The importance of revealing data on limitation of life sustaining therapy in critical ill elderly Covid-19 patients.
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ABSTRACT:
SUBMITTER: Flaatten H
PROVIDER: S-EPMC8588784 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description: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(LST) are no longer effective or consistent with patient preferences, limitations may be set so that LSTs are withdrawn or withheld from the patient.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.
| S-EPMC6625435 | biostudies-literature
Project description:BackgroundLimitations of life-sustaining therapies (LST) practices are frequent and vary among intensive care units (ICUs). However, scarce data were available during the COVID-19 pandemic when ICUs were under intense pressure. We aimed to investigate the prevalence, cumulative incidence, timing, modalities, and factors associated with LST decisions in critically ill COVID-19 patients.MethodsWe did an ancillary analysis of the European multicentre COVID-ICU study, which collected data from 163 ICUs in France, Belgium and Switzerland. ICU load, a parameter reflecting stress on ICU capacities, was calculated at the patient level using daily ICU bed occupancy data from official country epidemiological reports. Mixed effects logistic regression was used to assess the association of variables with LST limitation decisions.ResultsAmong 4671 severe COVID-19 patients admitted from February 25 to May 4, 2020, the prevalence of in-ICU LST limitations was 14.5%, with a nearly six-fold variability between centres. Overall 28-day cumulative incidence of LST limitations was 12.4%, which occurred at a median of 8 days (3-21). Median ICU load at the patient level was 126%. Age, clinical frailty scale score, and respiratory severity were associated with LST limitations, while ICU load was not. In-ICU death occurred in 74% and 95% of patients, respectively, after LST withholding and withdrawal, while median survival time was 3 days (1-11) after LST limitations.ConclusionsIn this study, LST limitations frequently preceded death, with a major impact on time of death. In contrast to ICU load, older age, frailty, and the severity of respiratory failure during the first 24 h were the main factors associated with decisions of LST limitations.
| S-EPMC10006561 | biostudies-literature
Project description: Not available
| S-EPMC9423697 | biostudies-literature
Project description:IntroductionMost successfully resuscitated cardiac arrest patients do not survive to hospital discharge. Many have withdrawal of life sustaining therapy (WLST) as a result of the perception of poor neurologic prognosis. The characteristics of these patients and differences in their post-arrest care are largely unknown.MethodsUtilizing the Penn Alliance for Therapeutic Hypothermia Registry, we identified a cohort of 1311 post-arrest patients from 26 hospitals from 2010 to 2014 who remained comatose after return of spontaneous circulation. We stratified patients by whether they had WLST post-arrest and analyzed demographic, arrest, and post-arrest variables.ResultsIn our cohort, 565 (43%) patients had WLST. In multivariate regression, patients who had WLST were less likely to go to the cardiac catheterization lab (OR 0.40; 95% CI: 0.26-0.62) and had shorter hospital stays (OR 0.93; 95% CI: 0.91-0.95). When multivariate regression was limited to patient demographics and arrest characteristics, patients with WLST were older (OR 1.18; 95% CI: 1.07-1.31 by decade), had a longer arrest duration (OR 1.14; 95% CI: 1.05-1.25 per 10min), more likely to be female (OR: 1.41; 95% CI: 1.01-1.96), and less likely to have a witnessed arrest (OR 0.65; 95% CI: 0.42-0.98).ConclusionPatients with WLST differ in terms of demographic, arrest, and post-arrest characteristics and treatments from those who did not have WLST. Failure to account for this variability could affect both clinical practice and the interpretation of research.
| S-EPMC5541857 | biostudies-literature
Project description:Data sets plagued with missing data and performance-affecting model parameters represent recurrent issues within the field of data mining. Via random forests, the influence of data reduction, outlier and correlated variable removal and missing data imputation technique on the performance of habitat suitability models for three macrophytes (Lemna minor, Spirodela polyrhiza and Nuphar lutea) was assessed. Higher performances (Cohen's kappa values around 0.2-0.3) were obtained for a high degree of data reduction, without outlier or correlated variable removal and with imputation of the median value. Moreover, the influence of model parameter settings on the performance of random forest trained on this data set was investigated along a range of individual trees (ntree), while the number of variables to be considered (mtry), was fixed at two. Altering the number of individual trees did not have a uniform effect on model performance, but clearly changed the required computation time. Combining both criteria provided an ntree value of 100, with the overall effect of ntree on performance being relatively limited. Temperature, pH and conductivity remained as variables and showed to affect the likelihood of L. minor, S. polyrhiza and N. lutea being present. Generally, high likelihood values were obtained when temperature is high (>20?°C), conductivity is intermediately low (50-200 mS m-1) or pH is intermediate (6.9-8), thereby also highlighting that a multivariate management approach for supporting macrophyte presence remains recommended. Yet, as our conclusions are only based on a single freshwater data set, they should be further tested for other data sets.
| S-EPMC6162213 | biostudies-literature
Project description:PurposeThe "Act on Hospice and Palliative Care and Decisions on Life-Sustaining Treatment for Patients at the End-of-Life" was enacted on February 3, 2016 and went into effect on February 4, 2018 in Korea. This study reviewed the first year of determination to life-sustaining treatment (LST) through data analysis of the National Agency for Management of Life-Sustaining Treatment.Materials and methodsThe National Agency for Management of LST provided data between February 4, 2018 and January 31, 2019 anonymously from 33,549 patients. According to the forms patients were defined as either elf-determinants or family-determinants.ResultsThe median age of the patient was 73 and the majority was male (59.9%). Cancer patients were 59% and self-determinants were 32.1%. Cancer patients had a higher rate of self-determinants than non-cancer (47.3% vs. 10.1%). Plan for hospice service was high in cancer patients among self-determinants (81.0% vs. 37.5%, p < 0.001). In comparison to family-determinants, self-determinants were younger (median age, 67 years vs. 75 years; p < 0.001) and had more cancer diagnosis (87.1% vs. 45.9%, p < 0.001). Decision of withholding or withdrawing of LSTs in cancer patients was higher than non-cancer patients in four items.ConclusionCancer patients had a higher rate in self-determination and withholding or withdrawing of LSTs than non-cancer patients. Continued revision of the law and education of the public will be able to promote withdrawing or withholding the futile LSTs in patients at end-of-life. Further study following the revision of the law should be evaluated to change of end-of-life care.
| S-EPMC8524023 | biostudies-literature
Project description:To measure the frequency of withdrawal of life-sustaining therapy for perceived poor neurologic prognosis among decedents in hospitals of different sizes and teaching statuses.DesignWe performed a multicenter, retrospective cohort study.SettingFour large teaching hospitals, four affiliated small teaching hospitals, and nine affiliated nonteaching hospitals in the United States.PatientsWe included a sample of all adult inpatient decedents between August 2017 and August 2019.Measurements and main resultsWe reviewed inpatient notes and categorized the immediately preceding circumstances as withdrawal of life-sustaining therapy for perceived poor neurologic prognosis, withdrawal of life-sustaining therapy for nonneurologic reasons, limitations or withholding of life support or resuscitation, cardiac death despite full treatment, or brain death. Of 2,100 patients, median age was 71 years (interquartile range, 60-81 yr), median hospital length of stay was 5 days (interquartile range, 2-11 d), and 1,326 (63%) were treated at four large teaching hospitals. Withdrawal of life-sustaining therapy for perceived poor neurologic prognosis occurred in 516 patients (25%) and was the sole contributing factor to death in 331 (15%). Withdrawal of life-sustaining therapy for perceived poor neurologic prognosis was common in all hospitals: 30% of deaths at large teaching hospitals, 19% of deaths in small teaching hospitals, and 15% of deaths at nonteaching hospitals. Withdrawal of life-sustaining therapy for perceived poor neurologic prognosis happened frequently across all hospital units. Withdrawal of life-sustaining therapy for perceived poor neurologic prognosis contributed to one in 12 deaths in patients without a primary neurologic diagnosis. After accounting for patient and hospital characteristics, significant between-hospital variability in the odds of withdrawal of life-sustaining therapy for perceived poor neurologic prognosis persisted.ConclusionsA quarter of inpatient deaths in this cohort occurred after withdrawal of life-sustaining therapy for perceived poor neurologic prognosis. The rate of withdrawal of life-sustaining therapy for perceived poor neurologic prognosis occurred commonly in all type of hospital settings. We observed significant unexplained variation in the odds of withdrawal of life-sustaining therapy for perceived poor neurologic prognosis across participating hospitals.
| S-EPMC8280080 | biostudies-literature
Project description:Sepsis is a frequent complication in critically ill patients and highly heterogeneous that is associated with high morbidity and mortality rates, especially in the elderly population. Utilizing RNA-Sequencing (RNA-Seq) to analysis biological pathways is widely used in clinical and molecular genetics studies, but in elderly patients with sepsis are still lacking. Hence, we aim to investigate the mortality-relevant biological features and transcriptomic features in elderly patients who were admitted to intensive care unit (ICU) for sepsis.
2022-11-03 | GSE216902 | GEO
Project description:BackgroundThe coronavirus (COVID-19) pandemic and the risk of an extensive overload of the healthcare systems have elucidated the need to make decisions on the level of life-sustaining treatment for patients requiring hospitalisation. The purpose of the study was to investigate the proportion and characteristics of COVID-19 patients with limitation of life-sustaining treatment decisions and the degree of patient involvement in the decisions.MethodsA retrospective observational descriptive study was conducted in three Danish regional hospitals, looking at all patients ≥ 18 years of age admitted in 2020 with COVID-19 as the primary diagnosis. Lists of hospitalised patients admitted due to COVID-19 were extracted. The data registration included age, gender, comorbidities, including mental state, body mass index, frailty, recent hospital admissions, COVID-19 life-sustaining treatment, ICU admission, decisions on limitations of life-sustaining treatment before and during current hospitalisation, hospital length of stay, and hospital mortality.ResultsA total of 476 patients were included. For 7% (33/476), a decision about limitation of life-sustaining treatment had been made prior to hospital admission. At the time of admission, one or more limitations of life-sustaining treatment were registered for 16% (75/476) of patients. During the admission, limitation decisions were made for an additional 11 patients, totaling 18% (86/476). For 40% (34/86), the decisions were either made by or discussed with the patient. The decisions not made by patients were made by physicians. For 36% (31/86), no information was disclosed about patient involvement.ConclusionsLife-sustaining treatment limitation decisions were made for 18% of a COVID-19 patient cohort. Hereof, more than a third of the decisions had been made before hospital admission. Many records lacked information on patient involvement in the decisions.
| S-EPMC8686092 | biostudies-literature
Project description:Little is known about patients with intracerebral hemorrhage (ICH) who undergo chronic life-sustaining procedures. We sought to explore variations in treatment, Medicare payments, and mortality among elderly patients with ICH who received a feeding tube, a tracheostomy, or neither chronic life-sustaining procedure. Medicare Provider Analysis and Review files from 2004 linked to Center for Medicaid and Medicare Services denominator files through January 2005 were analyzed. Patients over age 65 years with a primary diagnosis of ICH based on discharge code (ICD-9-CM 431) were divided into those who underwent tracheostomy, those who underwent feeding tube placement but not tracheostomy, and those who underwent neither procedure. Thirty-day and 1-year survival rates were estimated using Kaplan-Meier methods. Among the 32,210 patients studied, 6% underwent feeding tube placement, and 2.5% underwent tracheostomy. Compared with the patients who did not undergo a chronic life-sustaining procedure, those who underwent tracheostomy had a longer length of stay (median, 25 days vs 4 days; P < .01) and greater Medicare spending (median, $81,479 vs $6,008; P < .01) during their initial hospitalization. The 30-day and 1-year cumulative mortality risks were 47% and 59%, respectively, in patients who did not undergo a chronic life-sustaining procedure, 21% and 53% in patients who underwent feeding tube placement, and 19% and 65% in those who underwent tracheostomy (P < .01, log-rank test across the 3 groups). Our findings show high 1-year mortality among elderly patients with ICH, even in those who undergo chronic life-sustaining procedures. Medicare payments for patients who undergo tracheostomy are substantial. More information about functional outcomes is needed.
| S-EPMC3202018 | biostudies-literature