Effect of Decisions to Withhold Life Support on Prolonged Survival

Chen, Yen-Yuan; Connors, Alfred F.; Garland, Allan

doi:10.1378/chest.07-1500

Cited by 35 publications

(29 citation statements)

References 37 publications

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“…While DNR patients felt that a DNR order would emphasize a more "natural" and comfort-oriented plan of care, FC patients felt that a DNR order would lead to passive or suboptimal care, or outright euthanasia. Indeed, some observational studies suggest that orders limiting life support are associated with a higher mortality rate 20,21 , although other studies have not supported these findings 22 . Certainly, all health care practitioners have an obligation to ensure that patients with a DNR order continue to receive all other appropriate medical therapies (including life-prolonging therapies) consistent with their goals of care.…”

Section: Discussionmentioning

confidence: 99%

Why Do Patients Agree to a “Do Not Resuscitate” or “Full Code” Order? Perspectives of Medical Inpatients

et al. 2011

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BACKGROUND:The majority of patients who die in hospital have a "Do Not Resuscitate" (DNR) order in place at the time of their death, yet we know very little about why some patients request or agree to a DNR order, why others don't, and how they view discussions of resuscitation status. METHODS:We conducted semi-structured interviews of English-speaking medical inpatients who had clearly requested a DNR or full code (FC) order after a discussion with their admitting team, and analyzed the transcripts using a modified grounded-theory approach. RESULTS:We achieved conceptual saturation after conducting 44 interviews (27 DNR, 17 FC) over a 4-month period. Patients in the DNR group were much older than those in the FC group, but they had broadly similar admission diagnoses and comorbidities. DNR patients reported much greater familiarity with the subject and described a more positive experience than FC patients with their resuscitation discussions. Participants typically requested FC or DNR orders based on personal, relational or philosophical considerations, but these considerations manifested differently depending on the participant's preference for resuscitation. Most FC patients stated that would not want a prolonged period of life support, and they would not want resuscitation in the event of a poor quality of life. FC and DNR patients understood resuscitation and DNR orders differently. DNR patients described resuscitation in graphic, concrete terms that emphasized suffering and futility, and DNR orders in terms of comfort or natural processes. FC patients understood resuscitation in an abstract sense as something that restores life, while DNR orders were associated with substandard care or even euthanasia.CONCLUSION: Our study identified important differences and commonalities between the perspectives of DNR and FC patients. We hope that this information can be used to help physicians better understand the needs of their patients when discussing resuscitation.

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Section: Discussionmentioning

confidence: 99%

Why Do Patients Agree to a “Do Not Resuscitate” or “Full Code” Order? Perspectives of Medical Inpatients

et al. 2011

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“…Characteristics suggestive of psychological symptom distress were consultation with a hospital chaplain during the hospitalization (24); brain dysfunction (delirium or dementia) at discharge (17); or prescription of anxiolytics, tricyclic antidepressants, g-aminobutyric acid analogs, or antipsychotics at discharge (23). Characteristics suggestive of an anticipated poor prognosis were a diagnosis of active malignancy (22), a "do-not-resuscitate" order at the time of hospital discharge (25), or a designation of "comfort care" as the goal of care at the time of discharge to the post-acute care facility. We assessed these proxies for potential palliative care needs by reviewing discharge summaries (discharge diagnoses, assessment, and plan sections), institutional claims data, and electronic medical record orders and prescriptions.…”

Section: Measurementsmentioning

confidence: 99%

High Burden of Palliative Needs among Older Intensive Care Unit Survivors Transferred to Post–Acute Care Facilities. A Single-Center Study

et al. 2013

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Rationale: Adults with chronic critical illness (tracheostomy after > 10 d of mechanical ventilation) have a high burden of palliative needs, but little is known about the actual use and potential need of palliative care services for the larger population of older intensive care unit (ICU) survivors discharged to post-acute care facilities.Objectives: To determine whether older ICU survivors discharged to post-acute care facilities have potentially unmet palliative care needs. Methods:We examined electronic records from a 1-year cohort of 228 consecutive adults > 65 years of age who had their first medical-ICU admission in 2009 at a single tertiary-care medical center and survived to discharge to a post-acute care facility (excluding hospice). Use of palliative care services was defined as having received a palliative care consultation. Potential palliative care needs were defined as patient characteristics suggestive of physical or psychological symptom distress or anticipated poor prognosis. We examined the prevalence of potential palliative needs and 6-month mortality. Measurements and Main Results:The median age was 78 years (interquartile range, 71-84 yr), and 54% received mechanical ventilation for a median of 7 days (interquartile range, 3-16 d). Six subjects (2.6%) received a palliative care consultation during the hospitalization. However, 88% had at least one potential palliative care need; 22% had chronic wounds, 37% were discharged on supplemental oxygen, 17% received chaplaincy services, 23% preferred to not be resuscitated, and 8% were designated "comfort care." The 6-month mortality was 40%.Conclusions: Older ICU survivors from a single center who required postacute facility care had a high burden of palliative care needs and a high 6-month mortality. The in-hospital postcritical acute care period should be targeted for palliative care assessment and intervention.

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“…8 Furthermore, patient preferences regarding resuscitation are not considered in widely used ICU mortality prediction models. 9,10 Frailty is a measurable clinical phenotype of increased vulnerability to adverse health outcomes due to age or diseaseassociated decreased physiologic reserves.…”

Section: Statistical Analysesmentioning

confidence: 99%

A Prognostic Model for 6-Month Mortality in Elderly Survivors of Critical Illness

Baldwin¹,

Narain²,

Lederer³

et al. 2011

Chest

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A dults older than 65 years of age now comprise more than one-half of all ICU admissions in the United States. 1 Approximately 1.4 million elderly (aged Ն 65 years) Medicare benefi ciaries are discharged each year after receiving intensive care. 2 With technological advances, many critically ill elderly adults now survive what were previously fatal illnesses, 3,4 but outcomes can be poor. Among the 33% of elderly ICU patients discharged to skilled-care facilities, nearly one-half are rehospitalized and 25% to 65% die within 6 months. 2,5 While predictive models exist for ICU survivors of prolonged mechanical ventilation and elders hospitalized without intensive care, 6,7 there are no existing clinical prediction tools to help predict outcome explicitly for elderly ICU survivors. A validated prediction model for postdischarge mortality in elderly ICU survivors could (1) risk-stratify patients for clinical trials of novel preventative, rehabilitative, and therapeutic interventions; (2) help determine appropriate levels of postacute care; and (3) aid providers in addressing expectations and end-of-life care with these patients and their families.We aimed to derive and externally validate a prediction model for 6-month mortality among elderly ICU survivors. We hypothesized that including markers of frailty and disability as well as patient preferences regarding resuscitation in our model would be important in predicting 6-month mortality. Withholding life-supporting therapies often indicates

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Effect of Decisions to Withhold Life Support on Prolonged Survival

Cited by 35 publications

References 37 publications

Why Do Patients Agree to a “Do Not Resuscitate” or “Full Code” Order? Perspectives of Medical Inpatients

Why Do Patients Agree to a “Do Not Resuscitate” or “Full Code” Order? Perspectives of Medical Inpatients

High Burden of Palliative Needs among Older Intensive Care Unit Survivors Transferred to Post–Acute Care Facilities. A Single-Center Study

A Prognostic Model for 6-Month Mortality in Elderly Survivors of Critical Illness

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