Global variability in withholding and withdrawal of life-sustaining treatment in the intensive care unit: a systematic review

Mark, Nicholas M.; Rayner, Samuel G.; Lee, N. J.; Curtis, J. Randall

doi:10.1007/s00134-015-3810-5

Cited by 237 publications

(166 citation statements)

References 74 publications

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“…There is a great variability among the ICU's with regard to LTE decisions, 17 a fact that is related to regional and cultural factors. A study carried out in France showed that in 584 (52%) of 1132 patients who died, there was some type of LTE involved, with more refusal to introduce new therapies than withdrawal of prescribed treatments.…”

Section: Discussionmentioning

confidence: 99%

Palliative extubation: case analysis in an Intensive Care Unit

Rebelatto¹,

Moritz²

2017

Mundo da Saúde

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Current technological advancements have allowed for the prolongation of the dying process, especially in Intensive Care Units (ICU). This has increased the need for decisions on the limitation of therapeutic effort (LTE), such as the use of palliative extubation that, although difficult from an emotional standpoint, has legal and ethical justifications, and has increased family acceptance. The objective was to evaluate the clinical and demographical profile of patients submitted to palliative extubation (PT) in the ICU of the University Hospital of the Universidade Federal de Santa Catarina (HU/ UFSC), Brazil. This was a historical cohort whose data were obtained from forms filled out by critical care doctors from the Hospital Death Commission at the HU/UFSC. Patients submitted to LTE that died between January 2011 and December 2014 were included in the study. The use of PT and clinical and epidemiological data were collected. LTE was indicated in 374 (53.8%) patients, with 23 (6.1%) receiving PT. Average age of patients undergoing PT was 73.8 years; 10 patients were over 60, and 9 were over 80 years of age. Ten (43.4%) patients had been previously in the ICU. The average time from checking in at the ICU and extubation was 4.4 days, and between extubation and death it was 2.5 days. Neurological disease was the main cause of death of patients subjected to PT. All family members were aware of the extubation. Family members from 2 families witnessed the extubation. Morphine was the most common analgesic prescribed. It is concluded that patients submitted to PT were older, with neurological diseases, and the average time from extubation to death was 2.5 days ResumoO desenvolvimento tecnológico do mundo atual tem permitido o prolongamento do morrer, principalmente em unidades de terapia intensiva (UTI). Torna-se crescente a necessidade de decisões de limite de esforço terapêutico (LET), do qual se destaca a extubação paliativa (EP), que embora difícil de ser aceita do ponto de vista emocional, tem respaldo ético-legal e aumenta a satisfação familiar. O estudo teve como objetivo avaliar o perfil clínico-demográfico dos pacientes extubados paliativamente (ExPl) na UTI do HU/UFSC. Trata-se de coorte histórico, cujos dados foram coletados através das fichas preenchidas por médicos intensivistas que constituem a Comissão de Óbito da instituição. Foram incluídos os pacientes que morreram na UTI/HU/UFSC, após indicação de LET, entre janeiro/2011 e dezembro/2014. Foram selecionados os pacientes que foram ExPl, sendo anotados seus dados clínicos e epidemiológicos. LET foi apontado em 374 (53,8%) pacientes, sendo 23 (6,1%) ExPl. A média da idade dos ExPl foi de 73,8 anos, 10 tinham mais de 60 e 9 mais de 80 anos. Dez (43,4%) pacientes já haviam sido internados previamente em UTI. O tempo médio entre a internação-extubação foi 4,4 dias e entre extubação-morte foi de 2,5 dias. Doença neurológica foi a principal causa da morte dos pacientes ExPl. Todos os familiares estavam cientes da EP. Familiares de 2 pacientes acompa...

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Section: Discussionmentioning

confidence: 99%

Palliative extubation: case analysis in an Intensive Care Unit

Rebelatto¹,

Moritz²

2017

Mundo da Saúde

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“…Among the many potential contributors to these adverse bereavement outcomes are the circumstances surrounding and processes of limiting life support. This hypothesis is supported by evidence that ICU deaths are commonly preceded by decisions to withdraw life support [3], and evidence that both ICU processes of care [4,5] and behaviors of ICU clinicians [1,6] near the end of life can influence family members' post-ICU psychological outcomes. Thus, uncertainty regarding which approaches to withdrawing mechanical ventilation are least distressing for patients and families [7,8] represents an important area for rigorous investigation.…”

mentioning

confidence: 94%

Life after death in the ICU: detecting family-centered outcomes remains difficult

2017

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Family members of patients who die in the ICU experience significant and lasting psychological burdens, such as post-traumatic stress disorder (PTSD), anxiety, depression, and prolonged grief [1,2]. Among the many potential contributors to these adverse bereavement outcomes are the circumstances surrounding and processes of limiting life support. This hypothesis is supported by evidence that ICU deaths are commonly preceded by decisions to withdraw life support [3], and evidence that both ICU processes of care [4,5] and behaviors of ICU clinicians [1,6] near the end of life can influence family members' post-ICU psychological outcomes. Thus, uncertainty regarding which approaches to withdrawing mechanical ventilation are least distressing for patients and families [7,8] represents an important area for rigorous investigation.In this context, Reignier and colleagues performed a prospective observational cohort study to compare psychological symptoms in over 400 family members of patients who died after withdrawal of mechanical ventilation by immediate extubation vs. terminal weaning in 43 French ICUs [9]. Impressively, the authors were able to assess the primary endpoint of PTSD symptoms 3 months after death among over 95% of enrolled family members. Secondary endpoints included symptoms of anxiety, depression, and complicated grief among family members, symptom burdens of patients during the dying process, and strains on ICU staff.The authors found no differences between groups in any of the psychological outcomes reported by family members at 3 months. This was a durable finding when adjusted for patient characteristics and center effects, and at 6-and 12-month follow-up assessments. ICU staff experienced similar levels of job strain regardless of the withdrawal method chosen, with the exception of nursing assistants who reported less strain with immediate extubation. Patients in the immediate extubation group experienced more gasping and airway obstruction and received significantly lower doses, on average, of sedatives and analgesics compared to those undergoing terminal weaning. Given these results, the authors conclude that the choice between these two approaches to withdrawal of mechanical ventilation does not impact psychological symptoms among family members. They also suggest, and we agree, that standardized approaches to medication administration near the end of life may reduce patient suffering.This study is innovative in empirically evaluating the impact of how mechanical ventilation is withdrawn on family-centered outcomes. It is also strengthened by the diverse sample of ICUs, and the outstanding follow-up rate. However, the ability to draw conclusions is tempered by the non-randomized design. Although the authors appropriately note that randomly assigning ICUs to an unfamiliar withdrawal method might engender low adherence to the assigned interventions, the observational design amounts to a comparison of withdrawal methods on family members who chose (or whose clinicians chose for them) a particul...

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“…Although the authors note that an expert overview of the legal and ethical framework of withdrawal of life-sustaining treatments in Canada was provided for workshop participants, the inclusion of ethicists and legal experts in the consensus process would have been beneficial [2]. Finally, there are many aspects of end-of-life care that are influenced by regional policies [8], so it is important to acknowledge that consensus achieved in one region may not apply in another. The guidelines proposed by Downar and colleagues [2] were generated by experts from a single country and may not be compatible with ethical and legal standards in other nations.…”

mentioning

confidence: 99%