions: In general, a large percentage of patients in our study had a DNAR order in place (88.6%). However, 27 patients (4.3%) died without CPR attempt or DNAR order. DNAR orders had not been discussed with the patient/surrogate in almost three fourths of the patients. Further work has to be done to elucidate the barriers to discussions of CPR decisions with the patient.
La loi Claeys–Leonetti a donné le droit à « une sédation profonde et continue provoquant une altération de la conscience maintenue jusqu’au décès (SPCMD) ». Chaque situation de sa mise en œuvre soulève des questions éthiques, morales, mais aussi pratiques, techniques et organisationnelles. Comment s’approprier la SPCMD dans le contexte particulier de la réanimation ? Comment définir les contours de cette pratique sédative à visée palliative ? Quelles sont les modalités décisionnelles et pratiques de sa mise en œuvre ? La SPCMD se distingue des autres pratiques sédatives à visée palliative : elle consiste à rendre le patient inconscient sans communication possible ; son intention dès l’initiation est d’être poursuivie jusqu’au décès, l’inconscience provoquée est quant à elle l’objectif, et non pas l’effet indésirable. La SPCMD se distingue également de l’euthanasie : si la distinction peut parfois paraître complexe et ambiguë lorsqu’elle s’accompagne en réanimation de l’arrêt d’un traitement de maintien en vie, les intentions restent radicalement différentes. Si les modalités décisionnelles sont clairement précisées dans la loi, les étapes du processus décisionnel continuent de questionner les équipes de réanimation. Et les modalités d’application pratique sont moins claires, particulièrement dans le contexte de la réanimation. Si la loi actuelle est probablement insuffisamment connue et mise en œuvre, elle permet de soigner les patients en fin de vie, tout en respectant leur dignité.
Les soins palliatifs demandent de plus en plus de compétences médicales, soignantes, humaines et éthiques, afin d’asseoir leur légitimité dans des domaines de plus en plus pointus de la médecine – réanimation, néonatalogie, cancérologie, gériatrie – ainsi que dans la diversité des prises en charge, y compris au domicile ou en EPHAD.
Dans ce contexte de développement des formations et d’élargissement des champs de compétences de la pratique palliative, cette 5e édition du manuel offre :
-les indispensables connaissances thérapeutiques ;
-les outils, à destination des professionnels en vue d’acquérir une compétence clinique pour la rencontre et l’accompagnement humain, psychique et relationnelle de la personne malade ;
-une contextualisation de la pratique des soins palliatifs dans leur dimension sociale, sanitaire et politique ;
-des jalons pédagogiques pour le développement des soins palliatifs dans leur dimension pédagogique et de recherche.
Cette réédition totalement revue et enrichie contribue à une appropriation des évolutions législatives portées par la loi du 2 février 2016 créant de nouveaux droits en faveur des malades et des personnes en fin de vie (droits de la personne, sédation profonde et continue, souffrance, directives anticipées opposables, etc.). Les conditions du mourir interrogent à la fois nos obligations sociales et les exigences du soin. Alors que s'instaurent une nouvelle culture de la fin de vie, de nouvelles solidarités, quelles seront les incidences sur les pratiques professionnelles au service de la personne malade et de ses proches ? Ces situations toujours singulières, irréductibles aux débats généraux portant sur "la mort dans la dignité" justifient une exigence de clarification, la restitution d’expériences et la transmission de savoirs vrais.
Dans une approche pluridisciplinaire, cet ouvrage associe les meilleures compétences pour proposer une synthèse rigoureuse et complète des réflexions et des expériences au cœur des débats les plus délicats de notre société. Il constitue une indispensable référence à destination des professionnels mais tout autant d'un large public, la concertation nationale sur la fin de vie ayant fait apparaître un important besoin d'informations dans ces domaines à la fois intimes et publics.
BACKGROUND: With the highest number of cases in the world as of April 13, 2020, New York City (NYC) became the epicenter of the global coronavirus disease 2019 (COVID-19) pandemic. The data regarding palliative team involvement in patients with COVID-19, however, remains scarce. We aimed to investigate outcomes of palliative team involvement for the patients with COVID-19 in NYC.
METHODS: Consecutive 225 patients with confirmed COVID-19 requiring hospitalization in our urban academic medical center in NYC were analyzed. Patients were divided into 2 groups, those with a palliative care consult (palliative group: 14.2% [n = 32]) versus those with no palliative care consult (no palliative group: 85.8% [n = 193]).
RESULTS: The palliative group was older and had more comorbidities. During the hospital course, the palliative group had more intensive care unit stays, rapid response team activations, and more use of vasopressors (P < .05). Patients with palliative care had higher rates of invasive mechanical ventilation than those without (46.9% vs 10.4%, P < .001). Cardiopulmonary resuscitation was performed in 12 patients (6.5% vs 5.2%, P = .77) and death rate was 100% in both subsets. Notably, initial code status was not different between the 2 groups, however, code status at discharge was significantly different between them (P < .001). The rate of full code decreased by 70% in the palliative group and by 47.5% in the no palliative care group from admission to the time of death.
CONCLUSIONS: Critically ill patients hospitalized for COVID-19 benefit from palliative team consults by helping to clarify advanced directives and minimize futile resuscitative efforts.
Les infirmiers peuvent apporter une aide à la décision dans les situations d’urgence lors d’un choc septique, notamment si le malade n’a pas rédigé de directives anticipées et/ou désigné une personne de confiance. Ils peuvent entreprendre ou faciliter la collégialité des décisions nécessaires sur le plan juridique et éthique. Les habitus d’une équipe à la réflexion éthique et au recueil de données initial sont les garants du respect de la parole du patient.
Aim: To determine if frailty is associated with poor outcome following in-hospital cardiac arrest; to find if there is a “frailty threshold” beyond which cardiopulmonary resuscitation (CPR) becomes futile.
Methods: Retrospective review of patients aged over 60 years who received CPR between May 2017 and December 2018, in a tertiary referral hospital, which does not provide primary coronary revascularisation. Clinical Frailty Scale (CFS) and Charlson Comorbidity Index were retrospectively assigned.
Results: Data for 90 patients were analysed, the median age was 77 (IQR 70-83); 71% were male; 44% were frail (CFS > 4). Frailty was predictive of in-hospital mortality independent of age, comorbidity and cardiac arrest rhythm (OR 2.789 95% CI 1.145–6.795). No frail patients (CFS > 4) survived to hospital discharge, regardless of cardiac arrest rhythm, whilst 13 (26%) of the non-frail (CFS = 4) patients survived to hospital discharge. Of the 13 survivors (Age 72; range 61–86), 12 were alive at 1 year and had a good neurological outcome, the outcome for the remaining patient was unknown.
Conclusion: Frail patients are unlikely to survive to hospital discharge following in-hospital cardiac arrest, these results may facilitate clinical decision making regarding whether CPR may be considered futile. The Clinical Frailty Scale is a simple bedside assessment that can provide invaluable information when considering treatment escalation plans, as it becomes more widespread, larger scale observations using prospective assessments of frailty may become feasible.
Background: The association between palliative care and life-sustaining treatment following emergency department (ED) resuscitation is unclear. This study aims to analyze the usage of palliative care and life-sustaining treatments among ED triage level I resuscitation patients based on a nationally representative sample of patients in Taiwan.
Methods: A matched-pair retrospective cohort study was conducted to examine the association between palliative care and outcome variables using multivariate logistic regression and Kaplan–Meier survival analyses. Between 2009 and 2013, 336 ED triage level I resuscitation patients received palliative care services (palliative care group) under a universal health insurance scheme. Retrospective cohort matching was performed with those who received standard care at a ratio of 1:4 (usual care group). Outcome variables included the number of visits to emergency and outpatient departments, hospitalization duration, total medical expenses, utilization of life-sustaining treatments, and duration of survival following ED triage level I resuscitation.
Results: The mean survival duration following level I resuscitation was less than 1 year. Palliative care was administered to 15% of the resuscitation cohort. The palliative care group received significantly less life-sustaining treatment than did the usual care group.
Conclusion: Among patients who underwent level I resuscitation, palliative care was inversely correlated with the scope of life-sustaining treatments. Furthermore, triage level I resuscitation status may present a possible new field for starting palliative care intervention and reducing low-value care.
The devastating pandemic that has stricken the worldwide population induced an unprecedented influx of patients in ICUs, raising ethical concerns not only surrounding triage and withdrawal of life support decisions, but also regarding family visits and quality of end-of-life support. These ingredients are liable to shake up our ethical principles, sharpen our ethical dilemmas, and lead to situations of major caregiver sufferings. Proposals have been made to rationalize triage policies in conjunction with ethical justifications. However, whatever the angle of approach, imbalance between utilitarian and individual ethics leads to unsolvable discomforts that caregivers will need to overcome. With this in mind, we aimed to point out some critical ethical choices with which ICU caregivers have been confronted during the Covid-19 pandemic and to underline their limits. The formalized strategies integrating the relevant tools of ethical reflection were disseminated without deviating from usual practices, leaving to intensivists the ultimate choice of decision.
Background: Emergency departments routinely offer cardiopulmonary resuscitation and endotracheal intubation to patients in resuscitative states. With increasing longevity and prevalence of chronic conditions in Australia, there has been growing need to uptake and implement advance care directives and resuscitation plans. This study investigates the frequency of the presence of advance care directives and resuscitation plans and its utilisation in cardiopulmonary and endotracheal intubation decision making.
Methods: Retrospective audit of electronic patients’ medical records aged =65 years presenting over a 3-month period. Data collected included demographics, triage categories, advance care directive and/or resuscitation plans/orders status.
Results: A total of 6439 patients were included representing 29% of the total patient population during the study period. Participants were randomly selected (N = 300); mean age was 78.7 (±8.1) years. An advance care directive was present in only 8% and one in three patients (37%) had a previous resuscitation plan/order. Senior consultant was present at the department for consultation by junior doctors for most of the patients (82%). Acknowledgment of either advance care directive or resuscitation plans/orders in clinical notes was only 9.5% (n = 116).
Conclusion: Advance care directive prevalence was low with resuscitation plans/orders being more common. However, clinician acknowledgement was infrequent for both.
Background: Data are scarce on the withdrawal of life-sustaining therapies and limitation of care orders (LCOs) during physician-staffed Helicopter Emergency Medical Service (HEMS) missions. We investigated LCOs and the quality of information available when physicians made treatment decisions in prehospital care.
Methods: A prospective, nationwide, multicentre study including all Finnish physician-staffed HEMS bases during a six-month study period. All HEMS missions where a patient had pre-existing LCOs and/or a new LCO were included.
Results: There were 335 missions with LCOs, which represented 5.7% of all HEMS missions (n=5,895). There were 181 missions with pre-existing LCOs, and a total of 170 new LCOs were issued. Usually, the pre-existing LCO was a do not attempt cardiopulmonary resuscitation order only (n=133, 74%). The most frequent new LCO was ‘termination of cardiopulmonary resuscitation’ only (n=61, 36%), while ‘no intensive care’ combined with some other LCO was almost as common (n=54, 32%). When issuing a new LCO for patients who did not have any preceding LCOs (n=153), in every other (49%) case the physicians thought that the patient should have already had an LCO. When the physician made treatment decisions, patients’ background information from on-scene paramedics was available in 260 (78%) of the LCO missions, while patients’ medical records were available in 67 (20%) of the missions.
Conclusion: Making LCOs or treating patients with pre-existing LCOs is an integral part of HEMS physicians’ work, with every twentieth mission involving LCO patients. The new LCOs mostly concerned withholding or withdrawal of cardiopulmonary resuscitation and intensive care.