ORIGINAL ARTICLE
End-of-life management in intensive care units: a multicentre observational prospective cohort study
1
Hospital Universitario do Oeste do Parana, Cascavel, Parana, Brazil
2
Hospital Sao Lucas – FAG, Cascavel, Parana, Brazil
3
General ICU, Hospital Universitario do Oeste do Parana, Cascavel, Parana, Brazil
4
Hospital do Cancer/UOPECCAN, Cascavel, Parana, Brazil
Submission date: 2019-07-18
Final revision date: 2019-10-09
Acceptance date: 2019-10-19
Publication date: 2019-12-27
Anaesthesiol Intensive Ther 2019;51(5):348-356
KEYWORDS
TOPICS
ABSTRACT
Backgrounds:
The study was conducted to evaluate intensive care unit (ICU) patients that ultimately died but could have met criteria for end-of-life management/palliative care (ELM-PC), and to analyse the application of components of palliative care, either “unperformed procedures” or elements of “futile/unnecessary treatment”.
Methods:
An observational prospective cohort in five ICUs in Southern Brazil. Adult patients who died were evaluated, searching for criteria for ELM-PC. The correct application of nine preselected items by the ICU team was studied.
Results:
Among 253 admissions, 52 patients died; among these, 38.5% met criteria for ELM-PC. Among ELM-PC candidates (n = 20), the ELM-PC was started later (after day 3) in 60%, and only three patients received adequate palliative care. “Analgesia” and “daily family interviews” were the most correctly applied ELM-PC elements. “Terminal extubation/weaning” was not performed in any of the patients. A reduction in the lifespan from the onset of ELM-PC to death was observed in patients who underwent “correct” interventions – 66.6% died on the first day of ELM-PC.
Conclusions:
In a patient cohort from a low-medium-income country, one-third of patients who died in the ICU had criteria (indications) for ELM-PC; however, the palliative care was adequately performed for only 15% of patients, with great heterogeneity and delays regarding its initiation.
The study was conducted to evaluate intensive care unit (ICU) patients that ultimately died but could have met criteria for end-of-life management/palliative care (ELM-PC), and to analyse the application of components of palliative care, either “unperformed procedures” or elements of “futile/unnecessary treatment”.
Methods:
An observational prospective cohort in five ICUs in Southern Brazil. Adult patients who died were evaluated, searching for criteria for ELM-PC. The correct application of nine preselected items by the ICU team was studied.
Results:
Among 253 admissions, 52 patients died; among these, 38.5% met criteria for ELM-PC. Among ELM-PC candidates (n = 20), the ELM-PC was started later (after day 3) in 60%, and only three patients received adequate palliative care. “Analgesia” and “daily family interviews” were the most correctly applied ELM-PC elements. “Terminal extubation/weaning” was not performed in any of the patients. A reduction in the lifespan from the onset of ELM-PC to death was observed in patients who underwent “correct” interventions – 66.6% died on the first day of ELM-PC.
Conclusions:
In a patient cohort from a low-medium-income country, one-third of patients who died in the ICU had criteria (indications) for ELM-PC; however, the palliative care was adequately performed for only 15% of patients, with great heterogeneity and delays regarding its initiation.
REFERENCES (27)
1.
Cook D, Rocker G. Dying with dignity in the intensive care unit. N Engl J Med 2014; 3790: 2506-2512.
2.
Angus DC, Barnato AE, Linde-Zwirble WT, et al., for the Robert Wood Johnson Foundation ICU End-Of-Life Peer Group. Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med 2004; 32: 638-643.
3.
Associação de Medicina Intensiva Brasileira/AMIB. Project Brazilian ICUs. Available at: http://www.utisbrasileiras. com.br/en/amib/.
4.
World Health Organization. Palliative Care Infographics, 2017. Available at: http://www.who.int/ncds/manage... palliative-care/pc-infographics/en/.
5.
Lautrette A, Darmon M, Megarbane B, et al. A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med 2007; 356: 469-478 [Erratum: N Engl J Med 2007; 357: 203].
6.
Campbell ML, Guzman JA. A proactive approach to improve end-of-life care in a medical intensive care unit for patients with terminal dementia. Crit Care Med 2004; 32: 1839-1843.
7.
Kübler A, Siewiera J, Durek G, et al. Guidelines regarding the ineffective maintenance of organ functions (futile therapy) in ICU patients incapable of giving informed statements of will. Anaesthiol Intens Ther 2014; 46: 215-220.
8.
Minne L, Abu-Hanna A, de Jonge E. Evaluation of SOFA-based models for predicting mortality in the ICU: a systematic review. Crit Care 2008; 12: R161.
9.
Lobo SM, Rezende E, Knibel MF, et al. Early determinants of death due to multiple organ failure after noncardiac surgery in high-risk patients. Anesth Analg 2011; 112: 877-883.
10.
Orban JC, Walrave Y, Mongardon N. Causes and characteristics of death in Intensive Care Units: a prospective multicenter study. Anesthesiology 2017; 126: 882-889.
11.
Friedrich JO, Wilson G, Chant C. Long-term outcomes and clinical predictors of hospital mortality in very long stay intensive care unit patients: a cohort study. Critical Care 2006; 10: R59.
12.
Chen YC, Fan HY, Randall Curtis J, et al. Determinants of receiving palliative care and ventilator withdrawal among patients with prolonged mechanical ventilation. Crit Care Med 2017; 45: 1625-1634.
13.
Van der Heide A, Van Delden JJM, Onwuteaka-Philipsen BD. End-of-life decisions in the Netherlands over 25 years. N Engl J Med 2017; 377: 492-494.
14.
The SUPPORT Principal Investigators. A controlled trial to improve care for seriously ill hospitalized patients. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). JAMA 1995; 274: 1591-1598.
15.
Sprung CL, Cohen SL, Sjokvist P, et al. End-of-life practices in European intensive care units: the Ethicus Study. JAMA 2003; 290: 790-797.
16.
Cottereau A, Robert R, Le Gouge A, et al. ICU physicians’ and nurses’ perceptions of terminal extubation and terminal weaning: a self-questionnaire study. Intensive Care Med 2016; 42: 1248-125.
17.
Paruk F, Kissoon N, Hartog CS, et al. The Durban World Congress Ethics Round Table Conference Report: III. Withdrawing mechanical ventilation – the approach should be individualized. J Crit Care 2014; 29: 902-907.
18.
Piva J, Lago P, Othero J, et al. Evaluating end of life practices in tem Brazilian paedriatric and adult intensive care units. J Med Ethics 2010; 36: 344-348.
19.
Parr JD, Zhang B, Nilsson ME, et al. The influence of age on the likelihood of receiving end-of-life care consistent with patient treatment preferences. J Palliat Med 2010; 13: 719-726.
20.
Siewiera J, Tomaszewski D, Piechocki J, Kübler A. Withholding and withdrawing life-sustaining treatment: Experiences in limiting futile therapy from three Polish intensive care departments. Adv Clin Exp Med 2019; 28: 541-546.
21.
Melville A, Kolt G, Anderson D, Mitropoulos J, Pilcher D. Admission to Intensive Care for palliative care or potential organ donation: demographics, circumstances, outcomes, and resource use. Crit Care Med 2017; 45: 1050-1059.
22.
Braus N, Campbell TC, Kwekkeboom KL, et al. Prospective study of a proactive palliative care rouding intervention in a medical ICU. Intensive Care Med 2016; 42: 54-62.
23.
Zalenski RJ, Jones SS, Courage C, et al. Impact of palliative care screening and consultation in the ICU: A multihospital quality improvement project. J Pain Sympt Manag 2017; 53: 5-11.
24.
Koff G, Vaid U, Len E, Crawford A, Oxman DA. Differences in utilization of life support and end-of-life care for medical ICU patients with versus without cancer. Crit Care Med 2017; 45: 379-383.
25.
Khandelwal N, Benkeser D, Coe NB, Engelberg RA, Teno JM, Randall Curtis J. Patterns of cost for patients dying in the Intensive Care Unit and implications for cost savings of Palliative Care interventions. J Palliat Med 2016; 19: 1171-1178.
26.
Kelley AS, Morrison RS. Palliative care for the seriously ill. N Engl J Med 2015; 373: 747-755.
27.
Aslakson R, Pronovost PJ. Health care quality in end-of-life care: Promoting Palliative Care in the Intensive Care Unit. Anesth Clin 2011; 29: 111-122.
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