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(LST) are no longer effective or consistent with patient preferences, limitations may be set so that LSTs are withdrawn or withheld from the patient.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.

Few surveys have focused on physician moral distress, burnout, and professional fulfilment. We assessed physician wellness and coping during the COVID-19 pandemic.DESIGN: Cross-sectional survey using four validated instruments. SETTING:Sixty-two sites in Canada and the United States. SUBJECTS:Attending physicians (adult, pediatric; intensivist, nonintensivist) who worked in North American ICUs. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS:We analysed 431 questionnaires (43.3% response rate) from 25 states and eight provinces. Respondents were predominantly male (229 [55.6%]) and in practice for 11.8 ± 9.8 years. Compared with prepandemic, respondents reported significant intrapandemic increases in days worked/mo, ICU bed occupancy, and self-reported moral distress (240 [56.9%]) and burnout (259 [63.8%]). Of the 10 top-ranked items that incited moral distress, most pertained to regulatory/organizational (n = 6) or local/institutional (n = 2) issues or both (n = 2). Average moral distress (95.6 ± 66.9), professional fulfilment (6.5 ± 2.1), and burnout scores (3.6 ± 2.0) were moderate with 227 physicians (54.6%) meeting burnout criteria. A significant dose-response existed between COVID-19 patient volume and moral distress scores. Physicians who worked more days/mo and more scheduled in-house nightshifts, especially combined with more unscheduled in-house nightshifts, experienced significantly more moral distress. One in five physicians used at least one maladaptive coping strategy. We identified four coping profiles (active/social, avoidant, mixed/ ambivalent, infrequent) that were associated with significant differences across all wellness measures. CONCLUSIONS: Despite moderate intrapandemic moral distress and burnout, physicians experienced moderate professional fulfilment. However, one in five physicians used at least one maladaptive coping strategy. We highlight potentially modifiable factors at individual, institutional, and regulatory levels to enhance physician wellness.

Background: Home oxygen therapy is a mainstay of treatment for patients with various cardiopulmonary diseases. In spite of warnings against smoking while using home oxygen, many patients sustain burn injuries. Objectives: We aimed to quantify the morbidity and mortality of such patients admitted to our regional burn unit over a 6-year period. Methods: A retrospective chart review of all patients admitted to a regional burn center from 2008 through 2013 was completed. Admitted patients sustaining burns secondary to smoking while using home oxygen therapy were selected as the study population to determine morbidity. Results: Fifty-five subjects were admitted to the burn unit for smoking-related home oxygen injuries. The age range was 40-84 years. Almost all subjects were on home oxygen for chronic obstructive pulmonary disease (96%). Seventy-two percent of burns involved <5% of the total body surface area, 51% of patients were intubated, and of those 33% had evidence of inhalation injury. The hospital mortality rate was 14.5%. The mean length of hospital stay was 8.6 days, and 54.5% were discharged to a nursing home or another advanced facility. Finally, concomitant substance abuse was found in 27%, and a previous history of injury from smoking while on home oxygen was discovered in 14.5%. Conclusions: This single-center analysis is one of the largest describing burn injuries stemming from smoking while using home oxygen therapy. We identified the morbidity and mortality associated with these injuries. Ongoing education and careful consideration of prescribing home oxygen therapy for known smokers is highly encouraged.

To determine predictors and pregnancy outcomes associated with antepartum discharge against medical advice (AMA D/C). Retrospective cohort study of state-level maternal and infant hospital discharge data linked to vital statistics data for antepartum admissions in California from 1995 to 2005. (N = 203,250). After adjusting for comorbid conditions, the odds of AMA D/C for Black women were twice that of white women (OR = 2.00, 95% CI 1.70-2.35). Publicly insured women had 3.5 times the odds of AMA D/C compared to privately insured women (OR = 3.54, 95% CI 3.02-4.15). AMA D/C was also higher among substance abusers and women with mental illness (OR = 1.96, 95% CI 1.43-2.67 and OR = 4.45, 95% CI 3.81-5.21 respectively). Most notably, AMA D/C tripled the odds of fetal death in patients admitted for pregnancy-induced hypertension (OR = 3.08, 95% CI 1.36-6.98) and increased the odds of neonatal morbidity (respiratory distress syndrome OR = 1.35, 95% CI 1.07-1.70 and small-for-gestational-age OR = 1.47, 95% CI 1.15-1.89) in patients admitted with preterm premature rupture of membranes. Vulnerable populations and patients with comorbid medical and mental illnesses are at increased risk for AMA D/C and its associated adverse pregnancy outcomes. Targeted interventions and resources to support at-risk populations are needed.

Background Reports on outcomes following severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection in lung transplant recipients remain limited. Methods We performed a single‐center, observational study of outcomes in lung transplant recipients diagnosed with SARS‐CoV‐2 between 5/1/2020 and 3/15/2022 that were followed for a median of 123 days. We analyzed changes in spirometry, acute lung allograft dysfunction (ALAD) incidence, hospitalization, mechanical ventilation needs, secondary infection, and survival. Results In our cohort of 336 patients, 103 developed coronavirus disease (COVID) (27 pre‐Delta, 20 Delta, and 56 Omicron‐era). Twenty‐five patients (24%) required hospitalization and 10 patients ultimately died (10%). Among 85 survivors who completed ambulatory spirometry, COVID‐19 did not alter change in forced expiratory volume in 1 s (FEV1) or forced vital capacity (FVC) over time compared to the preceding 6 months. The pre‐COVID FEV1 change was −0.05 ml/day (IQR −0.50 to 0.60) compared to −0.20 ml/day (IQR −1.40 to 0.70) post‐COVID (p = .16). The pre‐COVID change in FVC was 0.20 ml/day (IQR −0.60 to 0.70) compared to 0.05 ml/day (IQR −1.00 to 1.10) post‐COVID (p = .76). Although the cohort overall had stable lung function, 33 patients (39%) developed ALAD or accelerated chronic lung allograft dysfunction (FEV1 decline >10% from pre‐COVID baseline). Nine patients (35%) with ALAD recovered lung function. Within 3 months of acute COVID infection, 18 patients (17%) developed secondary infections, the majority being bacterial pneumonia. Finally, vaccination with at least two doses of mRNA vaccine was not associated with improved outcomes. Conclusions This study describes the natural history of SARS‐CoV‐2 infection in a large cohort of lung transplant recipients. Although one third of patients develop ALAD requiring augmented immunosuppression, infection with SARS‐CoV‐2 is not associated with worsening lung function.