When Intensive Care Becomes Good End-of-Life Care.
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ABSTRACT:
SUBMITTER: Wunsch H
PROVIDER: S-EPMC7124727 | biostudies-literature | 2020 Apr
REPOSITORIES: biostudies-literature
Publications
When Intensive Care Becomes Good End-of-Life Care.
American journal of respiratory and critical care medicine 20200401 7
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Project description:ObjectiveMost deaths in Pediatric Intensive Care Units involve forgoing life-sustaining treatment. Such deaths required carefully planned end-of-life care built on compassion and focused on palliative care measures. This study aims to assess topics related to the end of life care in Brazilian pediatric intensive care units from the perspective of a multidisciplinary team.MethodThe authors used a tested questionnaire, utilizing Likert-style and open-ended questions. After ethics committee approval, it was sent by email from September to November/2019 to three Pediatric Intensive Care Units in the South and Southeast of Brazil. One unit was exclusively dedicated to oncology patients; the others were mixed units.ResultsFrom 144 surveys collected (23% response rate) 136 were analyzed, with 35% physicians, 30% nurses, 21% nurse technicians, and 14% physiotherapists responding. Overall, only 12% reported enough end-of-life care training and 40% reported never having had any, albeit this was not associated with the physician's confidence in forgoing life-sustaining treatment. Furthermore, 60% of physicians and 46% of other professionals were more comfortable with non-escalation than withdrawing therapies, even if this could prolong suffering. All physicians were uncomfortable with palliative extubation; 15% of all professionals have witnessed it. The oncologic team uniquely felt that "resistance from the teams of specialists" was the main barrier to end-of-life care implementation.ConclusionMost professionals felt unprepared to forego life-sustaining treatment. Even for terminally ill patients, withholding is preferred over the withdrawal of treatment. Socio-cultural barriers and the lack of adequate training may be contributing to insecurity in the care of terminally ill patients, diverging from practices in other countries.
| S-EPMC10373144 | biostudies-literature
Project description:Purpose The purpose of this study was to determine the effects of awareness of good death and end-of-life care attitudes on end-of-life care performance in long-term care hospital nurses. Methods This study used a cross-sectional study design. The participants were 147 nurses working at six long-term care hospitals with more than 200 beds in B city, South Korea. Data were collected using self-reported questionnaires, and analyzed with descriptive statistics, the t-test, analysis of variance, Pearson correlation coefficients, and multiple stepwise regression analysis using IBM/SPSS 26.0 for Windows. Results The participants’ awareness of good death, end-of-life care attitudes, and end-of-life care performance were positively correlated. The factors affecting end-of-life care performance were age, education level, awareness of good death, and end-of-life care attitudes; these variables explained 19.0% of end-of-life care performance. Conclusion In order to improve long term care hospital nurses’ end-of-life care performance, continuing education and training should be provided regarding awareness of good death and end-of-life care attitudes.
| S-EPMC10180001 | biostudies-literature
Project description:BackgroundLittle is known about importance and implementation of end-of-life care (EOLC) in German intensive care units (ICU). This survey analyses preferences and differences in training between "medical" (internal medicine, neurology) and "surgical" (surgery, anaesthesiology) residents during intensive care rotation.MethodsThis is a point-prevalence study, in which intensive care medicine course participants of one educational course were surveyed. Physicians from multiple ICU and university as well as non-university hospitals and all care levels were asked to participate. The questionnaire was composed of a paper and an electronic part. Demographic and structural data were prompted and EOLC data (48 questions) were grouped into six categories considering importance and implementation: category 1 (important, always implemented), 2 (important, sometimes implemented), 3 (important, never implemented) and 4-6 (unimportant, implementation always, sometimes, never). The trial is registered at the "Deutsches Register für klinische Studien (DRKS)", Study number DRKS00026619, registered on September 10th 2021, www.drks.de .ResultsOverall, 194/ 220 (88%) participants responded. Mean age was 29.7 years, 55% were female and 60% had scant ICU working experience. There were 64% medical and 35% surgical residents. Level of care and size of ICU differed significantly between medical and surgical (both p < 0.001). Sufficient implementation was stated for 66% of EOLC questions, room for improvement (category 2 and 3) was seen in 25, and 8% were classified as irrelevant (category 6). Areas with the most potential for improvement included prognosis and outcome and patient autonomy. There were no significant differences between medical and surgical residents.ConclusionsEven though EOLC is predominantly regarded as sufficiently implemented in German ICU of all specialties, our survey unveiled still 25% room for improvement for medical as well as surgical ICU residents. This is important, as areas of improvement potential may be addressed with reasonable effort, like individualizing EOLC procedures or setting up EOLC teams. Health care providers as well as medical societies should emphasize EOLC training in their curricula.
| S-EPMC9115951 | biostudies-literature
Project description:ObjectiveIntensive care unit (ICU) admissions near the end of life have been associated with worse quality of life and burdensome costs. Patients may not benefit from ICU admission if appropriate end-of-life care can be delivered elsewhere. The objective of this study was to descriptively analyze patients receiving end-of-life care in an emergency department (ED)-based ICU (ED-ICU).MethodsThis is a retrospective analysis of patient outcomes and resource use in adult patients receiving end-of-life care in an ED-ICU. In 2015, an "End of Life" order set was created to standardize delivery of palliative therapies and comfort measures. We identified adult patients (>18 years) receiving end-of-life care in the ED-ICU from December 2015 to March 2020 whose clinicians used the end-of-life order set.ResultsA total of 218 patients were included for analysis; 50.5% were female, and the median age was 73.6 years. The median ED-ICU length of stay was 13.3 hours (interquartile range, 7.4-20.6). Two patients (0.9%) were admitted to an inpatient ICU, 117 (53.7%) died in the ED-ICU, 77 (35.3%) were admitted to a non-intensive care inpatient service, and 22 (10.1%) were discharged from the ED-ICU.ConclusionsAn ED-ICU can be used for ED patients near the end of life. Only 0.9% were subsequently admitted to an ICU, and 10.1% were discharged from the ED-ICU. This practice may benefit patients and families by avoiding costly ICU admissions and benefit health systems by reducing ICU capacity strain.
| S-EPMC7771771 | biostudies-literature
Project description:BackgroundEnd-of-life (EOL) care is associated with high resource utilization. Recognizing and effectively communicating that EOL is near promotes more patient-centered care, while decreasing futile interventions. We hypothesize that provider assessment of futility during the surgical intensive care unit (SICU) admission would result in higher rates of Do Not Resuscitate (DNR).MethodsWe performed a retrospective review of a prospective SICU registry of all deceased patients across a health system, 2018-2022. The registry included a subjective provider assessment of patient's expected survival. We employed multivariable logistic regression to adjust for clinical factors while assessing for association between code status at death and provider's survival assessment with attention to race-based differences.Results746 patients-105 (14.1%) traumatically injured and 641 (85.9%) non-traumatically injured-died over 4.5 years in the SICU (mortality rate 5.9%). 26.3% of these deaths were expected by the ICU provider. 40.9% of trauma patients were full code at the time of death, compared with 15.6% of non-traumatically injured patients. Expected death was associated with increased odds of DNR code status for non-traumatically injured patients (OR 1.8, 95% CI 1.03 to 3.18), but not for traumatically injured patients (OR 0.82, 95% CI 0.22 to 3.08). After adjusting for demographic and clinical characteristics, black patients were less likely to be DNR at the time of death (OR 0.49, 95% CI 0.32 to 0.75).Conclusion20% of patients who died in our SICU had not declared a DNR status, with injured black patients more likely to remain full code at the time of death. Further evaluation of this cohort to optimize recognition and communication of EOL is needed to avoid unnecessary suffering.Level of evidenceLevel III/prognostic and epidemiological.
| S-EPMC11409343 | biostudies-literature
Project description:ContextAlthough patient and physician characteristics are thought to be predictive of discretionary interventions at the end of life (EoL), few studies have data on both parties.ObjectiveTo test the hypothesis that patient preferences and physician attitudes are both independently associated with discretionary interventions at the EoL.MethodsWe report secondary analyses of data collected prospectively from physicians (n = 38) and patients with advanced cancer (n = 265) in the Values and Options in Cancer Care study. Predictor variables were patient attitudes toward EoL care and physician-reported comfort with medical paternalism, assessed indirectly using a modified version of the Control Preference Scale. We explored whether the magnitude of the physician variable was influenced by the inclusion of particular patient treatment-preference variables (i.e., effect modification). Outcomes were a chemotherapy use score (≤14 days before death [scored 2], 15-31 days before death [scored 1], and >31 days [scored 0]) and an emergency department visit/inpatient admission score (two or more admissions in the last 31 days [scored 2], one admission [1], and 0 admissions [0]) in the last month of life.ResultsChemotherapy scores were nearly 0.25 points higher if patients expressed a preference for experimental treatments with unknown benefit at study entry (0.238 points, 95% CI = 0.047-0.429) or reported an unfavorable attitude toward palliative care (0.247 points, 95% CI = 0.047-0.450). A two-standard deviation difference in physician comfort with medical paternalism corresponded to standardized effects of 0.35 (95% CI = 0.03-0.66) for chemotherapy and 0.33 (95% CI = 0.04-0.61) for emergency department visits/inpatient admissions. There was no evidence of effect modification.ConclusionPatient treatment preferences and physician attitudes are independently associated with higher levels of treatment intensity before death. Greater research, clinical, and policy attention to patient treatment preferences and physician comfort with medical paternalism might lead to improvements in care of patients with advanced disease.
| S-EPMC6679778 | biostudies-literature
Project description:To explore nurses' perceptions of obstacles to the provision of end of life care (EoLC) in the intensive care unit (ICU) in Saudi Arabia.A modified version of a questionnaire developed by Beckstrand and Kirchhoff was administered in one setting at Riyadh, Saudi Arabia between March and April 2015.A total of 87 questionnaires were returned from 140 potential respondents, representing a 62% response rate. Findings highlighted concerns associated with patient's family, physicians who differed in opinions, cultural differences and language barriers. The nurses also noted issues in awareness and involvement in education about EoLC and futile care.Findings highlight a number of key obstacles to the provision of quality EoLC in ICUs for nurses. Further development of both EoLC guidelines and education about EoLC in ICUs is recommended.
| S-EPMC5556278 | biostudies-other
Project description:BackgroundLongstanding concerns regarding end of life in the ICU led in France to the publication of guidelines, updated in 2009, that take into account the insights provided by a recent law (Leonetti's law) regarding patients' rights. After the French President asked a specific expert to review end of life issues, the French Intensive Care Society (SRLF) surveyed their members (doctors and paramedics) about various aspects of end of life in the ICU.MethodsSRLF members were invited to respond to a questionnaire, sent by Email, designed to assess their knowledge of Leonetti's law and to determine how many caregivers would agree with the authorization of lethal drug administration in selected end of life situations.ResultsQuestionnaires returned by 616 (23%) of 2,700 members were analyzed. Most members (82.5%) reported that they had a good knowledge of Leonetti's law, which most (88%) said they have often applied. One third of respondents had received 'assisted death' requests from patients and more than 50% from patients' relatives. One quarter of respondents had experienced the wish to give lethal drugs to end of life patients. Assuming that palliative care in the ICU is well-managed, 25.7% of the respondents would approve a law authorizing euthanasia, while 26.5% would not. Answers were influenced by the fear of a possible risk of abuse. Doctors and nurses answered differently.ConclusionICU caregivers appear to be well acquainted with Leonetti's law. Nevertheless, in selected clinical situations with suitable palliative care, one quarter of respondents were in favor of a law authorizing administration of lethal drugs to patients.
| S-EPMC4015966 | biostudies-literature
Project description:ContextFamily surveys are an important source of information about quality of end-of-life care in the intensive care unit (ICU). The burden associated with completing such surveys is not well studied.Objectives1) To assess the predictors of burden that families report with completing surveys for patients who died in the ICU and 2) to examine associations between quality-of-care ratings and survey burden.MethodsData were collected from 14 hospitals as part of a cluster randomized trial to integrate palliative care into the ICU. Survey questions included demographics, quality of dying, satisfaction with care, and overall level of burden associated with survey completion. Patient characteristics were identified from chart abstraction and death certificates. Multivariable linear regression with robust SEs was used to examine associations between survey burden, subject characteristics, and family ratings of quality of care.ResultsOf the families surveyed, 62% rated the survey to be no or low burden. Family members of older patients reported less survey burden (P = 0.016), and those who lived with the patient reported higher survey burden (P = 0.043). Family members reporting lower ratings of satisfaction with care and quality of dying reported higher survey burden (P < 0.001).ConclusionMost families reported no to low burden. Family members who live with their loved one are particularly vulnerable to survey burden and those of older patients report less burden. The association between low quality-of-care ratings and survey burden suggests that the response bias in this type of research is toward overestimating quality of care.
| S-EPMC3488148 | biostudies-literature