Terminal withdrawal of mechanical ventilation in adult intensive care units: A systematic review and narrative synthesis of perceptions, experiences and practices.

BACKGROUND: During the terminal withdrawal of life-sustaining measures for intensive care patients, the removal of respiratory support remains an ambiguous practice. Globally, perceptions and experiences of best practice vary due to the limited evidence in this area. AIM: To identify, appraise and synthesise the latest evidence around terminal withdrawal of mechanical ventilation in adult intensive care units specific to perceptions, experiences and practices. DESIGN: Mixed methods systematic review and narrative synthesis. A review protocol was registered on PROSPERO (CRD42018086495). DATA SOURCES: Four electronic databases were systematically searched (Medline, Embase, CENTRAL and CINAHL). Obtained articles published between January 2008 and January 2020 were screened for eligibility. All included papers were appraised using relevant appraisal tools. RESULTS: Twenty-five papers were included in the review. Findings from the included papers were synthesised into four themes: 'clinicians' perceptions and practices'; 'time to death and predictors'; 'analgesia and sedation practices'; 'physiological and psychological impact'. CONCLUSIONS: Perceptions, experiences and practices of terminal withdrawal of mechanical ventilation vary significantly across the globe. Current knowledge highlights that the time to death after withdrawal of mechanical ventilation is very short. Predictors for shorter duration could be considered by clinicians and guide the choice of pharmacological interventions to address distressing symptoms that patients may experience. Clinicians ought to prepare patients, families and relatives for the withdrawal process and the expected progression and provide them with immediate and long-term support following withdrawal. Further research is needed to improve current evidence and better inform practice guidelines.

Improving quality of withdrawal of life-sustaining measures in organ donation: a framework and implementation toolkit.

BACKGROUND: Donation after circulatory determination of death (DCD) is responsible for the largest increase in deceased donation over the past decade. When the Canadian DCD guideline was published in 2006, it included recommendations to create standard policies and procedures for withdrawal of life-sustaining measures (WLSM) as well as quality assurance frameworks for this practice. In 2016, the Canadian Critical Care Society produced a guideline for WLSM that requires modifications to facilitate implementation when DCD is part of the end-of-life care plan. METHODS: A pan-Canadian multidisciplinary collaborative was convened to examine the existing guideline framework and to create tools to put the existing guideline into practice in centres that practice DCD. RESULTS: A set of guiding principles for implementation of the guideline in DCD practice were produced using an iterative, consensus-based approach followed by development of four implementation tools and three quality assurance and audit tools. CONCLUSIONS: The tools developed will aid DCD centres in fulsomely adapting the Canadian Critical Care Society Withdrawal of Life-Sustaining Measures guideline.

RéSUMé: CONTEXTE : Au cours des dix dernières années, le don d'organe après un décès cardiocirculatoire (DDC) a été à l'origine de la plus importante augmentation de dons provenant d'individus décédés. Les lignes directrices canadiennes sur le DDC, publiées en 2006, recommandaient la création de politiques et de procédures standard pour l'interruption des traitements de maintien des fonctions vitales (TMFV) ainsi que celle de cadres d'assurance de la qualité pour cette pratique. En 2016, la Société canadienne de soins intensifs a publié des recommandations concernant les TMFV; ces recommandations nécessitent des modifications pour pouvoir être facilement mises en œuvre lorsque le DDC fait partie du plan de soins de fin de vie. MéTHODE : Un groupe collaboratif multidisciplinaire pancanadien s'est réuni afin d'examiner le cadre établi par les lignes directrices existantes et créer des outils pour mettre en œuvre ces recommandations dans les centres pratiquant le DDC. RéSULTATS : En utilisant une approche itérative et consensuelle, un ensemble de principes directeurs a été créé pour mettre en œuvre des directives concernant la pratique du DDC : quatre outils d'implantation et trois outils d'assurance de la qualité et d'audit ont été mis au point. CONCLUSION : Les outils créés aideront les centres de DDC à adapter de manière plus complète les Lignes directrices pour l'interruption des traitements de maintien des fonctions vitales de la Société canadienne de soins intensifs.

The influence of corticosteroid treatment on the outcome of influenza A(H1N1pdm09)-related critical illness.

BACKGROUND: Patients with 2009 pandemic influenza A(H1N1pdm09)-related critical illness were frequently treated with systemic corticosteroids. While observational studies have reported significant corticosteroid-associated mortality after adjusting for baseline differences in patients treated with corticosteroids or not, corticosteroids have remained a common treatment in subsequent influenza outbreaks, including avian influenza A(H7N9). Our objective was to describe the use of corticosteroids in these patients and investigate predictors of steroid prescription and clinical outcomes, adjusting for both baseline and time-dependent factors. METHODS: In an observational cohort study of adults with H1N1pdm09-related critical illness from 51 Canadian ICUs, we investigated predictors of steroid administration and outcomes of patients who received and those who did not receive corticosteroids. We adjusted for potential baseline confounding using multivariate logistic regression and propensity score analysis and adjusted for potential time-dependent confounding using marginal structural models. RESULTS: Among 607 patients, corticosteroids were administered to 280 patients (46.1%) at a median daily dose of 227 (interquartile range, 154-443) mg of hydrocortisone equivalents for a median of 7.0 (4.0-13.0) days. Compared with patients who did not receive corticosteroids, patients who received corticosteroids had higher hospital crude mortality (25.5% vs 16.4%, p = 0.007) and fewer ventilator-free days at 28 days (12.5 ± 10.7 vs 15.7 ± 10.1, p < 0.001). The odds ratio association between corticosteroid use and hospital mortality decreased from 1.85 (95% confidence interval 1.12-3.04, p = 0.02) with multivariate logistic regression, to 1.71 (1.05-2.78, p = 0.03) after adjustment for propensity score to receive corticosteroids, to 1.52 (0.90-2.58, p = 0.12) after case-matching on propensity score, and to 0.96 (0.28-3.28, p = 0.95) using marginal structural modeling to adjust for time-dependent between-group differences. CONCLUSIONS: Corticosteroids were commonly prescribed for H1N1pdm09-related critical illness. Adjusting for only baseline between-group differences suggested a significant increased risk of death associated with corticosteroids. However, after adjusting for time-dependent differences, we found no significant association between corticosteroids and mortality. These findings highlight the challenges and importance in adjusting for baseline and time-dependent confounders when estimating clinical effects of treatments using observational studies.

How is life support withdrawn in intensive care units: A narrative review.

PURPOSE: Decisions to withdraw life-sustaining therapy (WDLS) are relatively common in intensive care units across Canada. As part of preliminary work to develop guidelines for WDLS, we performed a narrative review of the literature to identify published studies of WDLS. MATERIALS AND METHODS: A search of MEDLINE and EMBASE databases was performed. The results were reviewed and only articles relevant to WDLS were included. Any references within these articles deemed to be relevant were subsequently included. RESULTS: The initial search identified 3687 articles. A total of 100 articles of interest were identified from the initial search and a review of their references. The articles were primarily composed of observational data and expert opinion. The information from the literature was organized into 6 themes: preparation for WDLS, monitoring parameters, pharmacologic symptom management, withdrawing life-sustaining therapies, withdrawal of mechanical ventilation, and bereavement. CONCLUSIONS: This review describes current practices and opinions about WDLS, and also demonstrates the significant practice variation that currently exists. We believe that the development of guidelines to help increase transparency and standardize the process will be an important step to ensuring high quality care during WDLS.

Guidelines for the withdrawal of life-sustaining measures.

BACKGROUND: Withdrawal of life-sustaining measures is a common event in the intensive care unit yet it involves a complex balance of medical, legal and ethical considerations. Very few healthcare providers have been specifically trained to withdraw life-sustaining measures, and no comprehensive guidelines exist to help ensure clinicians deliver the highest quality of care to patients and families. Hence, we sought to develop guidelines for the process of withdrawing life-sustaining measures in the clinical setting. METHODS: We convened an interdisciplinary group of ICU care providers from the Canadian Critical Care Society and the Canadian Association of Critical Care Nurses, and used a modified Delphi process to answer key clinical and ethical questions identified in the literature. RESULTS: A total of 39 experienced clinicians completed the initial workshop, and 36 were involved in the subsequent Delphi rounds. The group developed a series of guidelines to address (1) preparing for withdrawal of life-sustaining measures; (2) assessment of distress; (3) pharmaceutical management of distress; and (4) discontinuation of life-sustaining measures and monitoring. The group achieved consensus on all aspects of the guidelines after the third Delphi round. CONCLUSION: We present these guidelines to help physicians provide high-quality end of life (EOL) care in the ICU. Future studies should address their effectiveness from both critical care team and family perspectives.

2009 influenza A (H1N1): a clinical review.

Since the onset of the 2009 influenza A (H1N1) pandemic, the virus has caused significant morbidity and mortality. Most cases of 2009 H1N1 have presented as mild febrile illnesses with cough, sore throat, and occasional gastrointestinal symptoms. Dyspnea has been more commonly associated with the onset of severe pulmonary disease. Unlike seasonal influenza, the prevalence of 2009 H1N1 is greatest among children and young adults, although older patients and those with comorbidities are more likely to experience worse clinical outcomes. Among the most severely affected, critical illness evolves within 4 to 6 days from symptom onset, and approximately 70% of these patients require mechanical ventilation ranging in duration from days to weeks. Compared with prior influenza seasons, the need for rescue oxygenation therapy with nitric oxide, prone ventilation, high-frequency oscillation, and extracorporeal membrane oxygenation has increased. Specific medical care with neuraminidase inhibitors and antibiotics for secondary bacterial pneumonia are the mainstays of therapy. With optimal care, mortality rates range from 5% to 7% among those hospitalized and reach approximately 20% among those admitted to the intensive care unit.