A survey of use of mTOR inhibitors in patients with lymphangioleiomyomatosis listed for lung transplant.

BACKGROUND: Lymphangioleiomyomatosis (LAM) is an uncommon indication for lung transplantation. The use of mechanistic target of rapamycin (mTOR) inhibitors, which are the mainstay of treatment in progressive LAM, in patients awaiting lung transplant is controversial. We sought to examine worldwide practice patterns in use of mTOR inhibitors in LAM patients on the lung transplant waiting list. METHODS: We designed and disseminated an online survey about institution-specific practice patterns, particularly regarding listing LAM patients for lung transplant and use of mTOR inhibitors in those patients on the transplant waitlist. RESULTS: Of the 49 unique respondent programs, 83.6% had previously listed a LAM patient for lung transplant. Thirteen centers allowed patients to continue on mTOR inhibitor until time of lung transplant. None of those centers reported any complications or deaths attributable to mTOR inhibitor adverse effects. CONCLUSION: There exists significant variability in practice patterns concerning the use of mTOR inhibitors in LAM patients on the lung transplant waiting list. Our survey suggests favorable outcomes for those patients that did continue mTOR inhibitor up to time of transplant. Further data regarding the risk of anastomotic complication with use of mTOR inhibitors in the pre-transplant period would help provide clarity in this debate.

Underweight Patients With Cystic Fibrosis Have Acceptable Survival Following Lung Transplantation: A United Network for Organ Sharing Registry Study.

BACKGROUND: Reduced BMI is an absolute contraindication for lung transplantation (LTx) at most centers in the United States. The objective of this study was to quantify post-LTx survival of moderate to severely underweight patients with cystic fibrosis (CF) (BMI < 17 kg/m2) in the United States relative to normal-weight recipients with CF and other frequently transplanted patient cohorts. METHODS: Using United Network for Organ Sharing Registry data (undergoing transplant from June 2005-November 2015), Kaplan-Meier estimates of median posttransplant survival were calculated for all patients with CF, COPD, and idiopathic pulmonary fibrosis (IPF), as well as low and normal weight CF subgroups. Cox regression modeling stratified according to transplant center assessed risk of posttransplant mortality in recipients with CF and a BMI < 17 kg/m2 compared with recipients with COPD (reference). RESULTS: Median posttransplant survival (95% CI) for CF, COPD, and IPF was 7.9 (7.2-8.6), 5.9 (5.6-6.2), and 5.5 (5.2-5.8) years, respectively. Although an absolute decrease was noted in posttransplant survival for recipients with CF and a BMI < 17 kg/m2, compared with those with CF and a BMI ≥ 17 kg/m2 (7.0 years [4.5-7.9] vs 8.2 years [7.3-9.0]), Cox modeling found no increased mortality risk (adjusted hazard ratio, 1.09; 95% CI, 0.90-1.32; P = .38). There was no difference in posttransplant mortality between patients with CF and a BMI < 17 kg/m2 and recipients with COPD and all BMIs (adjusted hazard ratio, 1.04; 95% CI, 0.86-1.25; P = .71). CONCLUSIONS: Transplant recipients with CF and a BMI < 17 kg/m2 had posttransplant survival rates comparable to those of other groups frequently undergoing transplantation. BMI < 17 kg/m2 as a single risk factor in the CF population should not be treated as an absolute contraindication to LTx.

Frailty Phenotypes, Disability, and Outcomes in Adult Candidates for Lung Transplantation.

RATIONALE: Frailty is associated with morbidity and mortality in abdominal organ transplantation but has not been examined in lung transplantation. OBJECTIVES: To examine the construct and predictive validity of frailty phenotypes in lung transplant candidates. METHODS: In a multicenter prospective cohort, we measured frailty with the Fried Frailty Phenotype (FFP) and Short Physical Performance Battery (SPPB). We evaluated construct validity through comparisons with conceptually related factors. In a nested case-control study of frail and nonfrail subjects, we measured serum IL-6, tumor necrosis factor receptor 1, insulin-like growth factor I, and leptin. We estimated the association between frailty and disability using the Lung Transplant Valued Life Activities disability scale. We estimated the association between frailty and risk of delisting or death before transplant using multivariate logistic and Cox models, respectively. MEASUREMENTS AND MAIN RESULTS: Of 395 subjects, 354 completed FFP assessments and 262 completed SPPB assessments; 28% were frail by FFP (95% confidence interval [CI], 24-33%) and 10% based on the SPPB (95% CI, 7-14%). By either measure, frailty correlated more strongly with exercise capacity and grip strength than with lung function. Frail subjects tended to have higher plasma IL-6 and tumor necrosis factor receptor 1 and lower insulin-like growth factor I and leptin. Frailty by either measure was associated with greater disability. After adjusting for age, sex, diagnosis, and transplant center, both FFP and SPPB were associated with increased risk of delisting or death before lung transplant. For every 1-point worsening in score, hazard ratios were 1.30 (95% CI, 1.01-1.67) for FFP and 1.53 (95% CI, 1.19-1.59) for SPPB. CONCLUSIONS: Frailty is prevalent among lung transplant candidates and is independently associated with greater disability and an increased risk of delisting or death.

Pulmonary hypertension is associated with increased post-lung transplant mortality risk in patients with chronic obstructive pulmonary disease.

BACKGROUND: Pulmonary hypertension associated with lung disease (PHLD) has been shown to be a predictor of disease severity and survival in patients awaiting lung transplantation. Little is known about the relationship of PHLD and survival after lung transplantation or how this may vary by disease. This study evaluated the effect of PHLD on 1-year survival after lung transplantation for patients with the 3 most common indications for transplantation: chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis (IPF), and cystic fibrosis (CF). METHODS: Organ Procurement and Transplantation Network data were obtained for all lung transplant recipients who received an allograft between May 2005 and June 2010. The relationship between PHLD and 1-year survival after lung transplantation for each diagnostic group was examined with Kaplan-Meier estimates and Cox regression. Covariates included in the model were those defined in the current Lung Allocation Score system post-transplant survival model, including age, serum creatinine, percentage predicted forced vital capacity, functional status, and mechanical ventilation use at time of transplant. The estimated relative risk was calculated using Poisson regression with robust error variance and adjustment for covariates. RESULTS: Sample sizes for COPD, IPF, and CF patients were 2,025, 2,304, and 866, respectively. The 1-year post-transplant survival for COPD patients with PHLD was 76.9% vs 86.2% for COPD patients without PHLD (p = 0.001). In multivariate Cox regression analysis COPD patients with PHLD had a 1.74 (95% confidence interval, 1.3-2.3) times higher risk of 1-year post-transplant mortality (p = 0.001). Similar analyses for IPF and CF diagnostic groups showed no significant difference in survival between patients with and without PHLD. CONCLUSIONS: COPD patients with PHLD have increased post-transplant 1-year mortality. No significant difference was seen in patients with IPF or CF. Further studies to evaluate the potential mechanisms for this difference between diagnoses are needed.

Obese patients with idiopathic pulmonary fibrosis have a higher 90-day mortality risk with bilateral lung transplantation.

BACKGROUND: Obese patients with idiopathic pulmonary fibrosis (IPF) have higher 90-day mortality after lung transplantation. We sought to determine whether body mass index (BMI) differentially modified the effect of transplant procedure type on 90-day mortality in IPF patients. METHODS: We analyzed data from the Organ Procurement and Transplantation Network (OPTN) for all patients with IPF who were transplanted between 2000 and 2010. Post-transplant survival was examined using Kaplan-Meier estimates. Multivariable logistic regression modeling was used to determine the difference in 90-day survival. The primary variable of interest was the interaction term between body mass index (BMI) and transplant type. RESULTS: A total of 3,389 (58% single-lung transplant [SLT] and 42% bilateral lung transplant [BLT]) subjects were included. Multivariable logistic regression modeling demonstrated a statistically significant interaction between BMI and transplant type (p = 0.047). Patients with a BMI > 30 kg/m(2) who received a BLT are 1.71 times (95% CI [1.03 to 2.85], p = 0.038) more likely to die within 90 days than BLT recipients with a BMI of 18.5 to 30 kg/m(2). CONCLUSIONS: Our results suggest that obese patients who receive a BLT may be at higher risk of 90-day mortality compared with patients of normal weight. Further study is needed to obtain more detailed information about comorbidities and other risk factors for early death that are not included in the OPTN database.

De novo donor-specific HLA antibodies are associated with early and high-grade bronchiolitis obliterans syndrome and death after lung transplantation.

BACKGROUND: The development of human leukocyte antigen (HLA) antibody responses has been associated with worse clinical outcomes, such as bronchiolitis obliterans syndrome (BOS) and death, in lung transplant recipients (LTRs). However, the role of donor-specific HLA antibody (DSA) responses as a risk factor for poor outcomes remains controversial. METHODS: We prospectively screened 445 LTRs for DSA at our institution at the time of surveillance bronchoscopies for the first 2 years after transplantation between 2003 and 2008, and evaluated clinical outcomes. For this purpose, we used the combination of panel-reactive antibodies (PRA) by enzyme-linked immunosorbent assay (ELISA) and the Luminex single-antigen bead (SAB) assay (One Lambda, Canoga Park, CA). RESULTS: We detected de novo DSA (dnDSA) in 58 of 445 (13%) LTRs in our cohort. Freedom from BOS was significantly reduced in LTRs with dnDSA versus those without dnDSA (p < 0.001). Using a Cox proportional hazards model, the development of dnDSA was associated with a significantly increased hazard ratio (HR = 6.59 [4.53 to 9.59]; p < 0.001) for BOS and high-grade BOS (Stage ≥ 2) (HR = 5.76 [3.48 to 9.52]; p < 0.001). Freedom from death was significantly reduced in LTRs with dnDSA (p < 0.001), including mortality attributable to BOS (HR = 9.86 [4.91 to 19.78]; p < 0.001). CONCLUSIONS: Taken together, our findings provide evidence that dnDSA is associated with accelerated BOS kinetics and severity, as well as death due to BOS after lung transplantation. In addition, these data support regular monitoring for the development of dnDSA in LTRs and underscore the need for novel strategies to mitigate the increased risk of poor outcomes associated with dnDSA.

Circulatory death determination in uncontrolled organ donors: a panel viewpoint.

One barrier for implementing programs of uncontrolled organ donation after the circulatory determination of death is the lack of consensus on the precise moment of death. Our panel was convened to study this question after we performed a similar analysis on the moment of death in controlled organ donation after the circulatory determination of death. We concluded that death could be determined by showing the permanent or irreversible cessation of circulation and respiration. Circulatory irreversibility may be presumed when optimal cardiopulmonary resuscitation efforts have failed to restore circulation and at least a 7-minute period has elapsed thereafter during which autoresuscitation to restored circulation could occur. We advise against the use of postmortem organ support technologies that reestablish circulation of warm oxygenated blood because of their risk of retroactively invalidating the required conditions on which death was declared.

An official American Thoracic Society/International Society for Heart and Lung Transplantation/Society of Critical Care Medicine/Association of Organ and Procurement Organizations/United Network of Organ Sharing Statement: ethical and policy considerations in organ donation after circulatory determination of death.

RATIONALE: Donation after circulatory determination of death (DCDD) has the potential to increase the number of organs available for transplantation. Because consent and management of potential donors must occur before death, DCDD raises unique ethical and policy issues. OBJECTIVES: To develop an ethics and health policy statement on adult and pediatric DCDD relevant to critical care and transplantation stakeholders. METHODS: A multidisciplinary panel of stakeholders was convened to develop an ethics and health policy statement. The panel consisted of representatives from the American Thoracic Society, Society of Critical Care Medicine, International Society for Heart and Lung Transplantation, Association of Organ Procurement Organizations, and the United Network of Organ Sharing. The panel reviewed the literature, discussed important ethics and health policy considerations, and developed a guiding framework for decision making by stakeholders. RESULTS: A framework to guide ethics and health policy statement was established, which addressed the consent process, pre- and post mortem interventions, the determination of death, provisions of end-of-life care, and pediatric DCDD. CONCLUSIONS: The information presented in this Statement is based on the current evidence, experience, and clinical rationale. New clinical research and the development and dissemination of new technologies will eventually necessitate an update of this Statement.

Nature and correlates of post-traumatic stress symptomatology in lung transplant recipients.

BACKGROUND: The burden of post-traumatic stress disorder (PTSD) symptoms may be associated with worse outcomes after transplantation. Little is known about the prevalence and correlates of PTSD symptoms in lung transplant recipients. METHODS: We conducted a cross-sectional study of lung transplant recipients between April 2008 and February 2010 at a single center. The PTSD Checklist was used to determine the burden of PTSD symptomatology (total score) and percent of subjects with a provisional PTSD diagnosis (validated algorithms). We assessed the relationship between PTSD symptom burden and patient characteristics with multivariable logistic modeling. RESULTS: We enrolled 210 subjects (response rate 91%). Most patients were female (50%), and Caucasian (89%). The median age was 59 (interquartile range [IQR] 48 to 63) years and the median time between transplant and follow-up was 2.4 (IQR 0.7 to 5.3) years. Clinically significant PTSD symptomatology was observed in 12.6% (8.4% to 17.9%) of subjects. Subjects were more likely to endorse symptoms of re-experiencing (29.5%) and arousal (33.8%) than avoidant symptoms (18.4%). Multivariable linear regression showed higher PTSD symptom scores among recipients who were: younger (p < 0.001); without private insurance (p = 0.001); exposed to trauma (p < 0.001); or diagnosed with bronchiolitis obliterans syndrome (p = 0.005). CONCLUSIONS: Overall prevalence of PTSD (12.6%) in our study was two times higher than the general population. Patient characteristics found to be associated with an increased burden of PTSD symptoms may be useful to consider in future interventions designed to reduce this comorbidity.

Early major neurologic complications after lung transplantation: incidence, risk factors, and outcome.

BACKGROUND: Early major neurologic complications after lung transplantation represent a major source of morbidity for patients and compromise their quality of life; however, the mechanisms underlying neurologic complications and their impact on outcomes in lung transplantation remain largely unknown. METHODS: Patients who received lung transplants at our institution between January 2004 and December 2010 were identified (n=759). Data on complications including occurrence, timing, management, and outcome were extracted from our transplant database and medical record review. Major neurologic complications were defined as those that were potentially life threatening, required urgent treatment/intubation, or required admission to the intensive care unit. RESULTS: Seventy (9.2%) patients experienced major neurologic complications within 2 weeks after lung transplantation. Most common complications were stroke (41%) and severe toxic/metabolic encephalopathy (37%). Multivariate analysis demonstrated that advanced age, history of coronary artery disease, prolonged use of cardiopulmonary bypass, and severe primary graft dysfunction increased the risk for death in patients with early major neurologic complications (P<0.05). There was a significant difference in survival between patients with neurologic complications and without (90-day mortality: 15% of patients who developed neurologic complications versus 4% of patients who did not; P=0.03; 5-year survival: 51.1% in patients who developed neurologic complication versus 62.1% in patients who did not; P<0.05). CONCLUSIONS: Early major neurologic complications after lung transplantation are common and carry substantial morbidity and mortality. Given the risk factors identified in this study, additional pretransplantation workup and intraoperative and postoperative monitoring for high-risk patients may help reduce the incidence of neurologic complications.

Donor smoking history and age in lung transplantation: a revisit.

BACKGROUND: When selecting a donor for lung transplantation, it is generally believed that the best outcomes occur when the donor has no smoking history. Because we experienced unexpected adverse outcomes after transplant of lungs from teenaged donors with no smoking history, this study revisited the effects of donor smoking history in relation to age on transplant outcomes. METHODS: We conducted a retrospective review of 532 consecutive lung transplants performed at our institution. Most donors (293, 55%) had a history of smoking; 239 donors were nonsmokers. The smoking donors were further subgrouped based on consumption (<20, 20-40, or >40 pack-years). The nonsmoking donors were subgrouped by age (<20 years or ≥20 years). Recipients' characteristics and outcomes were compared. RESULTS: The recipients of lungs from donors with a smoking history showed better 5-year survival than recipients of lungs from nonsmokers (65.8% vs. 48.3%, P<0.05), but recipients of lungs from heavy smokers (>40 pack-years smoking history) exhibited a significantly higher incidence of severe primary graft dysfunction and higher short- and long-term mortality than the recipients of lungs from donors who smoked less. Surprisingly, recipients of lungs from teenaged donors with no smoking history exhibited a higher morbidity and mortality than recipients of lungs from adult nonsmoking donors but did not exhibit decreased posttransplant forced expiratory volume in 1 sec. CONCLUSIONS: In this large, single-center experience, the absence of smoking history in the donor did not result in better long-term outcomes after lung transplantation. Potential problems with lungs from teenaged donors with no smoking history were suggested.

Reduction in airway complications after lung transplantation with novel anastomotic technique.

BACKGROUND: Bronchial anastomotic complications develop in 31% of lung transplant recipients, leading to additional operative procedures and increased morbidity. Advances in surgical technique have thus far resulted in only modestly improved outcomes. We hypothesized that creating the bronchial anastomosis at the secondary carina using a combination of running and figure-of-eight sutures would minimize donor bronchial ischemia and airway complications. METHODS: This retrospective review of a single surgeon's operative experience from 2000 to 2007 compares a new bronchial anastomotic technique with the conventional technique. The primary outcome was the occurrence of bronchial anastomotic complications requiring invasive intervention. The secondary outcome was distal airway complications. Patients were monitored for 1 year after transplant. Recipient and donor demographic data as well as relevant variables from their preoperative, perioperative, and postoperative courses were collected for analysis. These data were compared using t tests for normally distributed continuous variables, Mann-Whitney tests for nonnormally distributed continuous variables, and χ2 tests or Fisher exact test for categoric variables. Logistic regression was used to control for covariates while comparing the primary outcome between the new and conventional bronchial anastomotic techniques. RESULTS: The analysis included 230 patients, representing 407 anastomoses. The occurrence of anastomotic complications requiring intervention and distal airway complications decreased from 18.1% to 2.3% of anastomoses and 12.2% to 4.4% of patients, respectively. After controlling for available risk factors, the new technique significantly reduced both anastomotic (p<0.001) and distal (p=0.03) airway complications. CONCLUSIONS: This new anastomotic technique dramatically reduces anastomotic and distal airway complications after lung transplantation.

ICU care associated with symptoms of depression and posttraumatic stress disorder among family members of patients who die in the ICU.

BACKGROUND: Psychologic symptoms of posttraumatic stress disorder (PTSD) and depression are relatively common among family members of patients who die in the ICU. The patient-level risk factors for these family symptoms are not well understood but may help to target future interventions. METHODS: We performed a cohort study of family members of patients who died in the ICU or within 30 h of ICU transfer. Outcomes included self-reported symptoms of PTSD and depression. Predictors included patient demographics and elements of palliative care. RESULTS: Two hundred twenty-six patients had chart abstraction and family questionnaire data. Family members of older patients had lower scores for PTSD (P = .026). Family members that were present at the time of death (P = .021) and family members of patients with early family conferences (P = .012) reported higher symptoms of PTSD. When withdrawal of a ventilator was ordered, family members reported lower symptoms of depression (P = .033). There were no other patient characteristics or elements of palliative care associated with family symptoms. CONCLUSIONS: Family members of younger patients and those for whom mechanical ventilation is not withdrawn are at increased risk of psychologic symptoms and may represent an important group for intervention. Increased PTSD symptoms among family members present at the time of death may reflect a closer relationship with the patient or more involvement with the patient's ICU care but also suggests that family should be offered the option of not being present.

Development of a predictive model for long-term survival after lung transplantation and implications for the lung allocation score.

BACKGROUND: Improving long-term survival after lung transplantation can be facilitated by identifying patient characteristics that are predictors of positive long-term outcomes. Validated survival modeling is important for guiding clinical decision-making, case-mix adjustment in comparative effectiveness research and refinement of the lung allocation system (LAS). METHODS: We used the registry of the International Society for Heart and Lung Transplantation (ISHLT) to develop and validate a predictive model of 5-year survival after lung transplantation. A total of 18,072 eligible cases were randomly split into development and validation datasets. Pre-transplant recipient variables considered included age, gender, diagnosis, body mass index, serum creatinine, hemodynamic variables, pulmonary function variables, viral status and comorbidities. Predictors were considered in a stepwise approach with the Akaike Information Criteria (AIC). Time-dependent receiver operator characteristic (ROC) curves assessed predictive ability. A 1-year conditional model and three models for disease subgroups were considered. ROC methods were used to characterize the predictive potential of the LAS post-transplant model at 1 and 5 years. RESULTS: The baseline model included age, diagnosis, creatinine, bilirubin, oxygen requirement, cardiac output, Epstein-Barr virus status, transfusion history and diabetes history. Prediction of long-term survival was poor (area under the curve [AUC] = 0.582). Neither the 1-year conditional model (AUC = 0.573) nor models designed for separate diseases (AUC = 0.553 to 0.591) improved survival prediction. The predictive ability of the LAS post-transplant parameters was similar to that of our model (1-year AUC = 0.580 and 5-year AUC = 0.566). CONCLUSIONS: Models developed from pre-transplant characteristics poorly predict long-term survival. Models for separate diseases and 1-year conditional models did not improve prediction. Better databases and approaches to predict survival are needed to improve lung allocation.

The circulatory-respiratory determination of death in organ donation.

OBJECTIVE: Death statutes permit physicians to declare death on the basis of irreversible cessation of circulatory-respiratory or brain functions. The growing practice of organ donation after circulatory determination of death now requires physicians to exercise greater specificity in circulatory-respiratory death determination. We studied circulatory-respiratory death determination to clarify its concept, practice, and application to innovative circulatory determination of death protocols. RESULTS: It is ethically and legally appropriate to procure organs when permanent cessation (will not return) of circulation and respiration has occurred but before irreversible cessation (cannot return) has occurred because permanent cessation: 1) is an established medical practice standard for determining death; 2) is the meaning of "irreversible" in the Uniform Determination of Death Act; and 3) does not violate the "Dead Donor Rule." CONCLUSIONS: The use of unmodified extracorporeal membrane oxygenation in the circulatory determination of death donor after death is declared should be abandoned because, by restoring brain circulation, it retroactively negates the previous death determination. Modifications of extracorporeal membrane oxygenation that avoid this problem by excluding brain circulation are contrived, invasive, and, if used, should require consent of surrogates. Heart donation in circulatory determination of death is acceptable if proper standards are followed to declare donor death after establishing the permanent cessation of circulation. Pending additional data on "auto-resuscitation," we recommend that all circulatory determination of death programs should utilize the prevailing standard of 2 to 5 mins of demonstrated mechanical asystole before declaring death.

Predictors of symptoms of posttraumatic stress and depression in family members after patient death in the ICU.

BACKGROUND: Patients' deaths in the ICU have been associated with a high burden of psychologic symptoms in families. This study identifies characteristics associated with psychologic symptoms in family members. METHODS: Families of patients dying in the ICU or within 30 h of ICU discharge in 11 hospitals previously participated in a randomized trial. In the current study, we assessed these families for symptoms of posttraumatic stress disorder (PTSD) and depression with follow-up surveys. Outcomes included validated measures of PTSD (PTSD Checklist) and depressive (Patient Health Questionnaire) symptoms. Predictors included family member mental-health history, involvement in decision making, and demographics. RESULTS: Surveys were completed by 226 families. Response rate was 46% in the original randomized trial and 82% in this study. Prevalence (95% CI) of PTSD and depressive symptoms were 14.0% (9.7%-19.3%) and 18.4% (13.5%-24.1%), respectively. Family characteristics associated with increased symptoms included: female gender (PTSD, P = .020; depression, P = .005), knowing the patient for a shorter duration (PTSD, P = .003; depression, P = .040), and discordance between family members' preferences for decision making and their actual decision-making roles (PTSD, P = .005; depression, P = .049). Depressive symptoms were also associated with lower educational level (P = .002). Families with psychologic symptoms were more likely to report that access to a counselor (PTSD, P < .001; depression, P = .003) and information about spiritual services might have been helpful while the patient was in the ICU (PTSD, P = .024; depression, P = .029). CONCLUSIONS: Families demonstrated a high prevalence of psychologic symptoms after a death in the ICU. Characteristics associated with symptoms may help target interventions to reduce these symptoms. TRIAL REGISTRATION: clinicaltrials.gov; Identifier: NCT00685893.

Posttraumatic stress disorder following critical illness.

Posttraumatic stress disorder (PTSD) is a common psychiatric condition that can occur after a traumatic event. Individuals exposed to traumatic events are at risk for PTSD and other psychologic morbidity, such as depression, panic disorder, generalized anxiety disorder, and substance abuse. The burden of PTSD can be high, with inability to work or return to prior levels of functioning. Emerging literature suggests a significantly increased risk for symptoms of PTSD among survivors of critical illness and the families of patients who survive or die after critical illness. This review summarizes these studies and provides suggestions for current clinical implications and for future research.

Family member satisfaction with end-of-life decision making in the ICU.

RATIONALE: Families of ICU patients may be at risk for increased psychological morbidity due to end-of-life decision making. The identification of chart-based quality indicators of palliative care that predict family satisfaction with decision making may help to guide interventions to improve decision making and family outcomes. OBJECTIVE: To determine patient and family characteristics and chart the documentation of processes of care that are associated with increased family satisfaction with end-of-life decision making for ICU patients. METHODS: We conducted a cohort study of ICU patients dying in 10 medical centers in the Seattle-Tacoma area. MEASUREMENT: Outcomes from family surveys included summary scores for family satisfaction with decision making and a single-item score that indicated feeling supported during decision making. Predictor variables were obtained from surveys and chart abstraction. MAIN RESULTS: The survey response rate was 41% (442 of 1,074 families responded). Analyses were conducted of 356 families with questionnaire and chart abstraction data. Family satisfaction with decision making was associated with the withdrawal of life support, and chart documentation of physician recommendations to withdraw life support, discussions of patients' wishes, and discussions of families' spiritual needs. Feeling supported during decision making was associated with the withdrawal of life support, spiritual care involvement, and chart documentation of physician recommendations to withdraw life support, expressions of families' wishes to withdraw life support, and discussions of families' spiritual needs. CONCLUSIONS: Increased family satisfaction with decision making is associated with withdrawing life support and the documentation of palliative care indicators including the following: physician recommendations to withdraw life support; expressions of patients' wishes; and discussions of families' spiritual needs. These findings provide direction for future studies to investigate approaches to improving family satisfaction in end-of-life decision making. In addition, because there were few nonwhites in this study, these results may not be generalizable to more diverse populations. Future studies should target diverse populations in order to test whether similar factors are similarly important for end-of-life decision making.

Lung allocation score for lung transplantation: impact on disease severity and survival.

BACKGROUND: Prior to implementation of the lung allocation score (LAS) system, allocation of donor lungs was based on accrued time on the waiting list and was potentially influenced by center-specific thresholds for listing. The impact of LAS implementation on patient characteristics and survival is unknown. METHODS: United Network of Organ Sharing data were obtained on all lung transplant candidates listed and all patients undergoing transplantation in region 6 between May 4, 2003, and May 4, 2006. Each data set was divided into two cohorts: 2 years before LAS implementation, and 1 year after LAS implementation. LAS was calculated and compared by cohort. Pre-LAS and post-LAS differences in patient characteristics were examined. Waiting list and posttransplant survival rates for each cohort were examined using Kaplan-Meier estimates and Cox regression. RESULTS: After LAS implementation, the distribution of diagnoses in patients undergoing transplantation significantly changed (p = 0.02), while the distribution of diagnoses in those listed did not (p = 0.17). Characteristics of patients on the waiting list were similar, except that a higher proportion of nonwhite patients were listed (p = 0.04) and lower FVC (p < 0.001) was observed after LAS implementation. Similarly, characteristics of patients undergoing transplantation did not change, except that posttransplant hospital length of stay was shorter (p = 0.01) after LAS implementation. Calculated LAS was higher after LAS implementation (p = 0.006). After controlling for age and diagnosis, neither waiting list nor transplant survival was significantly different (p = 0.93 and p = 0.81, respectively). CONCLUSIONS: After LAS implementation, the distribution of diagnoses in lung transplant recipients was significantly changed, while that of candidates was not. Posttransplant and waiting list survival were not affected by the LAS system, but power was limited. Larger and long-term survival studies are needed to determine if the LAS system improves overall allocation and survival for patients interested in lung transplantation.