Limitation to Advanced Life Support in patients admitted to intensive care unit with integrated palliative care

Abstract

ObjectiveTo estimate the incidence of limitations to Advanced Life Support in critically ill patients admitted to an intensive care unit with integrated palliative care.MethodsThis retrospective cohort study included patients in the palliative care program of the intensive care unit of Hospital Paulistano over 18 years of age from May 1, 2011, to January 31, 2014. The limitations to Advanced Life Support that were analyzed included do-not-resuscitate orders, mechanical ventilation, dialysis and vasoactive drugs. Central tendency measures were calculated for quantitative variables. The chi-squared test was used to compare the characteristics of patients with or without limits to Advanced Life Support, and the Wilcoxon test was used to compare length of stay after Advanced Life Support. Confidence intervals reflecting p ≤ 0.05 were considered for statistical significance.ResultsA total of 3,487 patients were admitted to the intensive care unit, of whom 342 were included in the palliative care program. It was observed that after entering the palliative care program, it took a median of 2 (1 - 4) days for death to occur in the intensive care unit and 4 (2 - 11) days for hospital death to occur. Many of the limitations to Advanced Life Support (42.7%) took place on the first day of hospitalization. Cardiopulmonary resuscitation (96.8%) and ventilatory support (73.6%) were the most adopted limitations.ConclusionThe contribution of palliative care integrated into the intensive care unit was important for the practice of orthothanasia, i.e., the non-extension of the life of a critically ill patient by artificial means.

Limitation of life support techniques at admission to the intensive care unit: a multicenter prospective cohort study

“…Survival was affected by the same patient-related factors and by the number of reasons for LLST, the type of limitation, and the specific life support techniques limited. A study in Brazil found 9.8% of patients admitted to the ICU had limitations on advanced life support, and LLST decisions were associated with older age, clinical diagnosis, Karnofsky performance status score < 40%, and SAPS3 score > 49 points [ 24 ]. As in our study, Godfrey et al [ 20 ] found that older age, more comorbid disease, and more acute physiological disturbance were associated with mortality in patients with LLST at admission; moreover, 30% were discharged directly to their homes.…”

“…Our findings suggest a trend toward an increase in LLST at ICU admission; whereas earlier studies found limitations in only 1 to 3% of patients [ 20 , 25 ], we found limitations in nearly 8%. This trend may be related to patients’ increasing age and complexity (associated comorbidities and frailty) due to increased life expectancy, changes in patterns of end-of-life trajectories [ 26 ], changes in ICU admission criteria, and advanced life directives in patients with advanced cancer and organ failure [ 24 ]. Thus, many patients (oncological, hematologic, and geriatric patients) are admitted to ICUs for therapeutic tests or conditioning treatments because ICU admission seems to improve outcomes in these situations; for example, in cancer patients requiring mechanical ventilation are widely viewed as poor candidates for intensive care unit (ICU) admission.…”

Cuidados paliativos e limitação de suporte de vida em terapia intensiva

“…The limitation of life support has been applied as a strategy to minimize pain and suffering when the prognosis of the clinical status becomes irreversible, avoiding futile treatments and enabling death with dignity 18,19 . These concepts, such as offering a dignified death, avoiding dysthanasia or not prolonging the patient's suffering, are verified in various ways in the participants' statements:…”

Cardiopulmonary resuscitation in cancer patients: is there a problem?

“…We do not know of specific studies investigating the frequency of advance directives in cancer patients. As recently demonstrated in a general population of ICU patients in Brazil, it is very probable that the integration of cancer patients into a palliative care approach, even if the therapeutic projection is optimal, will increase the percentage of advance directives and will thus avoid unreasonable care decisions or, if they are undertaken, will avoid prosecuting them for a long period [11].…”