Management of decision of withholding and withdrawing life-sustaining treatments in French EDs

Abstract

Background Decisions of withholding or withdrawing life sustaining-treatments in emergency department are part of current practice but the decision-making process remains poorly described in the literature. Study objective We conducted a study in two phases, the first comprising a retrospective chart review study of patients dying in the ED and the second comprising survey study of health care workers at 10 urban emergency departments in France. Method In a first step, we analyzed medical records based on fifteen criteria of the decision-making process grouped into four categories: the collegiality, the traceability, the management and the communication as recommended by the international guidelines. In a second step, we conducted an auto-administrated survey to assess how the staff members (medical, paramedical) feel with the decision-making process. Results There were 273 deaths which occurred in the ED over the study period and we included 145 (53.1%) patients. The first-step analysis revealed that the traceability of the decision and the information given to patient or the relatives were the most reported points according to the recommendations. Three of the ten emergency departments had developed a written procedure. The collegial discussion and the traceability of the prognosis assessment were significantly increased in emergency department with a written procedure as well as management of pain, comfort care, and the communication with the patient or the relatives. In the second-step analysis, among the 735 staff members asked to take part in the survey, 287 (39.0%) answered. The medical and paramedical staff expressed difficult experience regarding the announcement and the communication with the patient and the relatives. Conclusion The management of the decision to withhold or withdraw life-sustaining treatments must be improved in emergency departments according to the guidelines. A standard written procedure could be useful in clinical practice despite the lack of experienced difference between centers with and without procedures.

D-dimer, BNP/NT-pro-BNP, and creatinine are reliable decision-making biomarkers in life-sustaining therapies withholding and withdrawing during COVID-19 outbreak

“…The COVID-19 pandemic has forced onto the medical community ethical questions combined with an unprecedented strain on the healthcare system, in particular in the emergency department and medical ward, to avoid transfer in intensive care units already overwhelmed. Decision of withholding or withdrawing life-sustaining treatments in emergency departments (ED) in France has been described mainly in patients older than 80 years with chronic underlying diseases, metastatic cancer, or previous functional limitations (12,13,(21)(22)(23)(24). Thus, our population is in line with decisions of withholding or withdrawing life-sustaining treatments usually carried out in emergency departments.…”

“…This law, in its new version, underlines the importance of information given to the patient, and also it states that failing to have an advance directive, the medical team should consult with the designated trusted third party or the relatives. While decision of LST has been largely described within ICU worldwide, limited data exist in the ED or medical ward (MW) setting ( 12 , 13 ). At the beginning of the COVID-19 outbreak, the unknown evolution of the disease and the very limited therapeutic options made LST decisions much more complicated.…”

Pathway of Suspected-COVID-19 Patients From French Emergency Departments During The First Outbreak: A Prospective Controlled Cohort Study

“…In our opinion, this can be explained by the fact that the COVID-19 health crisis led healthcare teams to anticipate the potential aggravation of patients. Indeed, it has been previously shown that there was little anticipation regarding end-of-life decisions in the EDs and that the management such decisions should be improved (23)(24). The decision-making process of these decisions is especially di cult in the context of emergency medicine because of lack of time, absence of anticipation in chronic diseases, and restrictions of access to families in EDs due to the pandemic.…”

Teto terapêutico e a adequação do tratamento no Serviço de Urgência – estudo retrospectivo

“…A definição de teto terapêutico ainda não foi estabelecida de forma conclusiva no contexto de medicina de emergência e, face à sua complexidade, começam a surgir posições de diversas sociedades devido a uma exploração limitada do assunto (11,13). A decisão sobre a manutenção de medidas de suporte de vida ou a sua retirada são frequentes no SU, assim como a implementação de cuidados aos doentes em fim de vida que permitem uma morte decente, livre de angústia e sofrimento evitável para o doente e familiares de acordo com os padrões clínicos, culturais, espirituais e éticos (12,14,15). Decorrentes da limitação terapêutica, surge a implementação de cuidados paliativos no SU, que representam uma grande sobrecarga sobre os profissionais de saúde e ao próprio SU (16).…”