Few data are available regarding treatment outcomes in lung cancer patients with metastasis who initiated mechanical ventilation in the emergency department (ED). We aimed to evaluate 28-day mortality in lung cancer patients with metastasis who initiated mechanical ventilation in the ED. Patients with solid malignancy who initiated mechanical ventilation in the ED of a tertiary hospital were retrospectively identified and stratified into four groups according to the presence of lung cancer and metastasis. Among 212 included patients, the mortality rates by the 28th hospital day were as follows: 44.2% (19/43) in non-lung cancer patients without metastasis, 63.2% (43/68) in non-lung cancer patients with metastasis, 52.4% (11/21) in lung cancer patients without metastasis, and 66.2% (53/80) in lung cancer patients with metastasis. In multivariable analysis, lung cancer patients with metastasis had significantly higher odds ratio for 28-day mortality than non-lung cancer patients without metastasis (adjusted odds ratio [OR] = 7.17, 95% confidence interval [CI] = 2.14–24.01). Sepsis-related respiratory failure (adjusted OR = 2.60, 95% CI = 1.16–5.84) and cardiopulmonary resuscitation (adjusted OR = 13.34, 95% CI = 4.45–39.95) over respiratory failure without sepsis and acute organ dysfunction process measured by sequential organ failure assessment (SOFA) score (adjusted OR = 1.15, 95% CI = 1.05–12.6) were independently associated with an increase in mortality rate. In conclusion, the treatment outcomes in lung cancer patients with metastasis who initiated mechanical ventilation in the ED were poor. Aggressive resuscitation versus end-of-life care in advance of an unexpected medical crisis should be considered in lung cancer patients with metastasis via a multidisciplinary approach with a consideration of underlying comorbid illnesses in the acute organ dysfunction processes.
Questions related to end-of-life decision making are common in clinical ethics and may be exceedingly difficult. Chief among these are the provision of cardiopulmonary resuscitation (CPR) and do-not-resuscitate orders (DNRs). To better address such questions, clarity is needed on the values of medical ethics that underlie CPR and the relevant moral framework for making treatment decisions. An informed consent model is insufficient to provide justification for CPR. Instead, ethical justification for CPR rests on the rule of rescue and on substituted interest judgments. Patients' known wishes and values are relevant, particularly in protecting them from unwanted CPR. Clinicians should rescue patients with the means at their disposal, as a prima facie moral imperative, unless there are compelling reasons to refrain. We present a moral framework for making decisions regarding CPR and DNR.
En évoluant depuis les années 1980, la réanimation néonatale moderne a réduit de façon importante la morbi-mortalité des nouveau-nés prématurés. Cela a fait naître un ensemble de situations questionnantes en sauvant des vies au prix de séquelles parfois lourdes. Les pratiques des néonatologistes ont évolué allant de "l’arrêt de vie" à l’accompagnement du patient et de sa famille dans le cadre des soins palliatifs. Cette évolution a été ponctuée de plusieurs avis du Comité consultatif national d’éthique pour les sciences de la vie et de la santé (CCNE ; avis nos 63, 65 et 121) parlant d’abord "d’exception d’euthanasie" puis de grave transgression. Les études Épipage 1 et 2 ont influencé le CCNE en montrant par un suivi longitudinal une nette amélioration de la morbi-mortalité tous termes confondus sur les dernières décennies. Dans le même temps, les lois de 2002 et de 2005 relatives aux droits des malades et à la fin de vie étaient votées. Il persiste des situations difficiles, surtout dans les cas d’arrêt de nutrition et d’hydratation artificielles, le corps de l’enfant mourant de dénutrition semblant une vision insoutenable. Certains auteurs légitiment une "sédation terminale" systématique, concomitante de l’arrêt de la nutrition et de l’hydratation pour « limiter les souffrances ». D’autres parlent de "réparer une erreur de réanimation" pour les enfants vivants grâce à la réanimation. Ils pensent pouvoir "défaire" les choses et différencient ainsi une vie "naturelle" d’une vie "artificielle". Cela légitime la conduite d’une étude pour comprendre sur quels arguments sont prises les décisions de fin de vie en réanimation néonatale.
AIM: "Early" withdrawal of life support therapies (eWLST) within the first 3 calendar days after resuscitation from cardiac arrest (CA) is discouraged. We evaluated a prospective multicenter registry of patients admitted to hospitals after resuscitation from CA to determine predictors of eWLST and estimate its impact on outcomes.
METHODS: CA survivors enrolled from 2012-2017 in the International Cardiac Arrest Registry (INTCAR) were included. We developed a propensity score for eWLST and matched a cohort with similar probabilities of eWLST who received ongoing care. The incidence of good outcome (Cerebral Performance Category of 1 or 2) was measured across deciles of eWLST in the matched cohort.
RESULTS: 2688 patients from 24 hospitals were included. Median ischemic time was 20 (IQR 11, 30) minutes, and 1148 (43%) had an initial shockable rhythm. Withdrawal of life support occurred in 1162 (43%) cases, with 459 (17%) classified as eWLST. Older age, initial non-shockable rhythm, increased ischemic time, shock on admission, out-of-hospital arrest, and admission in the United States were each independently associated with eWLST. All patients with eWLST died, while the matched cohort, good outcome occurred in 21% of patients. 19% of patients within the eWLST group were predicted to have a good outcome, had eWLST not occurred.
CONCLUSIONS: Early withdrawal of life support occurs frequently after cardiac arrest. Although the mortality of patients matched to those with eWLST was high, these data showed excess mortality with eWLST.
BACKGROUND: We attempted to identify factors associated with physicians' decisions to terminate CPR and to explore the role of family in the decision-making process.
METHODS: We conducted a retrospective observational study in a single center in Taiwan. Patients who experienced in-hospital cardiac arrest (IHCA) between 2006 and 2014 were screened for study inclusion. Multivariate survival analysis was conducted to identify independent variables associated with IHCA outcomes using the Cox proportional hazards model.
RESULTS: A total of 1525 patients were included in the study. Family was present at the beginning of CPR during 722 (47.3%) resuscitation events. The median CPR duration was significantly shorter for patients with family present at the beginning of CPR than for those without family present (23.5 mins vs 30 min, p = 0.01). Some factors were associated with shorter time to termination of CPR, including arrest in an intensive care unit, Charlson comorbidity index score greater than 2, age older than 79 years, baseline evidence of motor, cognitive, or functional deficits, and vasopressors in place at time of arrest. After adjusting for confounding effects, family presence was associated with shorter time to termination of CPR (hazard ratio, 1.25; 95% confidence interval, 1.06-1.46; p = 0.008).
CONCLUSION: Clinicians' decisions concerning when to terminate CPR seemed to be based on outcome prognosticators. Family presence at the beginning of CPR was associated with shorter duration of CPR. Effective communication, along with outcome prediction tools, may avoid prolonged CPR efforts in an East Asian society.
OBJECTIVES: To describe the use of acute resuscitation plans (ARPs) among patients on a subacute geriatric ward and to identify factors associated with use of ARPs in these patients.
METHODS: The hospital records of all patients admitted to the geriatric medicine ward in 2016 were retrospectively audited.
RESULTS: An ARP was completed before separation for 333/442 (75.3%) admissions. In the event of arrest, 240 (54.3%) patients had an ARP specifying “care of the dying”, 93 (21.0%) had an ARP specifying “cardiopulmonary resuscitation” and 109 (24.7%) had no resuscitation plan. Age 85-94 years (OR 1.65, P = 0.04) and =95 years (OR 9.59, P = 0.003), as well as Charlson index of comorbidity =2 (OR 3.4, P < 0.001), Australian-born (OR 2.09, P = 0.002) and admission during October-December (OR 3.81, P < 0.001) were independently associated with increased use of ARPs.
CONCLUSIONS: Acute resuscitation plan use was associated with older age, higher comorbidity, birth in Australia and admission later in the year.
INTRODUCTION: There is no standard for categorizing reasons for death in those who achieve return of spontaneous circulation (ROSC) after cardiac arrest but die before hospital discharge. Categorization is important for comparing outcomes across studies, assessing benefits of interventions, and developing quality-improvement initiatives. We developed and tested a method for categorizing reasons for death after cardiac arrest in both in-hospital (IHCA) and out-of-hospital (OHCA) arrests.
METHODS: Single-center, retrospective, cohort study of patients with ROSC after IHCA or OHCA between 2008 and 2017 who died before hospital discharge. Traumatic arrests and patients with "do-not-resuscitate" orders prior to their arrest were excluded. Two investigators assigned each patient to one of five predefined reasons for death. Interrater reliability was assessed using Fleiss' kappa. For final categorization, discrepancies were resolved by a third investigator.
RESULTS: There were 182 IHCA and 226 OHCA included. There was substantial agreement between raters (kappa of 0.62 and 0.61 for IHCA and OHCA, respectively). Reasons for death for IHCA and OHCA were: neurological withdrawal of care (27% vs 73%), comorbid withdrawal of care (36% vs 4%), refractory hemodynamic shock (25% vs 17%), respiratory failure (1% vs 3%), and sudden cardiac death (11% vs 4%). The differences in reasons for death among the two groups were significant (p-value < 0.001).
CONCLUSIONS: Categorizing reasons for death after cardiac arrest with ROSC is feasible using our proposed categories, with substantial inter-rater agreement. Neurologic withdrawal of care is much less common in IHCA than OHCA, which may have implications for further research.
BACKGROUND: Women who suffer an out-of-hospital cardiac arrest receive bystander cardiopulmonary resuscitation (CPR) less often than men. Understanding public perceptions of why this occurs is a necessary first step toward equitable application of this potentially life-saving intervention.
METHODS: We conducted a national survey of members of the public using Mechanical Turk, Amazon’s crowdsourcing platform, to determine reasons why women might receive bystander CPR less often than men. Eligible participants were adults (=18 years) located in the United States. Responses were excluded if the participant was not able to define CPR correctly. Participants were asked to answer the following free-text question: “Do you have any ideas on why women may be less likely to receive CPR than men when they collapse in public?” Descriptive statistics were used to define the cohort. The free-text response was coded using open coding, and major themes were identified via classical content analysis.
RESULTS: In total, 548 subjects were surveyed. Mean age was 38.8 years, and 49.8% were female. Participants were geographically distributed as follows: 18.5% West, 9.2% Southwest, 22.0% Midwest, 27.5% Southeast, and 22.9% Northeast. After analysis, 3 major themes were detected for why the public perceives that women receive less bystander CPR. They include the following: (1) sexualization of women's bodies; (2) women are weak and frail and therefore prone to injury; and (3) misperceptions about women in acute medical distress. Overall, 41.9% (227) were trained in CPR while 4.4% reported having provided CPR in a medical emergency.
CONCLUSIONS: Members of the general public perceive fears about inappropriate touching, accusations of sexual assault, and fear of causing injury as inhibiting bystander CPR for women. Educational and policy efforts to address these perceptions may reduce the sex differences in the application of bystander CPR.
Do not attempt cardiopulmonary resuscitation decisions (DNACPR) are considered good medical practice for those dying at the end of natural life. They avoid intrusive and inappropriate intervention. Historically, informing patients of these decisions was discretionary to avoid undue distress. Recent legal rulings have altered clinical guidance: disclosure is now all but obligatory. The basis for these legal judgments was respect for the patient's autonomy as an expression of their human rights. Through critical analysis, this paper explores other bioethical considerations and the potential harms if they are ignored. Arguably, disclosure of DNACPR status on its own will do little to improve patient experience. A focus on good communication with those identified as approaching end-of-life will facilitate personalized care. Discussions around DNACPR may still occur, but only if likely to be beneficial and at a patient-appropriate pace (not dictated by the need to activate the decision).
BACKGROUND: Physician Orders for Life-Sustaining Treatment (POLST) can help ensure continuity of do-not-resuscitate (DNR) decisions and other care preferences after discharge from the hospital.
OBJECTIVE: We aimed to improve POLST completion rates for patients with DNR orders who were being discharged to a nursing home (NH) after an acute hospitalization at our institution.
DESIGN: We implemented an interprofessional quality improvement intervention involving education, communication skills, and nursing and case manager cues regarding POLST use. The intervention was later augmented with performance feedback and financial incentives for resident physicians who completed a POLST at NH transfer.
MEASURE: Whether patients with DNR orders at hospital discharge have a POLST at NH transfer.
RESULTS: The intervention resulted in increased POLST use for patients with DNR orders discharged to NH: baseline 25/65 (38%), intervention 36/71 (51%), and augmented intervention 44/63 (70%) (p < 0.01).
CONCLUSIONS: An interdisciplinary intervention can increase POLST use for patients with DNR orders transitioning to NH. Multiple components, including financial incentives and performance feedback, may be needed to effect statistically significant change.
Out-of-hospital cardiac arrest (OHCA) continues to be a leading cause of mortality worldwide. In Canada over 40,000 cardiac arrests that occur each year, a majority occur unexpectedly outside of the hospital setting. However, the reality is that without rapid and appropriate treatment within minutes, most victims will die before reaching the hospital. In the late 1980s case reports identifying favorable outcomes with the use of extracorporeal cardiopulmonary resuscitation (eCPR) in out-of-hospital cardiac arrest (OHCA) began to be reported. Since then case reports, observational studies, propensity analysis, and a systematic review of international practices continues to suggest eCPR as a feasible intervention for refractory ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT) in select adult patients. However, in spite of this mounting base of evidence, clinicians continue to report concerns over a paucity of robust data showing definitive eCPR effectiveness compared with conventional resuscitation. This review will explore the ethical issues related to the impact eCPR might have on the orthodoxy pertaining to current resuscitation strategies, the impact of shifting decision-making on families particularly in dealing with a "bridge to nowhere" scenario, a call to accounting for greater data integrity and improved outcome reporting to assess eCPR effectiveness, and addressing the "Should we just do it" question. A recommendation is proposed for the creation of an ethics consultation service to assist families and staff in dealing with the invariable value conflicts and stresses likely to arise.
Dans le cadre de la fin de vie d'une maladie neurodégénérative, les praticiens n'ont pas engagé leur responsabilité en refusant de mettre en oeuvre une réanimation active, qui aurait été scientifiquement inadaptée. La règle du consentement aux soins ne dérive pas vers un libre choix du traitement (CAA de Lyon, 14 mai 2018, n° 16LY02121).
Origine : BDSP. Notice produite par APHPDOC R0xFIH77. Diffusion soumise à autorisation
Cet article est une mise au point sur la mort inattendue du nourrisson, qui malgré une forte baisse, reste la 1ère cause de décès au-delà de la période néonatale, justifiant de renforcer les mesures de prévention et d'en comprendre la cause. (Adapté du R.A.).
Origine : BDSP. Notice produite par APHPDOC ltR0xAqF. Diffusion soumise à autorisation
CONTEXT/OBJECTIVE: Half of advanced cancer patients do not have accurate prognostic awareness (PA). However, few randomized clinical trials (RCTs) have focused on facilitating patients' PA to reduce their life-sustaining treatments (LSTs) at end of life (EOL). To address these issues, we conducted a double-blinded RCT on terminally ill cancer patients.
METHODS: Experimental-arm participants received an individualized, interactive intervention tailored to their readiness for advanced care-planning and prognostic information. Control-arm participants received a symptom-management educational treatment. Intervention effectiveness in facilitating accurate PA and reducing LSTs received, two secondary RCT outcomes, was evaluated by intention-to-treat analysis using multivariate logistic regression.
RESULTS: Participants (N=460) were randomly assigned 1:1 to experimental and control arms, each with 215 participants in the final sample. Referring to 151-180 days before death, experimental-arm participants had significantly higher odds of accurate PA than control-arm participants 61-90, 91-120, and 121-150 days before death (AOR [95% CI]: 2.04 [1.16-3.61], 1.94 [1.09-3.45], and 1.93 [1.16-3.21], respectively), but not 1-60 days before death. Experimental-arm participants with accurate PA were significantly less likely than control-arm participants without accurate PA to receive cardiopulmonary resuscitation (CPR) (0.16 [0.03-0.73]), but not less likely to receive intensive care unit care and mechanical ventilation in their last month.
CONCLUSIONS: Our intervention facilitated cancer patients' accurate PA early in their dying trajectory, reducing the risk of receiving CPR in the last month. Healthcare professionals should cultivate cancer patients' accurate PA early in the terminal-illness trajectory to allow them sufficient time to make informed EOL-care decisions to reduce CPR at EOL.
Introduction: Many cardiopulmonary resuscitation (CPR) attempts are unsuccessful and must be terminated. On the contrary, premature termination results in a self-fulfilling prophecy. This study aimed to investigate 1) physicians' self-assessed competence in terminating CPR, 2) physicians' and nurses' knowledge of the European Resuscitation Council guidelines on termination, and 3) single factors leading to termination.
Methods: Questionnaires were distributed at advanced cardiac life support (ACLS) courses at a university hospital in Denmark. Participants included ACLS health care providers, ie, physicians and nurses from cardiac arrest teams, intensive care and anesthetic units or medical wards with a duty to provide ACLS. Physicians were divided into junior physicians (house officers) and experienced physicians (specialist registrars and consultants).
Results: Overall, 308 participants responded (104 physicians and 204 nurses, response rate: 98%). Among physicians, 37 (36%) did not feel competent to decide when to terminate CPR (junior physicians: n=16, 64%, compared with experienced physicians: n=21, 28%, P=0.002). Two (2%) physicians and one (0.5%) nurse were able to state the contents of termination guidelines. Several factors were reported to impact termination, including absence of a pupillary light reflex (physicians: 17%, nurses: 22%) and cardiac standstill on echocardiography (physicians: 18%, nurses: 20%). Moreover, nine (9%) physicians and 35 (17%) nurses would terminate prolonged CPR despite a shockable rhythm present.
Conclusion: One-third of all physicians did not feel competent to decide when to terminate CPR. Physicians' and nurses' knowledge of termination guidelines was poor, and both professions reported unvalidated or controversial factors as a single reason for terminating CPR.
BACKGROUND: The Physician Orders for Life-Sustaining Treatment (POLST) began in Oregon in 1993 and has since spread nationally and internationally.
OBJECTIVES: Describe and compare demographics and POLST orders in two decedent cohorts: deaths in 2010-2011 (Cohort 1) and in 2015-2016 (Cohort 2).
DESIGN: Descriptive retrospective study.
SETTING/SUBJECTS: Oregon decedents with an active form in the Oregon POLST Registry.
MEASUREMENTS: Oregon death records were matched with POLST orders. Descriptive analysis and logistic regression models assess differences between the cohorts.
RESULTS: The proportion of Oregon decedents with a registered POLST increased by 46.6% from 30.9% (17,902/58,000) in Cohort 1 to 45.3% (29,694/65,458) in Cohort 2. The largest increase (83.3%) was seen in decedents 95 years or older with a corresponding 78.7% increase in those with Alzheimer's disease and dementia, while the interval between POLST form completion and death in these decedents increased from a median of 9-52 weeks. Although orders for do not resuscitate and other orders to limit treatment remained the most prevalent in both cohorts, logistic regression models confirm a nearly twofold increase in odds for cardiopulmonary resuscitation and full treatment orders in Cohort 2 when controlling for age, sex, race, education, and cause of death.
CONCLUSION: Compared with Cohort 1, Cohort 2 reflected several trends: a 46.6% increase in POLST Registry utilization most marked in the oldest old, substantial increases in time from POLST completion to death, and disproportionate increases in orders for more aggressive life-sustaining treatment. Based on these findings, we recommend testing new criteria for POLST completion in frail elders.
Newborn infants are among those most severely affected by humanitarian crises. Aid organisations increasingly recognise the necessity to provide for the medical needs of newborns, however, this may generate distinctive ethical questions for those providing humanitarian medical care. Medical ethical approaches to neonatal care familiar in other settings may not be appropriate given the diversity and volatility of humanitarian disasters, and the extreme resource limitations commonly faced by humanitarian aid missions. In this paper, we first systematically review existing guidelines relating to the treatment and resuscitation of newborns in humanitarian crises, finding little substantive ethical guidance for those providing humanitarian healthcare. We next draw on paradigm cases and published literature to identify and describe some of the major ethical questions common to these settings. We divide these questions into quality of life considerations, allocation of limited resources, and conflicting cultural norms and values. We finally suggest some preliminary recommendations to guide ethical decision-making around resuscitation of newborns and withdrawal of treatment in humanitarian settings.
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: A national Do Not Attempt Cardiopulmonary Resuscitation policy was rolled out for the National Health Service in Wales in 2015. A national steering group led on producing information videos and a website for patients, carers and healthcare professionals, forming part of a quality improvement program. Videos were planned, scripted and produced with healthcare professionals and patient/carer representatives, and were completed with both English and Welsh language versions. The TalkCPR videos encourage and promote open discussion about Cardiopulmonary Resuscitation (CPR) and DNACPR in palliative care situations.
METHODS: We worked with patient/carer groups to evaluate whether video resources to convey the salient facts involved in CPR and DNACPR decisions for people with palliative and life-limiting illness were acceptable or not. We conducted a mixed-method design service review in five phases to evaluate whether this technological resource could help. After creating video and website materials, they were evaluated by doctors, nurses and a patient/carer group. We also sent out one lightweight TalkCPR video media pad to each practice in Wales. These rechargeable electronic video media pads had communication videos pre-loaded for easy viewing, especially in areas with poor roaming data coverage.
RESULTS: Videos were demonstrably acceptable to both patient and carer groups, and improved healthcare professional confidence and understanding. Videos went live on the TalkCPR website, in all Welsh Health Boards and on Youtube, and are now used in routine practice throughout Wales.
CONCLUSION: This is the first time that DNACPR information videos are aimed directly at palliative care patients and carers, to explore this sensitive subject with them, and to encourage them to approach their doctor or nurse about it. The website, app and video media pads were developed by patients, the Digital Legacy Association, Welsh NHS IT services, Welsh Government, the Bevan Commission and the Dying Matters Charity in Wales 'Byw Nawr'. The GMC, the Royal College of General Practitioners and NICE have listed TalkCPR as a learning resource. There has also been a collaboration with Falmouth University Art College, who helped produce graphic designs to facilitate and encourage discussions about CPR and end of life care.
En Suisse, 45 % des décès ont lieu à l’hôpital. Les discussions à propos de la réanimation cardiopulmonaire (RCP) font donc partie des tâches du médecin hospitalier et ce, dès l’admission. Il existe des obstacles à ces discussions provenant tant des patients que des médecins. Or, une communication inadéquate ou insuffisante peut mener à une prise en charge inappropriée. Les moyens d’améliorer ces discussions comprennent la formation des médecins et l’insertion de la question de la réanimation cardiopulmonaire dans un entretien plus large visant à déterminer les objectifs thérapeutiques. Ces mesures pourraient permettre une meilleure compréhension et intégration des valeurs et préférences du patient et aboutir à une véritable décision partagée concernant la réanimation.