BACKGROUND: There is a paucity of data to predict early death or futility after trauma. The objective of this study was to characterize the laboratory values, blood product administration, and hospital disposition for patients with trauma who died within 72 h of admission.
METHODS: All deaths within 72 h of admission over a 5-y period at a level I trauma center were reviewed. Blood transfusion within the first 4 h of arrival and patient disposition from the emergency department to the operating room (OR), surgical intensive care unit, or the neuroscience intensive care unit (NSICU) were analyzed. Kaplan-Meier curves were generated to determine time to death.
RESULTS: A total of 622 subjects were identified; 39.5% died in the emergency department, 10.6% went directly to the OR, 13.6% were admitted to the surgical intensive care unit, and 29.7% admitted to the NSICU. Of these subjects, 201 (32.2%) patients received blood within the first 4 h. By 24 h, early blood transfusion was associated with more rapid death for patients who were admitted to the NSICU (80% versus 60% mortality, P = 0.01) but not for patients taken directly to the OR (80% versus 70% mortality, P = 0.2). Admission coagulopathy by international normalized ratio (P < 0.01), but not anemia (P = 0.64) or acidosis (P = 0.45), correlated with a shorter time to death. In contrast, laboratory values obtained at 4 h after admission did not correlate with time to death.
CONCLUSIONS: Our data demonstrate that admission coagulation derangement and need for early blood product transfusion are the two factors most associated with early death after injury, particularly in those patients with traumatic brain injury. These data will help construct future models for futility of continued care in patients with trauma.
Background: While grief research has focused on death-related losses and distressed outcomes, contemporary findings suggest that role losses can lead to grief, and growth can accompany grief. The current study aimed to replicate and extend the Papa, Lancaster, & Kahler, 2014 study by: (1) assessing common loss responses (prolonged grief, major depression, posttraumatic stress) and role centrality among bereaved, divorced, and unemployed individuals, and (2) exploring posttraumatic growth and stress appraisals among loss groups.
Method: A cross-sectional online survey was completed by 372 recently bereaved, divorced, and unemployed individuals. Exploratory factor analysis assessed common loss responses in the bereaved group. In the sample, multiple regressions assessed the relationship between role centrality, stress appraisals, and outcome variables (prolonged grief, posttraumatic growth); correlational analysis assessed the relationship between posttraumatic growth and psychopathology variables; qualitative analysis assessed examples of posttraumatic growth.
Results: A subset of each loss group reported prolonged grief and posttraumatic growth. Prolonged grief was a distinct factor from major depression and posttraumatic stress. Role centrality and stress appraisals were significantly associated with outcome variables. There was a weak, positive relationship between posttraumatic growth and psychopathology variables.
Limitations: Limitations included convenience sampling and a cross-sectional study design, which precluded assessing responses over time. Strengths included replicating existing literature and incorporating a strength-based measure.
Conclusions: Prolonged grief can emerge from death-related loss and role loss. Also, posttraumatic growth can accompany prolonged grief. In clinical practice, loss can be conceptualized broadly beyond bereavement and addressed with the potential for posttraumatic growth.
Due to stringent but necessary infection control mandates, the COVID-19 pandemic is increasingly resulting in family separation from loved ones admitted to intensive care units (ICUs). Even in normal circumstances, ICU families frequently experience significant psychological dysfunction—including posttraumatic stress disorder and other trauma-related reactions, especially during the end of life period. The COVID pandemic likely will exacerbate these reactions as more and more families are being barred from the ICU. Consequently, ICU families are facing additional barriers in fully understanding the complex medical needs of their loved ones (and hence being able to make informed care decisions on their behalf); establishing rapport and bonding with nurses and other members of the ICU treatment team; and, in the event that a loved one passes, achieving closure. ICU health care providers can take steps to mitigate these outcomes by being mindful of the unique stressors ICU families are currently facing and tailoring their communication and behavior accordingly.
Dans cette réflexion sur les soins palliatifs, nous pointons la parole médicale comme structurellement traumatique.
Fréquemment, elle bloque le sujet à l’Éternel présent et rend difficile la projection vers l’à-venir.
Nous avançons ici l’idée que l’accompagnement palliatif aide à se dégager de ce traumatisme. Nous distinguerons deux positions relationnelles différentes dans le rapport au patient, positions qui occasionnent des modalités distinctes de maniement de la parole...
Background: Our objectives were to test whether during a potentially life-threatening medical emergency, perceived threat (a patient’s sense of life endangerment) in the emergency department (ED) is common and associated with the subsequent development of posttraumatic stress disorder (PTSD) symptoms.
Methods: This study was an ED-based prospective cohort study in an academic hospital. We included adult patients requiring acute intervention in the ED for resuscitation of a potentially life-threatening medical emergency, defined as respiratory or cardiovascular instability. We measured patient-perceived threat in the ED using a validated patient self-assessment measure (score range = 0 to 21, with higher scores indicating greater perceived threat). We performed blinded assessment of PTSD symptoms 30 days after discharge using the PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (PCL-5).
Results: Ninety-nine of 113 (88%) patients completed follow-up, with 98% reporting some degree of perceived threat, median (interquartile range [IQR]) perceived threat score 12 (6 to 17), and 72% reported PTSD symptoms in relation to their ED visit (median [IQR] PC-5 score = 7 [0 to 30]). Patients with respiratory instability had higher median (IQR) perceived threat scores (16 [9 to 18] vs. 9 [6 to 14)] and PCL-5 scores (10 [2 to 40] vs. 3 [0 to 17]) compared to patients without respiratory instability. In a multivariable linear regression model adjusting for potential confounders, greater perceived threat in the ED was independently associated with higher PCL-5 scores (ß = 0.79, 95% confidence interval [CI] = 0.15 to 1.42). Among the individual perceived threat items, the feeling of helplessness during resuscitation had the strongest association with PCL-5 score (ß = 5.24, 95% CI = 2.29 to 8.18).
Conclusions: Perceived threat during potentially life-threatening emergencies is common and independently associated with development of PTSD symptoms. Additional research to test whether reduction of perceived threat in the ED attenuates the development of PTSD symptoms following potentially life-threatening emergencies is warranted.
Le deuil causé par le décès d’une personne importante est l’événement le plus difficile de la vie d’un enfant. L’expression clinique du deuil chez l’enfant dépend de différents facteurs et du niveau de développement affectif. L’état de deuil traumatique de l’enfant n’est pas reconnu par le DSM-5. Il se caractérise par des symptômes traumatiques persistants, intrusifs et de l’évitement. Dans le contexte de traumatismes de masse, les enfants endeuillés présentent un risque élevé de complications de type biopsychosociaux. Un enfant sur cinq développera des complications. Il est important d’évaluer ces enfants afin de mieux comprendre leur fonctionnement et de proposer une thérapie ciblée et fondée sur des preuves. Développer des recherches sur ce sujet est un véritable défi pour la pédopsychiatrie.
Tiré du blog Tumblr "The last Message Received", créé par une adolescente de 16 ans, Emily Trunko, ce livre est "dédié à toutes les personnes qui, un jour, ont reçu un dernier message". Dans son introduction, Emily Trunko explique que le recueil de ces "derniers messages", messages de rupture amoureuse ou amicale pour certains, ou dernier message de cette "conversation légère dont tu ignores qu'elle précède une mort soudaine", a permis de fédérer une véritable communauté. Chaque dernier message choisi est accompagné de quelques lignes écrites par le destinataire, qui en retrace les circonstances.
Qu'il s'agisse de surmonter un deuil ou de prévenir un acte suicidaire, ce florilège de messages choisis ne laisse pas insensible et fait réfléchir à la portée de nos écrits. "Et si ce message était les derniers mots que mon destinataire lirait de moi ?" résonne alors comme un leitmotiv, une invitation à être plus prévenant et plus conscient des autres avant cet acte banal : cliquer sur "envoyer".
Dans le vert feuillage de Grand-Pommier, vivent deux jeunes hiboux. L'un s'appelle Tibou, l'autre Brindille. Grand-Pommier veille sur eux depuis que leurs parents ont été tués par l'épervier.
Grand-Pommier, témoin de leur histoire, prend soin des deux petits hiboux et les aide à grandir, répond à leurs questions. Les deux petits hiboux parlent de leurs parents qui leur manquent, des dangers qu'ils courent à cause de l'épervier, de l'envie de s'envoler loin du nid. Beaucoup de sujets sont abordés pour apporter de multiples réponses aux petits lecteurs de ce livre.
The current article focused on examining the potential benefits of the End-of-Life (EoL) informal caregiving, communication, and ritualistic behaviors in adaptation to the conjugal bereavement across two different cultural-background contexts: France and Togo, West Africa. The investigation adopted a transnational approach including a total of 235 bereaved spouses. Despite the variation in the length of time since death, no significant difference was found between the Togolese and French bereaved with respect to the level of complicated grief symptoms. However, the Togolese bereaved perceived a significant postloss growth, fostered by EoL communication with the dying and the performance of ritualistic behaviors. In the French sample, bereaved individuals who had experienced more intimate communication with their dying spouse reported a high level of postloss growth. Moreover, findings showed that EoL caregiving without ritualistic support or communication is associated with poor postbereavement outcomes. These findings suggest a clinical need to promote informal caregiving to the dying, communication with the dying, and ritualistic support during the process of dying as entangled components of EoL care.
CONTEXT: The Trauma Quality Improvement Program Best Practice Guidelines recommend palliative care (PC) concurrent with restorative treatment for patients with life-threatening injuries. Measuring PC delivery is challenging: administrative data are nonspecific, and manual review is time intensive.
OBJECTIVES: To identify PC delivery to patients with life-threatening trauma and compare the performance of natural language processing (NLP), a form of computer-assisted data abstraction, to administrative coding and gold standard manual review.
METHODS: Patients 18 years and older admitted with life-threatening trauma were identified from two Level I trauma centers (July 2016-June 2017). Four PC process measures were examined during the trauma admission: code status clarification, goals-of-care discussion, PC consult, and hospice assessment. The performance of NLP and administrative coding were compared with manual review. Multivariable regression was used to determine patient and admission factors associated with PC delivery.
RESULTS: There were 76,791 notes associated with 2093 admissions. NLP identified PC delivery in 33% of admissions compared with 8% using administrative coding. Using NLP, code status clarification was most commonly documented (27%), followed by goals-of-care discussion (18%), PC consult (4%), and hospice assessment (4%). Compared with manual review, NLP performed more than 50 times faster and had a sensitivity of 93%, a specificity of 96%, and an accuracy of 95%. Administrative coding had a sensitivity of 21%, a specificity of 92%, and an accuracy of 68%. Factors associated with PC delivery included older age, increased comorbidities, and longer intensive care unit stay.
CONCLUSION: NLP performs with similar accuracy with manual review but with improved efficiency. NLP has the potential to accurately identify PC delivery and benchmark performance of best practice guidelines.
Many studies have highlighted the deleterious psychological impact of suicide on bereaved individuals. We examined the psychological processes facilitating posttraumatic growth (PTG) among 124 suicide-loss survivors, focusing on attachment styles, perceived burdensomeness, and thwarted belongingness. Securely attached individuals achieved higher PTG than insecurely attached individuals. Perceived burdensomeness and thwarted belongingness both mediated and moderated the associations between attachment and PTG. Anxiously or avoidantly attached individuals who also had a high level of perceived burdensomeness were the least likely to achieve PTG. Thus, these individuals may derive particular benefit from attachment-based therapeutic interventions focusing on interpersonal relationships.
BACKGROUND: Physician Orders for Life-Sustaining Treatment (POLST) forms are portable medical orders documenting patient treatment preferences in an acute health decline. It is unclear how these forms are used in the management of elderly trauma patients.
METHODS: Patients 65 years and older presenting to a Level I trauma center were identified between 2012 and 2017. Hospital trauma registry and medical records were used to identify a preinjury POLST and its acknowledgment by providers within 24 hours of arrival. A 1:1 propensity score matched sample was used to evaluate clinical outcomes based on the presence of a POLST limiting interventions with p less than 0.05 deemed significant.
RESULTS: There were 3,342 elderly trauma patients identified. One hundred ninety-two (6%) had a POLST identified by the institutional trauma registry dated before the injury. Do not attempt resuscitation (DNR) was listed in 154 patients (80%), and 79% desired to avoid the intensive care unit (ICU) with limited (54%) or comfort measures only (CMO, 25%). One hundred seven (76%) of admitted POLST DNR patients had a DNR code status for the majority of their admission. 59 (58%) of the limited and 29 (60%) of the comfort measures only patients were admitted to the ICU. Acknowledgment of a preinjury POLST or code status was explicitly documented in 110 cases (57%). Propensity score analysis yielded a comparison sample of 288 patients. In the matched comparison, an acknowledged POLST with limitations was associated with a shorter ICU stay (1.7 vs. 2.8 days, p = 0.008) but there was no difference in ICU admission (58% vs. 61%, p = 0.69), total length of stay (3.8 days vs. 4.8 days, p = 0.08), or in-hospital mortality (13% vs. 8%, p = 0.2).
CONCLUSION: Limited provider acknowledgment of preinjury medical directives necessitates protocol development for the management of frail elderly trauma patients. When acknowledged, patients with a POLST limiting interventions had fewer ICU days without increased in-hospital mortality compared with similarly injured elderly patients.
LEVEL OF EVIDENCE: Care Management, level IV.
Background: As the number of geriatric trauma patients rises, end-of-life planning is of increased importance. A community-wide initiative to increase advanced care planning was undertaken in the 1990s, resulting in a high rate (85%) of completed advanced directives (ADs).
Objectives: To assess the impact of ADs on quality measures of care and outcomes for elderly trauma patients. To determine if the historically high rate of completed ADs in the community applied to the trauma patient population.
Design: A single trauma center's registry was retrospectively reviewed. Patients with versus without an AD were compared. A case–control analysis was completed. Statistical analysis included chi-square test, Wilcoxon rank sum, and multivariate linear regression modeling.
Setting: American College of Surgeons-verified level II trauma center with a 325-bed teaching hospital.
Subjects: Patients =55 years admitted as level I or II activations from January 2007 through April 2017.
Measurements: Hospital and intensive care unit (ICU) length of stay (LOS), ventilator days, and 30-day mortality.
Results: Nine hundred thirty-six patients were identified; 173 (18%) had an AD and 763 (82%) did not. ADs were more common among older, female patients. The majority of patients with ADs lived within the medical center's service area (99% vs. 1%) and had a primary care provider within the health care system (72% vs. 28%). Although 30-day mortality was higher in patients with ADs versus without (21% vs. 15%; p = 0.03), this difference was not significant on case–control analysis (20% vs. 15%, p = 0.31). No difference was identified in LOS, ICU days, ventilator days, or charges.
Conclusions: Presence of an AD was not associated with any difference in 30-day mortality, LOS, or hospital charges. More widespread efforts at AD education and documentation are necessary, particularly in the setting of trauma.
En 2015, un long article dans le prestigieux The New Yorker a de nouveau attiré l'attention sur la pratique de l'euthanasie en Belgique, et particulièrement en Flandre. La journaliste Rachel Aviv y donne la parole à trois personnes : chacune, de façon abrupte et tragique, a perdu sa mère par euthanasie. La journaliste cite également quelques réactions des médecins concernés, et interroge des intellectuels faisant autorité dans notre pays. Rachel Aviv ne condamne pas, elle enregistre, observe, donne ses impressions et montre beaucoup d'empathie pour ces personnes profondément blessées. Ce récit touchant confirme ce que bon nombre de Belges savent déjà : l'expérimentation sociale de l'euthanasie, suite à la loi de 2002, n'est pas le récit à succès auquel certains voudraient nous faire croire.
This article reviews the nature of post-disaster peer support groups and highlights their role in addressing collective grief and trauma following mass fatality incidents. With reference to best practice guidelines for responding to collective trauma events the article highlights the functions of peer support in promoting social support, connectedness and self/community efficacy. Different types of UK-based peer support group are described – from independent user-based action groups to facilitated talking groups as part of wider community support networks. The establishment and delivery of the Manchester Attack Support Group Programme (following the 2017 Manchester Arena terror attack) is discussed as a contemporary example of a network of facilitated talking groups. It complements the participation of bereaved people and survivors in other independent and self-determined peer-based activities such as the Manchester Survivors Choir and terrorism-related campaigns.
Although positive growth is possible following the loss of a loved one, meaning construction and redefinition of reality may represent a very difficult transition. Professionals must be careful in how they convey optimism and the prospects of growth to families that have recently suffered trauma and loss. At the same time, it is certainly true that they are able to steer people towards recognition of strengths and the possibility of growth and learning. In this article, various approaches that could be used in establishing such outcomes are communicated, in order to assist in providing a way in which people can make life bearable after tragedy has struck.
BACKGROUND: Palliative Care (PC) is indicated in patients with functional dependency and advanced care needs in addition to those with life-threatening conditions. Older trauma patients have PC needs due to increased risk of mortality and poor long-term outcomes. We hypothesized that older trauma patients discharged alive with poor outcomes are not easily identified nor receive PC interventions.
METHODS: Prospective observational study of trauma patients 55 years or older. Patients with poor functional outcomes defined by discharge Glasgow Outcome Scale Extended (GOSE) 1-4 or death at 6-month follow-up were analyzed for rate and timing of PC interventions including goals of care conversation (GOCC), do-not-resuscitate (DNR) order, do not intubate (DNI) order, and withdrawal of life supporting measures. Logistic regression was performed for having and timing of GOCC.
RESULTS: Three hundred fifteen (54%) of 585 patients had poor outcomes. Of patients who died, 94% had GOCC compared with 31% of patients who were discharged with GOSE 3 or 4. In patients who died, 85% had DNR order, 18% had DNI order, and 56% had withdrawal of ventilator. Only 24% and 9% of patients with GOSE of 3 or 4, respectively, had DNR orders. Fifty percent of the patients who were dead at 6-month follow-up had GOCC during initial hospitalization. The median time to DNR in patients that died was 2 days compared with 5 days and 1 day in GOSE 3 and 4 (p = 0.046). Age, injury severity scale, and preexisting limited physiological reserve were predictive of having a GOCC.
CONCLUSION: The PC utilization was very high for older trauma patients who died in hospital. In contrast, the majority of those who were discharged alive, but with poor outcomes, did not have PC. Development of triggers to identify older trauma patients, who would benefit from PC, could close this gap and improve quality of care and outcomes.
BACKGROUND: A structured family meeting (FM) is recommended within 72 h of admission for trauma patients with high risk of mortality or disability. Multidisciplinary FMs (MDFMs) may further facilitate decision-making. We hypothesized that FM within three hospital days (HDs) or MDFM would be associated with increased use of comfort measures.
MATERIALS AND METHODS: We reviewed all adult trauma deaths at an academic level 1 trauma center from December 2014 to December 2017. Death in the first 24 h or on nonsurgical services were excluded. Demographics, injury characteristics, FM characteristics, and outcomes such as length of stay (LOS) were recorded. Early FM was defined as occurring within three HDs; MDFM required attendance by two or more specialty teams.
RESULTS: A total of 177 patients were included. Median LOS was 6 d (interquartile range 4-12). FMs were documented in 166 patients (94%), with 57% occurring early. MDFM occurred in 49 (28%), but usually occurred later (median HD 5 and interquartile range 2-8). Early FM was associated with reduced LOS (5 versus 11 d, P < 0.001), ventilator days (4 versus 9 d, P < 0.001), and deaths during a code (1.2% versus 13.2%, P < 0.001). MDFM was associated with higher use of comfort measures (88% versus 68%, P < 0.05). Of patients who transitioned to comfort care status (n = 130, 73.4%), code status change occurred earlier if an early FM occurred (5 versus 13 d, P < 0.001).
CONCLUSIONS: MDFM is associated with increased comfort care measures, whereas early FM is associated with reduced LOS, ventilator days, death during a code, and earlier comfort care transition.
Parents who experience the death of a child are at high risk for psychopathology. Because a large percentage of pediatric deaths occur in the pediatric intensive care unit each year, a follow-up meeting between bereaved parents and intensivists could provide essential emotional support, although some parents may not attend. The aim of this study was to explore demographic and medical factors that may distinguish between bereaved parents who attend a follow-up meeting with their child’s pediatric intensivist and those who do not. Our analysis revealed that parents of children who died of trauma were less likely to attend a follow-up meeting with an intensivist. It is possible that symptoms of posttraumatic stress play a role in these findings. Enhanced efforts to identify other interventions for this specific subset of bereaved parents may be necessary.
The impact of traumatic workplace death on bereaved families, including their mental health and well-being, has rarely been systematically examined. This study aimed to document the rates and key correlates of probable posttraumatic stress disorder (PTSD), major depressive disorder (MDD), and prolonged grief disorder (PGD) in family members following a workplace injury fatality. The hidden nature of the target population necessitated outreach recruitment techniques, including the use of social media, newspaper articles, radio interviews, and contact with major family support organizations. Data were collected using a cross-sectional design and international online survey. The PCL-C (PTSD), the PHQ-8 (MDD), and PG-13 (PGD) were used to measure mental health disorders. All are well-established self-report measures with strong psychometric qualities. Participants were from Australia (62%), Canada (17%), the USA (16%), and the UK (5%). The majority were females (89.9%), reflecting the gender distribution of traumatic workplace deaths (over 90% of fatalities are male). Most were partners/spouses (38.5%) or parents (35%) and over half (64%) were next of kin to the deceased worker. Most deaths occurred in the industries that regularly account for more than 70 percent of all industrial deaths-construction, manufacturing, transport, and agriculture forestry and fishing. At a mean of 6.40 years (SD = 5.78) post-death, 61 percent of participants had probable PTSD, 44 percent had probable MDD, and 43 percent had probable PGD. Logistic regressions indicated that a longer time since the death reduced the risk of having each disorder. Being next of kin and having a self-reported mental health history increased the risk of having MDD. Of the related information and support variables, having satisfactory support from family, support from a person to help navigate the post-death formalities, and satisfactory information about the death were associated with a decreased risk of probable PTSD, MDD, and PGD, respectively. The findings highlight the potential magnitude of the problem and the need for satisfactory information and support for bereaved families.