When life-sustaining treatments (LST) are no longer effective or consistent with patient preferences, limitations may be set so that LSTs are withdrawn or withheld from the patient. Many studies have examined the frequency of limitations of LST in intensive care unit (ICU) settings in the past 30 years. This systematic review describes variation and patient characteristics associated with limitations of LST in critically ill patients in all types of ICUs in the United States. A comprehensive search of the literature was performed by a medical librarian between December 2014 and April 2017. A total of 1,882 unique titles and abstracts were reviewed, 113 were selected for article review, and 36 studies were fully reviewed. Patient factors associated with an increased likelihood of limiting LST included white race, older age, female sex, poor preadmission functional status, multiple comorbidities, and worse illness severity score. Based on several large, multicenter studies, there was a trend toward a higher frequency of limitation of LST over time. However, there is large variability between ICUs in the proportion of patients with limitations and on the proportion of deaths preceded by a limitation. Increases in the frequency of limitations of LST over time suggests changing attitudes about aggressive end-of-life-care. Limitations are more common for patients with worse premorbid health and greater ICU illness severity. While some differences in the frequency of limitations of LST may be explained by personal factors such as race, there is unexplained wide variability between units.
Limited studies exist regarding the timing, location, or physicians involved in do-not-resuscitate (DNR) order placement in pediatrics. Prior pediatric studies have noted great variations in practice during end-of-life (EOL) care. This study aims to analyze the timing, location, physician specialties, and demographic factors influencing EOL care in pediatrics. We examined the time preceding and following the implementation of a pediatric palliative care team (PCT) via a 5-year, retrospective chart review of all deceased patients previously admitted to inpatient services. Thirty-five percent (167/471) of the patients in our study died with a DNR order in place. Sixty-two percent of patients died in an ICU following DNR order placement. A difference was noted in DNR order timing between patients on general inpatient units and those discharged to home compared with those in the ICUs (p = 0.02). The overall DNR order rate increased following the initiation of the PCT from 30.8% to 39.2% (p = 0.05), but no change was noted in the rate of death in the ICUs. Our study demonstrates a variation in the timing of death following DNR order placement when comparing ICUs and general pediatric floors. Following the initiation of the PCT, we saw increased DNR frequency but no change in the interval between a DNR order and death.
Contexte/Introduction: En France, la loi définit et interdit «l'obstination déraisonnable » et encadre la décision qui en découle de limiter, voire d’arrêter les thérapeutiques. Elle accorde aussi au patient le droit de désigner une personne de confiance et de formuler des directives anticipées à cet égard. Peu d’études ont été réalisées sur les décisions de limitation thérapeutique chez les traumatisés crâniens sévères, et encore moins concernant le rôle et l’implication des neurochirurgiens.
Objectifs: Le premier objectif de cette étude était d’évaluer l’observance de la loi n° 2005-370 du 22 avril 2005 relative aux droits des malades et à la fin de vie, qui encadre ces décisions. Le second objectif était d’estimer la fréquence des critères pronostiques et décisionnels utilisés par les neurochirurgiens.
Matériel et méthode : Une enquête de pratique par questionnaire envoyé par courriel aux neurochirurgiens membres de la Société française de neurochirurgie a été menée en France d’avril à juin 2016.
Résultats: Sur 197 neurochirurgiens contactés, 62 ont complété le questionnaire. Les discussions de limitation thérapeutique respectaient le principe de collégialité requis par la loi et incluaient le neurochirurgien référent du patient dans 100 % des cas. La personne de confiance et/ou la famille étaient toujours consultées, mais leur avis était pris en compte de façon variable. Les directives anticipées étaient le plus souvent inexistantes (68 %) [56 % ; 80 %] (27 %) ou inappropriées (27 %) [16 ; 38]. Les paramètres d’évaluation pronostique les plus utilisés étaient les paramètres cliniques, la pression intra-crânienne, la pression de perfusion cérébrale et l’imagerie cérébrale, avec toutefois une grande variabilité interindividuelle dans leur utilisation. Les critères décisionnels principaux étaient la qualité de vie et le handicap prévisibles, puis l’âge.
Conclusions: On observe globalement une bonne observance de la loi par les neurochirurgiens, sauf concernant l’appel au consultant externe. Cette étude confirme l’hétérogénéité dans l’utilisation des critères d’évaluation pronostique et la nécessité de poursuivre la recherche clinique pour parvenir à des pratiques standardisées permettant de limiter au maximum la part de subjectivité dans le processus décisionnel.
Objectives To assess the effect of using a treatment escalation/limitation plan (TELP) on the frequency of harms in 300 patients who died following admission to hospital.
Design A retrospective case note review of 300 unselected, consecutive deaths comprising: (1) patients with a TELP in addition to a do-not-attempt cardiopulmonary resuscitation order (DNACPR); (2) those with DNACPR only; and (3) those with neither. Patient deaths were classified retrospectively as ‘expected’ or ‘unexpected’ using the Gold Standard Framework Prognostic Indicator Guidance.
Setting Medical, surgical and intensive care units of a district general hospital.
Outcomes The primary outcome was the between-group difference in rates of harms, non-beneficial interventions (NBIs) and clinical ‘problems’ identified using the Structured Judgement Review Method.
Results 289 case records were evaluable. 155 had a TELP and DNACPR (54%); 113 had DNACPR only (39%); 21 had neither (7%). 247 deaths (86%) were ‘expected’. Among patients with ‘expected’ deaths and using the TELP/DNACPR as controls (incidence rate ratio (IRR)=1.00), the IRRs were: for harms, 2.99 (DNACPR only) and 4.00 (neither TELP nor DNACPR) (p<0.001 for both); for NBIs, the corresponding IRRs were 2.23 (DNACPR only) and 2.20 (neither) (p<0.001 and p<0.005, respectively); for ‘problems’, 2.30 (DNACPR only) and 2.76 (neither) (p<0.001 for both). The rates of harms, NBIs and ‘problems’ were significantly lower in the group with a TELP/DNACPR compared with ‘DNACPR only’ and ‘neither’: harms (per 1000 bed days) 17.1, 76.9 (p<0.001) and 197.8 (p<0.001) respectively; NBIs: 27.4, 92.1 (p<0.001) and 172.4 (p<0.001); and ‘problems’: 42.3, 146.2 (p<0.01) and 333.3 (p<0.001).
Conclusions The use of a TELP was associated with a significant reduction in harms, NBIs and ‘problems’ in patients admitted acutely and who subsequently died, especially if they were likely to be in the last year of life.
BACKGROUND: In intensive care units (ICUs), a patient's vital functions may be maintained, regardless of the patient's chances of survival. A key issue is how to precisely determine the moment in which life-support treatment should be withheld. In many countries, the decision-making process is regulated by the guidelines of scientific societies. However, heuristic errors may influence this process.
OBJECTIVES: The objective of this study was to assess factors involved in decisions to implement or withhold treatment in general ICUs in Poland.
MATERIAL AND METHODS: The medical records of patients treated in 3 clinical ICUs of general, cardiosurgical and neurosurgical profile were retrospectively analyzed. Patients with a diagnosis of brain death were finally excluded from the study.
RESULTS: The records of 1,449 patients hospitalized between January 1, 2014 and December 31, 2014 were analyzed. Of these, 226 patient cases were evaluated. There were no correlations between the placement of restrictions on resuscitation in specific cases, use of noradrenaline, frequency of blood gas testing, and patients' age. There was a relationship between these factors and the duration of hospitalization in the ICU. There was a direct relation between a "do not resuscitate" (DNR) order in a patient's record and the frequency of both resuscitation procedures and withholding catecholamine treatment in the hours preceding a patient's death.
CONCLUSIONS: Treatment was withheld in about 20% of cases involving dying patients in analyzed ICUs, regardless of age. Placing a limit on treatment consisted of either withholding new procedures or withdrawing existing therapy. The length of stay in the ICU affected the decisions to limit treatment.
BACKGROUND: In Pediatric Intensive Care Unit (PICU) two types of population require the intervention of neuropediatricians (NP): chronic brain diseases' patients who face repetitive and prolonged hospitalizations, and patients with acute brain failure facing the risk of potential neurologic sequelae, and both conditions may result in a limitation of life-sustaining treatments (LLST) decision.
OBJECTIVE: To assess NP's involvement in LLST decisions within the PICU of a tertiary hospital.
METHOD: Retrospective study of medical reports of patients hospitalized during 2014 in the Necker-Hospital PICU. Patients were selected using keywords ("cardiorespiratory arrest", "death", "withdrawal of treatment", "palliative care", "acute brain failure", or "chronic neurological disease"), and/or if they were assessed by a NP during the hospitalization. Demographic and medical data were analysed, including the NP's assessment and data about Collaborative Multidisciplinary Deliberation (CMD) to discuss potential LLST.
RESULTS: Among 1160 children, 274 patients were included and 142 (56%) were assessed by a NP during their hospitalization for diagnosis (n = 55) and/or treatment (n = 95) management. NP was required for 59%-100% of patients with neurological acute failure, and for 14-44% of patients with extra neurological failure. A LLST decision was taken after a CMD for 27 (9.8%) of them, and a NP was involved in 19/27 (70%) of these decisions that occurred during the hospitalization (n = 19) or before (n = 8).12 patients died thereafter the LLST decision (40% of the 30 dead patients).
CONCLUSION: NP are clearly involved in the decision-process of LLST for patients admitted in PICU, claiming for close collaboration to improve current practices and the quality of the care provided to children.
Le médecin urgentiste dans sa pratique en service d’accueil ou en pré-hospitalier est confronté à des situations de détresse vitale aiguë, qui imposent de se prononcer sur des actes afin d’apporter au patient un soin proportionné. La loi de 2005 sur le droit des malades, dite loi Leonetti, a clairement remis au centre des préoccupations, la lutte contre deux dérives génératrices de malaise et de perte de sens : l’acharnement thérapeutique et l’euthanasie. Le médecin doit ainsi clairement positionner son projet de soin sans tomber dans l’un de ces deux écueils. Ainsi sont mis en balance majoritairement, la poursuite d’une réanimation cardio- pulmonaire dans un arrêt cardiaque, l’intubation orotrachéale lors d’une nécessité de supplanter l’appareil ventilatoire, le remplissage vasculaire, la mise en route d’amines vasopressives ou l’acceptation d’un processus normal et l’accompagnement dans la dignité qui incombe au corps soignant.Naît alors de ce constat, la lourde problématique de la concrétisation de ces prises de décision. Comment le médecin est-il amené à orienter le soin proportionné vers tel ou tel acte dont peuvent découler des issues bien différentes ?
En France, la question de l'euthanasie divise encore l'opinion publique. Ce livre viendra donc utilement éclairer le débat. En effet, en Belgique, l'euthanasie a été dépénalisée en 2002. Elle est dorénavant considérée comme un acte de soins, pratiqué - exclusivement - par un médecin, à condition que le malade en fasse la demande expresse et répétée. Concrètement comment cela se passe-t-il ? Quelles sont les démarches à effectuer ? Quel est le rôle du médecin ? Et la famille dans tout ça ? Et les soins palliatifs ? L'auteur, médecin engagé dans la pratique de l'euthanasie depuis plus de dix ans, nous livre ici tant un état des lieux documenté, enrichi de cas concrets, qu'un témoignage nuancé et sincère.
[Quatrième de couverture]
Since 2013, Kaiser Permanente Northern California has engaged in a systematic effort to elicit, document, and honor the care preferences of patients as they near the end of life. This is done through its Advanced Steps program, in which selected patients discuss their preferences for future medical care with their healthcare agent during a structured conversation with a trained advance care planning facilitator. The facilitator then translates the patient's wishes into an actionable medical order set using a Physician's Order for Life-Sustaining Treatment (POLST) form. We wanted to know whether these patients' recorded wishes were concordant with care received at the end of life. To evaluate, we conducted an in-depth chart review of 300 patients who died in 2015 and had participated in the program. We determined that 290 patients received concordant care, whereas three patients received care discordant with their wishes before death. Seven patients did not have sufficient information in their record to determine concordance. Interestingly, we found care preferences often changed over time; ~20% of patients revised their end-of-life preferences after having the facilitated conversation, with most of those patients opting for less intensive care. Most changes to preferences were made verbally in the final setting of care. While advance care planning and the POLST form provide invaluable tools for recording patients' wishes, our study highlights a need to track patients' wishes as they evolve over time and a need for ongoing, real-time conversations about goals of care, even after a POLST is completed.
BACKGROUND: Despite the increase in the identification of patients at the end of life after the introduction of rapid response team (RRT), there is doubt as to whether there has been an improvement in the quality of care offered to these patients. Proper end-of-life care is the next expected step after identifying patients who are dying.
OBJECTIVE: To evaluate the end-of-life care after limitations of medical treatment (LOMTs) as defined by an RRT.
DESIGN: This is a single-center retrospective cohort study at a tertiary teaching hospital in Porto Alegre, Brazil, from July 2014 to July 2016.
SETTING/SUBJECTS: We included 242 patients with an LOMT as defined by the RRT.
MEASUREMENTS: Outcomes of interest included symptoms and palliative measures after RRT review.
RESULTS: During the study period, there were 5396 calls to 2937 patients, representing 126 calls per 1000 hospital discharges. Of these calls, 4.9% (n = 242) resulted in an LOMT. The primary care team agreed with the LOMT decision proposed by the RRT in 91.7% of cases. Regarding end-of-life symptoms, 7.4% and 5.8% of patients presented with intense or moderate pain, respectively, and 62.4% of patients presented dyspnea in the last 48 hours of hospitalization. Less than 15% of patients received attention for their spiritual needs and/or received psychological support.
CONCLUSIONS: Our data reinforce the important role of RRTs in the identification of end-of-life patients with clinical deterioration. Despite the increase in the identification of these patients, the quality of end-of-life care needs to be improved.
OBJECTIVE: Decisions to limit life-prolonging treatment (DLT) are often accompanied by psychological and ethical difficulties. The aim of the study is to investigate prevalence and intensity of moral distress (MD) as well as potential causes experienced by oncology physicians and nurses in DLT situations.
METHODS: This prospective study at a German university hospital included n = 100 advanced cancer inpatients with DLT. We surveyed their respective physicians and nurses to assess MD in DLT using an adapted distress thermometer and an open-ended question to specify reasons of MD. We also collected data on the decision-making process from the perspective of the clinicians.
RESULTS: Physicians report MD in 67% (n = 51) and nurses in 74% (n = 67) of the cases. The MD level in nurses (mean 2.3; SD 2.3) is significantly higher (P = .005) than in physicians (mean 1.5; SD 1.4). Uncertainties concerning ethical aspects in DLT in a patient case are associated with MD in both physicians (P = .024) and nurses (P = .004). Involvement of nurses in DLT is the strongest predictor (P = .000) for MD as indicated by physicians. Nurses experience MD especially, if the patient has a low quality of life (P = .001).
CONCLUSIONS: Moral distress is experienced by both oncologists and nurses in DLT. Nurses report higher MD intensity compared with physicians although the ultimate responsibility for DLT lies with the physicians. Support for the challenging decisions may be provided through the implementation of an ethical guideline and enhanced interprofessional communication.
On trouvera dans ce chapitre : - L'admission des enfants polyhandicapés en réanimation, une période douloureuse pour les parents ; - Quelques données épidémiologiques sur la réanimation des enfants polyhandicapés ; - Les indicateurs des admissions en réanimation des enfants polyhandicapés ; - Comment reconnaître, évaluer et accompagner la douleur chez l'enfant polyhandicapé ; - Le traitement de l'anxiété de l'enfant polyhandicapé en réanimation ; - La limitation et arrêt de soins (LAT) ; la fin de vie de l'enfant polyhandicapé en réanimation ; - Formation, soutien et encadrement de l'équipe paramédicale pour l'accueil et les soins des personnes polyhandicapées et de leurs familles ; - Participation et implication des familles et des professionnels de proximité à coté des personnels soignants de réanimation ; - Les relations du service de réanimation avec la (les) structures d'aval : IME, SSR, CAMSP, pour améliorer le parcours de santé de l'enfant polyhandicapé ; - Améliorer l'accompagnement de l'enfant polyhandicapée dans ce milieu "hostile" qu'est la réanimation nécessite la coopération de tous.
Origine : BDSP. Notice produite par MSSH-EHESP 8qqAR0xD. Diffusion soumise à autorisation
Objectifs : Evaluer les impacts de refus parentaux de limitation ou arrêt de traitement (refus) en Ile de France, leur fréquence depuis la loi française Claeys-Leonetti, les pratiques.
Matériels et méthodes : Etude régionale multicentrique rétrospective (questionnaires anonymisés) des 15 centres type 3 franciliens de 2016 à 2018.
Résultats : Quatorze centres ont répondu (26 médecins dont 18 femmes). Pour 12 pratiques analysées, les parents étaient prévenus de la réunion collégiale et leur avis connu : consultatif pour 1 centre et 8 refus, systématiquement suivi pour 3 centres et 5 refus, sinon, souvent suivi.
L’incidence était de 1 à 3 refus/an/centre avec 49 causes enregistrées : 22 volontés de vie malgré tout handicap, 20 causes religieuses, 7 manques de confiance. Un 2ème avis a été systématiquement proposé avec : soutien par l’équipe mobile de soins palliatifs, psychologue, représentant de culte, entretiens avec le chef de service, changement de médecin référent, médiateur, deux transferts ; aucune intervention judiciaire. Plusieurs des 64 évaluations du vécu révélaient une détresse morale : culpabilité (20), impuissance/inutilité (15), dépréciation personnelle (6). Dix-huit médecins avaient une capacité de résilience. Cinquante-six
explications des refus étaient données : loi dite difficile d’application (15), peu claire (3), mal expliquée (13), médiatisation de décisions judiciaires (14), évolution de la société (11). Les 51 propositions d’amélioration étaient : un soutien systématique pour les parents (25), leur implication plus grande (12), une meilleure explication de la loi (16).
Conclusion : Première à évaluer les refus de LAT depuis la loi Claeys-Léonetti, cette étude est préliminaire à un observatoire régional.
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.
BACKGROUND: Variability exists between ICUs in the limitations of therapy. Moreover practices may evolve over time. This single-center observational study aimed to compare withholding or withdrawing practices between 2012 and 2016.
METHODS: For each period and patient concerned by limitations, withholding "do-not start", withholding "do-not-increase" and withdrawal measures were recorded.
RESULTS: At a four-year interval, the rate of patients undergoing withholding or withdrawal rose from 10 to 23% and 4 to 7%, respectively. The proportion of patients dying in the ICU with previous limitations increased (53 to 89%), as did patients discharged alive despite withholding instructions (12 to 36%). The overall mortality (28%) was stable over time as the rate of failed resuscitation attempt declined (47 to 11%). In 2016 vs 2012, limitations started earlier following admission: 1 vs 7 days for withholding” do-not-start”, 4 vs 8 for withholding “do-not-increase”, 4 vs 7 for withdrawal. Notwithstanding the outcome and limitations applied, the median length of ICU stay of patients involved dropped from 13 days in 2012 to 8 days in 2016.
CONCLUSION: A timely inclination to forego hopeless treatments resulted in a lower rate of failed resuscitations before death without change in global mortality.
BACKGROUND: Limitation of life-sustaining treatment is increasingly common in critical care units, and controlled donation after circulatory death is starting to be included as an option within patient care plans. Lack of knowledge and misunderstandings can place a barrier between healthcare professionals.
OBJECTIVE: To determine the perceptions, knowledge and attitudes of physicians and nurses working in intensive care units regarding Limitation of life-sustaining treatment and controlled donation after circulatory death.
DESIGN, SETTINGS AND PARTICIPANTS: Cross-sectional study carried out in 13 Spanish hospitals by means of an ad hoc questionnaire.
METHODS: Contingency tables, Pearson's chi-squared test, Student's t-test and the Mann-Whitney u-test were used to carry out descriptive, bivariate and multivariate statistical analyses of responses.
RESULTS: Although Limitation of life-sustaining treatment is a widespread practice, the survey revealed that nurses feel excluded from the development of protocols and the decision-making process, whilst the perception of physicians is that they have greater knowledge of the topic, and decisions are reached in consensus.
CONCLUSIONS: Multi-disciplinary training programmes can help critical healthcare providers to work together with greater coordination, thus benefitting patients and their next of kin by providing excellent end-of-life care.
Purpose: To determine the frequency of limitations on life support techniques (LLSTs) on admission to intensive care units (ICU), factors associated, and 30-day survival in patients with LLST on ICU admission.
Methods: This prospective observational study included all patients admitted to 39 ICUs in a 45-day period in 2011. We recorded hospitals' characteristics (availability of intermediate care units, usual availability of ICU beds, and financial model) and patients' characteristics (demographics, reason for admission, functional status, risk of death, and LLST on ICU admission (withholding/withdrawing; specific techniques affected)). The primary outcome was 30-day survival for patients with LLST on ICU admission. Statistical analysis included multilevel logistic regression models.
Results: We recruited 3042 patients (age 62.5 ± 16.1 years). Most ICUs (94.8%) admitted patients with LLST, but only 238 (7.8% [95% CI 7.0–8.8]) patients had LLST on ICU admission; this group had higher ICU mortality (44.5 vs. 9.4% in patients without LLST; p < 0.001). Multilevel logistic regression showed a contextual effect of the hospital in LLST on ICU admission (median OR = 2.30 [95% CI 1.59–2.96]) and identified the following patient-related variables as independent factors associated with LLST on ICU admission: age, reason for admission, risk of death, and functional status. In patients with LLST on ICU admission, 30-day survival was 38% (95% CI 31.7–44.5). Factors associated with survival were age, reason for admission, risk of death, and number of reasons for LLST on ICU admission.
Conclusions: The frequency of ICU admission with LLST is low but probably increasing; nearly one third of these patients survive for = 30 days.
OBJECTIVES: To compare physicians' perceptions and practice of end-of-life care in the ICU in three East Asian countries cultures similarly rooted in Confucianism.
DESIGN: A structured and scenario-based survey of physicians who managed ICU patients from May 2012 to December 2012.
SETTING: ICUs in China, Korea, and Japan.
SUBJECTS: Specialists who are either intensivists or nonintensivist primary attending physicians in charge of patients (195 in China, 186 in Korea, 224 in Japan).
MEASUREMENTS AND MAIN RESULTS: Country was independently associated with differences in the practice of limiting multiple forms of life-sustaining treatments on multivariable generalized linear model analysis. Chinese respondents were least likely to apply do-not-resuscitate orders, even if they existed (p < 0.001). Japanese respondents were most likely to practice do not resuscitate for terminally ill patients during cardiac arrest, even when no such prior order existed (p < 0.001). Korean respondents' attitudes were in between those of Chinese and Japanese respondents as far as withdrawing total parenteral nutrition, antibiotics, dialysis, and suctioning was concerned. Chinese respondents were most uncomfortable discussing end-of-life care issues with patients, while Japanese respondents were least uncomfortable (p < 0.001). Chinese respondents were more likely to consider financial burden when deciding on limiting life-sustaining treatment (p < 0.001). Japanese respondents felt least exposed to personal legal risks when limiting life-sustaining treatment (p < 0.001), and the Korean respondents most wanted legislation to guide this issue (p < 0.001). The respondents' gender, religion, clinical experience, and primary specialty were also independently associated with the different perceptions of end-of-life care.
CONCLUSIONS: Despite similarities in cultures and a common emphasis on the role of family, differences exist in physician perceptions and practices of end-of-life ICU care in China, Korea, and Japan. These findings may be due to differences in the degree of Westernization, national healthcare systems, economic status, and legal climate.
Les infirmières occupent une place stratégique au plus près du patient et de ses proches dans le processus qui conduit à envisager la limitation des traitements oncologiques en phase avancée. Cette étape de la prise en charge nécessite un accompagnement, dans le cadre de la démarche palliative, qui, outre le patient et son entourage, concerne également l’oncologue.
IMPORTANCE: Critically ill patients often receive high-intensity life sustaining treatments (LST) in the intensive care unit (ICU), although they can be ineffective and eventually undesired. Determining the risk factors associated with reversals in LST goals can improve patient and provider appreciation for the natural history and epidemiology of critical care and inform decision making around the (continued) use of LSTs.
METHODS: This is a single institution retrospective cohort study of patients receiving life sustaining treatment in an academic tertiary hospital from 2009 to 2013. Deidentified patient electronic medical record data was collected via the clinical data warehouse to study the outcomes of treatment limiting Comfort Care and do-not-resuscitate (DNR) orders. Extended multivariable Cox regression models were used to estimate the association of patient and clinical factors with subsequent treatment limiting orders.
RESULTS: 10,157 patients received life-sustaining treatment while initially Full Code (allowing all resuscitative measures). Of these, 770 (8.0%) transitioned to Comfort Care (with discontinuation of any life-sustaining treatments) while 1,669 (16%) patients received new DNR orders that reflect preferences to limit further life-sustaining treatment options. Patients who were older (Hazard Ratio(HR) 1.37 [95% CI 1.28-1.47] per decade), with cerebrovascular disease (HR 2.18 [95% CI 1.69-2.81]), treated by the Medical ICU (HR 1.92 [95% CI 1.49-2.49]) and Hematology-Oncology (HR 1.87 [95% CI 1.27-2.74]) services, receiving vasoactive infusions (HR 1.76 [95% CI 1.28, 2.43]) or continuous renal replacement (HR 1.83 [95% CI 1.34, 2.48]) were more likely to transition to Comfort Care. Any new DNR orders were more likely for patients who were older (HR 1.43 [95% CI 1.38-1.48] per decade), female (HR 1.30 [95% CI 1.17-1.44]), with cerebrovascular disease (HR 1.45 [95% CI 1.25-1.67]) or metastatic solid cancers (HR 1.92 [95% CI 1.48-2.49]), or treated by Medical ICU (HR 1.63 [95% CI 1.42-1.86]), Hematology-Oncology (HR 1.63 [95% CI 1.33-1.98]) and Cardiac Care Unit-Heart Failure (HR 1.41 [95% CI 1.15-1.72]).
CONCLUSION: Decisions to reverse or limit treatment goals occurs after more than 1 in 13 trials of LST, and is associated with older female patients, receiving non-ventilator forms of LST, cerebrovascular disease, and treatment by certain medical specialty services.