End of life care in Italian intensive care units: where are we now?

Most patients in the ICU are unable to make decisions for themselves at the end of life (EOL), and the responsibility for these decisions falls to the medical staff and patients' relatives. Therefore, clinicians must frequently communicate with patients' relatives to understand the patients' values and preferences as they perform medical decision making. The family's role in this process varies: the entire burden of decision making could rest with the family, or family members could be informed of the decisions without admission into the decision-making process. In contrast to these two extremes, clinicians and family members may also enter into shared decision making: an exchange of views and opinions between clinicians and the patient's family to enable the two parties to reach decisions together. In this latter scenario, the effectiveness of the discussions that take place between clinicians and family members becomes a crucial marker of high-quality intensive care. In this review, we provide an overview of the current literature concerning the state of EOL care in European and Italian ICUs and then summarize several European and American recommendations for improving EOL care in the ICU. Finally, we examine the opportunity to use shared decision making to improve EOL care in the ICU through interdisciplinary communication, open and realistic discussion of prognosis with families, and an approach respecting different cultural perspectives.

[In clinical use conditions naloxone does not antagonize the effects of ketamine]. / In condizioni di impiego clinico il naloxone non antagonizza l'azione della ketamina.

PIP: 20 women undergoing voluntary induced abortion for the first time who were 25-35 years old and weighed 55-65 kg. received .2 mg/kg diazepam iv and 2 mg/kg ketamine iv. 5 and 10 minutes after starting of anesthesia, 10 patients received 4 mcg/kg naloxone iv for a total dose of 8 mcg/kg. The remaining 10 patients received 2 ml of physiological solution iv twice. The interval between the administration and onset of anesthesia was 78 + or - 10.3 seconds in the control group and 79.1 + or - 12.9 seconds in the treatment group. The duration of anesthesia was 7.5 + or - .8 minutes in controls and 7.4 + or - 1 minute in the naloxone-treated group. The recuperation as measured by answering simple commands was 23.8 = or - 3 minutes in controls and 24 + or - 4.2 minutes in the naloxone group. Recognition of persons was 36.5 + or - 5.3 minutes and 36 + or - 5.2 minutes, respectively; and the regaining of spacial- temporal orientation took 75 + or - 9.8 minutes and 73.8 + or - 12.2 minutes, respectively. These figures were without statistical significance. There were 13 and 14 instances of side effects in controls and the naloxone treatment group, respectively. 1 case of delirium occurred in both groups; 3 cases of diplopia in both groups; 6 and 5 instances of floating, respectively; 3 and 4 instances of vertigo, respectively; and 1 case of vomiting in the naloxone group. 1 patient in each group considered the experience unpleasant, 4 patients each were unaffected, and 1 each judged it pleasant. The score on the scale of analgesia was 2.4 + or - 1.2 in the control group and 2.3 + or - .9 in the naloxone-treated group. In conclusion, clinical doses of naloxone did not appreciably modify the action of ketamine, and clinical doses of ketamine do not interfere the opiate receptors.^ieng

[Impact of an integrated treatment approach of the severely injured patients (ISS =/> 16) on hospital mortality and quality of care]. / Impatto di un modello di gestione integrata dei pazienti con trauma grave (ISS >/= 16) sulla qualità del trattamento ospedaliero e sulla mortalità ospedaliera.

BACKGROUND: Outcome of severely injured patients is sharply influenced by the level of prehospital and hospital organization. OBJECTIVE: To evaluate the impact of the re-organization of the trauma care process on the quality of care and final outcome of major trauma (ISS =/< 16) victims. SETTING: the Emergency Department (ED) of a 1600 bedded tertiary care hospital. INTERVENTION: a standardized approach to major trauma patients (MT) was implemented: Written protocols were established and trauma teams were organized. All anesthesiologists and trauma surgeons involved in trauma care were enrolled in an educational program including ATLS Courses and the Italian Resuscitation Council Prehospital Trauma Care Course. One of the targets was to assure the early orthopedic stabilization of limb and pelvis fractures. METHODS: Data of all major trauma victims admitted to the ED during 3 comparable periods of time: before (Jan-May 1998), during (Jan-May 1999) and after (Jan-May 2000) the implementation of the process, were retrospectively and prospectively collected and analyzed. RESULTS: MT patients admitted to the hospital increased from 39 in 1998 to 106 in 2000. For similar ISS (30.2 +/- 11.3 in 1998, 29.6 +/- 13.7 in 1999 and 30.5 +/- 12.9 in 2000) hospital mortality dropped from 42% in 1998 to 20.8%. The mean time from hospital admission to surgical orthopedic stabilization was 12 days in 1998, 4.6 in 1999 and 1.3 in 2000. In 2000, 86% of the patients with limbs fractures who required surgical stabilization, were treated within 36 hours from admission vs 11% in 1998. CONCLUSIONS: The implementation of written protocols for trauma care, the organization of trauma teams, educational programs including ATLS and PTC-IRC Courses and a strategy of early stabilization of limb fractures are associated with a dramatic decrease in hospital mortality for major trauma.