Withdrawal of Life-Sustaining Therapies and Brain Death in the Intensive Care Unit

Varelas, Panayiotis N.; Abdelhak, Tamer; Hacein‐Bey, Lotfi

doi:10.1055/s-0028-1105969

Cited by 17 publications

(9 citation statements)

References 66 publications

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“…Nationally, 13.5% -15% of patients in neuro-ICUs have life-sustaining therapies withheld or withdrawn, and limitation of such therapies precedes up to 61% of all deaths in the neuro-ICU. [9-11] In those who do not die, recovery is prolonged. Brain-injured patients make their maximal spontaneous recovery over 3-6 months, though improvement can continue over the ensuing months with aggressive rehabilitation.…”

Section: Introductionmentioning

confidence: 99%

Integrating Palliative Care Into the Care of Neurocritically Ill Patients

Frontera

Curtis

Nelson

et al. 2015

Critical Care Medicine

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Objectives To describe unique features of neurocritical illness that are relevant to provision of high-quality palliative care; To discuss key prognostic aids and their limitations for neurocritical illnesses; To review challenges and strategies for establishing realistic goals of care for patients in the neuro-ICU; To describe elements of best practice concerning symptom management, limitation of life support, and organ donation for the neurocritically ill. Data Sources A search of Pubmed and MEDLINE was conducted from inception through January 2015 for all English-language articles using the term “palliative care,” “supportive care,” “end-of-life care,” “withdrawal of life-sustaining therapy,” “limitation of life support,” “prognosis,” or “goals of care” together with “neurocritical care,” “neurointensive care,” “neurological,” “stroke,” “subarachnoid hemorrhage,” “intracerebral hemorrhage,” or “brain injury.” Data Extraction and Synthesis We reviewed the existing literature on delivery of palliative care in the neurointensive care unit setting, focusing on challenges and strategies for establishing realistic and appropriate goals of care, symptom management, organ donation, and other considerations related to use and limitation of life-sustaining therapies for neurocritically ill patients. Based on review of these articles and the experiences of our interdisciplinary/interprofessional expert Advisory Board, this report was prepared to guide critical care staff, palliative care specialists, and others who practice in this setting. Conclusions Most neurocritically ill patients and their families face the sudden onset of devastating cognitive and functional changes that challenge clinicians to provide patient-centered palliative care within a complex and often uncertain prognostic environment. Application of palliative care principles concerning symptom relief, goal setting, and family emotional support, will provide clinicians a framework to address decision-making at a time of crisis that enhances patient/family autonomy and clinician professionalism.

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Section: Introductionmentioning

confidence: 99%

Integrating Palliative Care Into the Care of Neurocritically Ill Patients

Frontera

Curtis

Nelson

et al. 2015

Critical Care Medicine

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“…All five of the non-ICU cases (cases 10-14) followed the terminal trajectory. The causes of WLVAD in four cases were debility (cases [11][12][13][14], which means that they were not acutely sick; however, their declining functional status mainly contributed to the patients' request for WLVAD. WD_PT+ in those cases were obviously longer than the rest of the cases.…”

mentioning

confidence: 99%

Withdrawal of Left Ventricular Assist Devices: A Retrospective Analysis from a Single Institution

Nakagawa

Ando²,

Takayama

et al. 2020

Journal of Palliative Medicine

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Background: When left ventricular assist device (LVAD) therapy no longer is able to achieve patients' desired quality of life, withdrawal of LVAD therapy (WLVAD) may be requested. Objectives: To evaluate factors associated with WLVAD, including the time taken before WLVAD. Setting/Subjects: Sixty-two patients who newly underwent initial LVAD therapy during January 1, 2010 and October 30, 2018 and subsequently underwent WLVAD by December 31, 2018 were divided into those who participated in the decision of WLVAD (defined as PT+, n = 14), and those who could not participate in the decision because of the medical reasons (defined as PT-, n = 48). Measurements: Time to WLVAD in PT+ and PT-was defined as WD_PT+ (days between patients' request and WLVAD) and WD_PT-(days between when patients became unable to express themselves and WLVAD), respectively. Circumstances around WLVAD, including location of death and use of palliative care (PC), were reviewed. Results: Mean age at WLVAD was 65.4-10.1 years and 52 (83.9%) were men. Median days on LVAD support was 166.5 days (interquartile range = 838). The majority of WLVAD occurred in the intensive care unit (ICU) (83.6%) but less frequent in PT+ than in PT-(64.3% vs. 89.4%, p = 0.041). The median number of PC visits in the last month was higher in PT+ than in PT-(4.5 vs. 0.5, p = 0.005). The median WD_PT+ was 5.5 days and was significantly shorter in the ICU (1 day vs. 46 days, p = 0.013). The median WD_PT-was 5.5 days and tended to be shorter in the ICU (4 days vs. 13 days, p = 0.072). A multivariate analysis showed that male gender and ICU setting were both negatively associated with WD_PT-(p = 0.025 for men, p = 0.005 for ICU setting). Conclusions: The majority of WLVAD occurred in the ICU and required PC involvement. Time to WLVAD was shorter in the ICU. Requests for WLVAD directly made by patients, especially in a non-ICU setting, seemed to have posed more difficulty.

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“…Decisions to forgo treatment in intensive care units have been shown to be associated with several factors, including higher age of the patients, the severity of their illness, pre-existing severe medical conditions, physicians’ and patients’ religious affiliation, patients’ wishes, and the physicians’ prediction of a low likelihood of survival and poor future functional outcome [64,65,66,67,68]. Especially the latter is a strong determinant of life support limitation.…”

Section: Immune and Stress Markers For The Prediction Of Long-term Oumentioning

confidence: 99%

“…Especially the latter is a strong determinant of life support limitation. Outcome prediction (chances of recovery, expected time course of recovery and anticipated quality of life) influences treatment decisions of physicians [64,69,70,71] and is the most important criterion for patients and their relatives to make a decision of treatment withdrawal [67,72] – although the accuracy of early outcome prediction by physicians or currently used scoring systems, e.g. the Acute Physiology and Chronic Health Evaluation Score (APACHE) II, is only moderate [73].…”

Section: Immune and Stress Markers For The Prediction Of Long-term Oumentioning

confidence: 99%

Predicting Post-Stroke Infections and Outcome with Blood-Based Immune and Stress Markers

Meisel

Meisel²,

Harms³

et al. 2012

Cerebrovasc Dis

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About one third of early deaths and poor outcomes after acute stroke are caused by potentially preventable stroke-associated complications, especially infections. Early identification of patients at high risk of infections and poor prognosis with biomarkers might help to initiate adequate therapies and guide treatment decisions. Acute injury of the central nervous system, including stroke, disturbs the normally well-balanced interplay between the sympathetic nervous system and the immune system, thereby impairing the antibacterial immune response in stroke patients. Changes in immune and stress markers, for example a reduction in HLA-DR expression on monocytes or an increase in serum catecholamine levels, occur very early after stroke onset, explain the high susceptibility of stroke patients to bacterial infections, and are predictive of infectious complications occurring up to 2 weeks after stroke. Outcome prediction is of utmost importance for decision-making in stroke units as well as in neurological intensive care units. However, to date the accuracy of outcome prediction by physicians and clinical scoring systems is only moderate. So far, only two blood-based biomarkers have been identified as independent predictors of outcome and mortality after stroke: the stress marker copeptin and midregional pro-atrial natriuretic peptide. Careful evaluation of prognostic markers is needed to prevent the occurrence of self-fulfilling prophecy.

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Withdrawal of Life-Sustaining Therapies and Brain Death in the Intensive Care Unit

Cited by 17 publications

References 66 publications

Integrating Palliative Care Into the Care of Neurocritically Ill Patients

Integrating Palliative Care Into the Care of Neurocritically Ill Patients

Withdrawal of Left Ventricular Assist Devices: A Retrospective Analysis from a Single Institution

Predicting Post-Stroke Infections and Outcome with Blood-Based Immune and Stress Markers

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