Assessment of breathing in cardiac arrest: a randomised controlled trial of three teaching methods among laypersons.

BACKGROUND: The aim of this trial was to compare a video- and a simulation-based teaching method to the conventional lecture-based method, hypothesizing that the video- and simulation-based teaching methods would lead to improved recognition of breathing patterns during cardiac arrest. METHODS: In this Danish, investigator-initiated, stratified, randomised controlled trial, adult laypersons (university students, military conscripts and elderly retirees) participating in European Resuscitation Council Basic Life Support courses were randomised to receive teaching on how to recognise breathing patterns using a lecture- (usual practice), a video-, or a simulation-based teaching method. The primary outcome was recognition of breathing patterns in nine videos of actors simulating normal breathing, no breathing, and agonal breathing (three of each). We analysed outcomes using logistic regression models and present results as odds ratios (ORs) with 95% confidence intervals (CIs) and P-values from likelihood ratio tests. RESULTS: One hundred fifty-three participants were included in the analyses from February 2, 2018 through May 21, 2019 and recognition of breathing patterns was statistically significantly different between the teaching methods (P = 0.013). Compared to lecture-based teaching (83% correct answers), both video- (90% correct answers; OR 1.77, 95% CI: 1.19-2.64) and simulation-based teaching (88% correct answers; OR 1.48; 95% CI: 1.01-2.17) led to significantly more correct answers. Video-based teaching was not statistically significantly different compared to simulation-based teaching (OR 1.20; 95% CI: 0.78-1.83). CONCLUSION: Video- and simulation-based teaching methods led to improved recognition of breathing patterns among laypersons participating in adult Basic Life Support courses compared to the conventional lecture-based teaching method.

A critical assessment of early warning score records in 168,000 patients.

The national early warning score (NEWS) is recommended to detect deterioration in hospitalised patients. In 2013, a NEWS-based system was introduced in a hospital service with over 250,000 annual admissions, generating large amounts of NEWS data. The quality of such data has not been described. We critically assessed NEWS data recorded over 12 months. This observational study included NEWS records from adult inpatients hospitalized in the Capital Region of Denmark during 2014. Physiological variables and the use of supplementary oxygen (NEWS variables) were recorded. We identified implausible records and assessed the distributions of NEWS variable values. Of 2,835,331 NEWS records, 271,103 (10%) were incomplete with one or more variable missing and 0.2% of records containing implausible values. Digit preferences were identified for respiratory rate, supplementation oxygen flow, pulse rate, and systolic blood pressure. There was an accumulation of pulse rate records below 91 beats per minute. Among complete NEWS records, 64% had NEWS ≥ 1; 29% had NEWS ≥ 3; and 8% had NEWS ≥ 6. In a large set of NEWS data, 10% of the records were incomplete. In a system where data were manually entered into an electronic medical record, digit preferences and the accumulation of pulse rate records below 91 beats per minute, which is the limit for NEWS point generation, showed that staff practice influenced the recorded values. This indicates a potential limitation of transferability of research results obtained in such systems to fully automated systems.

Improving the Credibility of Child Sexual Assault Victims in Court: The Impact of a Sexual Assault Nurse Examiner.

The present study investigated the influence of a sexual assault nurse examiner's (SANE's) testimony on mock juror perceptions of a child or adolescent victim of child sexual assault. Community members (N = 252, 156 females) read a fictional criminal trial summary of a child sexual assault case in which the victim was 6 or 15 years old and the prosecution presented medical testimony from a SANE or a traditional registered nurse (RN), or did not present medical testimony. Mock jurors were more likely to render guilty verdicts when a SANE testified compared with the other two testimony conditions. In addition, pro-victim judgments (e.g., sympathy toward the victim) and negative defendant judgments (e.g., anger toward the defendant) mediated this relation. Finally, cognitive network representations of the case demonstrated that the RN and no-medical-testimony groups were similar and the SANE group was distinct from the other two conditions. We discuss these results in terms of the implications of SANE testimony in child sexual assault court cases.

The impact of frequency of behavior and type of contact on judgments involving a criminal stalking case.

We investigated mock juror perceptions of the frequency of behavior and type of contact in an ex-intimate stalking case. We used a mock-juror methodology, in which 204 community members (129 women) read a stalking trial summary, rendered a verdict, and evaluated the intent of the defendant to cause the victim fear and distress, as well as the victim's experience with these emotions. The trial varied as to whether there were 5 or 30 stalking incidents and whether the stalking involved personal contact or stalking via text message. Results showed that females were more likely to render a guilty verdict when the victim had been stalked 30 times rather than 5 times while males were equally likely to render a guilty verdict regardless of the frequency. Mock jurors were significantly more likely to render guilty verdicts in the personal contact condition than in the text message condition. Females' perceptions of the victim's fear and distress mediated the frequency of incidents x gender interaction. The victim's fear and the defendant's intentions mediated the main effect of type of contact on verdict. Cognitive network analyses showed that victim fear and the defendant's intent to cause fear were central to participant verdict decision making. We discuss these results in terms of the implications, specifically that victim fear should be a primary focus in stalking legislation.

Using simulation scenarios and a debriefing structure to promote feedback skills among interprofessional team members in clinical practice.

BACKGROUND: Team reflexivity and peer feedback in daily clinical work can improve patient safety. However, teams do not always engage in reflection after patient care. A reason could be that team members may lack skills in engaging in team reflection. This study explores the use of interprofessional team-based simulations to encourage and equip teams for reflective conversations in the real-world clinical practice. METHODS: This was a prospective, explorative study of team members' perceptions of the use of in situ simulation-based scenarios with critically ill patient cases to train team-based reflections and peer feedback. The study took place in two neurological wards. Prior to the intervention, a 1-day observation in each ward and semi-structured short interviews with physicians and nurses were conducted. RESULTS: A total of 94 staff members, 57 nurses, 8 nurse assistants and 29 physicians participated in the in situ simulation scenarios. All team members showed appreciation of the safe learning environment. The authors found that the simulations and the debriefing structure provided an opportunity for training of team reflexivity and feedback. The team members evaluated the simulation-based training very positively, and their initial reaction indicated that they found peer feedback useful for the individual and the team. This approach allowed them to reflect on their own clinical practice. CONCLUSION: The simulation-based training scenarios and the debriefing structure promoted team members' team reflexivity and peer feedback skills. The method is feasible and could be used in other specialties and situations. The team members' reactions to feedback were positive, and based on their reflections, there is a potential to increase both individual and team skills as well as improve patient treatment.

Whom Would You Help? The Impact of Perpetrator and Victim Gender on Bystander Behavior During a Sexual Assault.

We examined the impact of perpetrator and victim gender on bystander helping choices and assault perceptions. Participants (32 females, 37 males) read about two simultaneously occurring sexual assaults, indicated which victim they would help, and gave their perceptions of the assaults. We used a within-participants design that fully manipulated the perpetrator and victim gender for both assaults. Results showed female victims of male perpetrators and male victims of female perpetrators were most and least likely to be chosen for help, respectively. Cognitive networks derived from open-ended responses provided insight into the rationale used by participants to make helping decisions in ways that differed by perpetrator and victim gender.

The Eldicus prospective, observational study of triage decision making in European intensive care units: part I--European Intensive Care Admission Triage Scores.

OBJECTIVE: Life and death triage decisions are made daily by intensive care unit physicians. Scoring systems have been developed for prognosticating intensive care unit mortality but none for intensive care unit triage. The objective of this study was to develop an intensive care unit triage decision rule based on 28-day mortality rates of admitted and refused patients. DESIGN: Prospective, observational study of triage decisions from September 2003 until March 2005. SETTING: Eleven intensive care units in seven European countries. PATIENTS: All patients >18 yrs with a request for intensive care unit admission. INTERVENTIONS: Admission or rejection to an intensive care unit. MEASUREMENTS AND MAIN RESULTS: Clinical, laboratory, and physiological variables and data from severity scores were collected. Separate scores for accepted and rejected patients with 28-day mortality end point were built. Values for variables were grouped into categories determined by the locally weighted least squares graphical method applied to the logit of the mortality and by univariate logistic regressions for reducing candidates for the score. Multivariate logistic regression was used to construct the final score. Cutoff values for 99.5% specificity were determined. Of 6796 patients, 5602 were admitted and 1194 rejected. The initial refusal score included age, diagnosis, systolic blood pressure, pulse, respirations, creatinine, bilirubin, PaO2, bicarbonate, albumin, use of vasopressors, Glasgow Coma Scale score, Karnofsky Scale, operative status and chronic disorder, and the initial refusal receiver operating characteristics were area under the curve 0.77 (95% confidence interval 0.76-0.79). The final triage score included age, diagnosis, creatinine, white blood cells, platelets, albumin, use of vasopressors, Glasgow Coma Scale score, Karnofsky Scale, operative status and chronic disorder, and the final score receiver operating characteristics were area under the curve 0.83 (95% confidence interval 0.80-0.86). Patients with initial refusal scores >173.5 or final triage scores = 0 should be rejected. CONCLUSIONS: The initial refusal score and final triage score provide objective data for rejecting patients that will die even if admitted to the intensive care unit and survive if refused intensive care unit admission.

The Eldicus prospective, observational study of triage decision making in European intensive care units. Part II: intensive care benefit for the elderly.

RATIONALE: Life and death triage decisions are made daily by intensive care unit physicians. Admission to an intensive care unit is denied when intensive care unit resources are constrained, especially for the elderly. OBJECTIVE: To determine the effect of intensive care unit triage decisions on mortality and intensive care unit benefit, specifically for elderly patients. DESIGN: Prospective, observational study of triage decisions from September 2003 until March 2005. SETTING: Eleven intensive care units in seven European countries. PATIENTS: All patients >18 yrs with an explicit request for intensive care unit admission. INTERVENTIONS: Admission or rejection to intensive care unit. MEASUREMENTS AND MAIN RESULTS: Demographic, clinical, hospital, physiologic variables, and 28-day mortality were obtained on consecutive patients. There were 8,472 triages in 6,796 patients, 5,602 (82%) were accepted to the intensive care unit, 1,194 (18%) rejected; 3,795 (49%) were ≥ 65 yrs. Refusal rate increased with increasing patient age (18-44: 11%; 45-64: 15%; 65-74: 18%; 75-84: 23%; >84: 36%). Mortality was higher for older patients (18-44: 11%; 45-64: 21%; 65-74: 29%; 75-84: 37%; >84: 48%). Differences between mortalities of accepted vs. rejected patients, however, were greatest for older patients (18-44: 10.2% vs. 12.5%; 45-64: 21.2% vs. 22.3%; 65-74: 27.9% vs. 34.6%; 75-84: 35.5% vs. 40.4%; >84: 41.5% vs. 58.5%). Logistic regression showed a greater mortality reduction for accepted vs. rejected patients corrected for disease severity for elderly patients (age >65 [odds ratio 0.65, 95% confidence interval 0.55-0.78, p < .0001]) than younger patients (age <65 [odds ratio 0.74, 95% confidence interval 0.57-0.97, p = .01]). CONCLUSIONS: Despite the fact that elderly patients have more intensive care unit rejections than younger patients and have a higher mortality when admitted, the mortality benefit appears greater for the elderly. Physicians should consider changing their intensive care unit triage practices for the elderly.

Clinical assessment as a part of an early warning score-a Danish cluster-randomised, multicentre study of an individual early warning score.

BACKGROUND: The clinical benefit of Early Warning Scores (EWSs) is undocumented. Nursing staff's clinical assessment might improve the prediction of outcome and allow more efficient use of resources. We aimed to investigate whether the combination of clinical assessment and EWS would reduce the number of routine measurements without increasing mortality. METHODS: We did a cluster-randomised, crossover, non-inferiority study at eight hospitals in Denmark. Patients aged 18 years or older, admitted for more than 24 h were included. Admissions to paediatric or obstetric wards were excluded. The participating hospitals were randomly assigned 1:1 to start as either intervention or control with subsequent crossover. Primary outcomes were 30-day all-cause mortality (non-inferiority margin=0·5%) and average number of EWS per day per patient. The intervention was implementation of the Individual EWS (I-EWS), in which nursing staff can adjust the calculated score on the basis of their clinical assessment of the patient. I-EWS was compared with the National Early Warning Score (NEWS). The study is registered at ClinicalTrials.gov, NCT03690128 and is complete. FINDINGS: Unique admissions longer than 24 h were included from Oct 15, 2018 to Sept 30, 2019. Of 90 964 patients assessed, n=46 470 were assigned to the I-EWS group and n=44 494 to the NEWS group. Mortality within 30 days was 4·6% for the I-EWS group, and 4·3% for the NEWS group (adjusted odds ratio 1·05 [95% CI 0·99-1·12], p=0·12). In subgroup analyses I-EWS showed increased 30-day mortality for hospitals that did I-EWS in fall-winter, which was probably due to seasonality, and within patients admitted in a surgical specialty. Overall risk difference was 0·22% (95% CI -0·04 to 0·48) meaning that the non-inferiority criteria were met. The average number of scorings per patient per day was reduced from 3·14 to 3·10 (ie, a relative reduction of 0·64% [95% CI -0·16 to -1·11], p=0·0084) in the I-EWS group. INTERPRETATION: Including clinical assessment in I-EWS was feasible and overall non-inferior to the widely implemented NEWS in terms of all-cause mortality at 30 days, and the number of routine measurements was minimally reduced. However I-EWS should be used with caution in surgical patients. FUNDING: Capital Region Research Foundation, Gangsted Foundation, Candys Foundation, Herlev-Gentofte Hospital Research Foundation, Laerdal Foundation, and The Foundation of Director Boennelycke and wife.

Implications of ICU triage decisions on patient mortality: a cost-effectiveness analysis.

INTRODUCTION: Intensive care is generally regarded as expensive, and as a result beds are limited. This has raised serious questions about rationing when there are insufficient beds for all those referred. However, the evidence for the cost effectiveness of intensive care is weak and the work that does exist usually assumes that those who are not admitted do not survive, which is not always the case. Randomised studies of the effectiveness of intensive care are difficult to justify on ethical grounds; therefore, this observational study examined the cost effectiveness of ICU admission by comparing patients who were accepted into ICU after ICU triage to those who were not accepted, while attempting to adjust such comparison for confounding factors. METHODS: This multi-centre observational cohort study involved 11 hospitals in 7 EU countries and was designed to assess the cost effectiveness of admission to intensive care after ICU triage. A total of 7,659 consecutive patients referred to the intensive care unit (ICU) were divided into those accepted for admission and those not accepted. The two groups were compared in terms of cost and mortality using multilevel regression models to account for differences across centres, and after adjusting for age, Karnofsky score and indication for ICU admission. The analyses were also stratified by categories of Simplified Acute Physiology Score (SAPS) II predicted mortality (< 5%, 5% to 40% and >40%). Cost effectiveness was evaluated as cost per life saved and cost per life-year saved. RESULTS: Admission to ICU produced a relative reduction in mortality risk, expressed as odds ratio, of 0.70 (0.52 to 0.94) at 28 days. When stratified by predicted mortality, the odds ratio was 1.49 (0.79 to 2.81), 0.7 (0.51 to 0.97) and 0.55 (0.37 to 0.83) for <5%, 5% to 40% and >40% predicted mortality, respectively. Average cost per life saved for all patients was $103,771 (€82,358) and cost per life-year saved was $7,065 (€5,607). These figures decreased substantially for patients with predicted mortality higher than 40%, $60,046 (€47,656) and $4,088 (€3,244), respectively. Results were very similar when considering three-month mortality. Sensitivity analyses performed to assess the robustness of the results provided findings similar to the main analyses. CONCLUSIONS: Not only does ICU appear to produce an improvement in survival, but the cost per life saved falls for patients with greater severity of illness. This suggests that intensive care is similarly cost effective to other therapies that are generally regarded as essential.

Data concerning the Copenhagen tool: A research tool for evaluation of basic life Support educational interventions.

The data presented in this article are supplementary data related to the research article entitled "The Copenhagen Tool: A research tool for evaluation of BLS educational interventions" (Jensen et al., 2019). We present the following supplementary materials and data: 1) a standardized scenario used to introduce the test for gathering data on internal structure and additional response process; 2) test sheets used for rating test participant via video recordings; 3) interview-guide for collecting additional response process data; 4) items deemed relevant but not essential for laypersons, first responders and health personnel in the modified Delphi consensus process; 5) inter-rater reliability values for raters using the essential items of the tool to evaluate test participants via video recordings; 6) main themes from coding interviews with raters; 7) comparison of rater results and manikin software output.

Improving Patient Safety in Handover From Intensive Care Unit to General Ward: A Systematic Review.

OBJECTIVES: Despite of the increasing knowledge about patient safety improvements in the handover process in hospitals, we still lack knowledge about what magnitude of patient safety gains can be expected from improvements in handover between the intensive care unit (ICU) and the general ward. The aim of this systematic review was to investigate which handover tools are devised and evaluated with the aim of improving patient safety in the handover process from ICU to ward and whether the described handover tools fulfill their purpose. METHODS: A systematic literature search of 6 databases was performed to answer the review question, developed by using the "Patient Population, Intervention, Comparison, Outcome" format. Two authors independently performed the selection process, as well as the data extraction and quality assessment. The recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement were followed. RESULTS: Eight studies were finally included in the qualitative analysis. One study investigated a written information tool, 1 study investigated improved verbal information, 1 study investigated the effect of an additional safety check, and 5 studies investigated a Liaison Nurse as handover tool. Because of heterogeneity among the included studies, the study results could not be pooled. CONCLUSIONS: Not many well-conducted studies can shed light on this important topic. Giving patients and their families a supplementary written or verbal status report before transfer might improve patient safety. The introduction of a Liaison Nurse may be effective in improving communication between ICU and ward staff, which might reduce risks in patient safety. However, there is no evidence of improved mortality and/or readmission rates after introducing handover tools in the transfer from ICU to ward.

Adjusting Early Warning Score by clinical assessment: a study protocol for a Danish cluster-randomised, multicentre study of an Individual Early Warning Score (I-EWS).

INTRODUCTION: Track and trigger systems (TTSs) based on vital signs are implemented in hospitals worldwide to identify patients with clinical deterioration. TTSs may provide prognostic information but do not actively include clinical assessment, and their impact on severe adverse events remain uncertain. The demand for prospective, multicentre studies to demonstrate the effectiveness of TTSs has grown the last decade. Individual Early Warning Score (I-EWS) is a newly developed TTS with an aggregated score based on vital signs that can be adjusted according to the clinical assessment of the patient. The objective is to compare I-EWS with the existing National Early Warning Score (NEWS) algorithm regarding clinical outcomes and use of resources. METHOD AND ANALYSIS: In a prospective, multicentre, cluster-randomised, crossover, non-inferiority study. Eight hospitals are randomised to use either NEWS in combination with the Capital Region of Denmark NEWS Override System (CROS) or implement I-EWS for 6.5 months, followed by a crossover. Based on their clinical assessment, the nursing staff can adjust the aggregated score with a maximum of -4 or +6 points. We expect to include 150 000 unique patients. The primary endpoint is all-cause mortality at 30 days. Coprimary endpoint is the average number of times per day a patient is NEWS/I-EWS-scored, and secondary outcomes are all-cause mortality at 48 hours and at 7 days as well as length of stay. ETHICS AND DISSEMINATION: The study was presented for the Regional Ethics committee who decided that no formal approval was needed according to Danish law (J.no. 1701733). The I-EWS study is a large prospective, randomised multicentre study that investigates the effect of integrating a clinical assessment performed by the nursing staff in a TTS, in a head-to-head comparison with the internationally used NEWS with the opportunity to use CROS. TRIAL REGISTRATION NUMBER: NCT03690128.

The Copenhagen Tool a research tool for evaluation of basic life support educational interventions.

INTRODUCTION: Over the past decades, major changes have been made in basic life support (BLS) guidelines and manikin technology. The aim of this study was to develop a BLS evaluation tool based on international expert consensus and contemporary validation to enable more valid comparison of research on BLS educational interventions. METHODS: A modern method for collecting validation evidence based on Messick's framework was used. The framework consists of five domains of evidence: content, response process, internal structure, relations with other variables, and consequences. The research tool was developed by collecting content evidence based on international consensus from an expert panel; a modified Delphi process decided items essential for the tool. Agreement was defined as identical ratings by 70% of the experts. RESULTS: The expert panel established consensus on a three-levelled score depending on expected response level: laypersons, first responders, and health care personnel. Three Delphi rounds with 13 experts resulted in 16 "essential" items for laypersons, 21 for first responders, and 22 for health care personnel. This, together with a checklist for planning and reporting educational interventional studies within BLS, serves as an example to be used for researchers. CONCLUSIONS: An expert panel agreed on a three-levelled score to assess BLS skills and the included items. Expert panel consensus concluded that the tool serves its purpose and can act to guide improved research comparison on BLS educational interventions.

Understanding effects on excitability of simulated I (h) modulation in simple neuronal models.

The hyperpolarization-activated, inward, mixed cation current, I (h), appears in a wide variety of cells in the nervous system, contributes to diverse neuronal properties, and is up-regulated by a number of important neurotransmitters. Up-regulation of I (h) is usually associated with an excitability-enhancing depolarization of resting membrane potential and an excitability-depressing shunting effect caused by a decrease in input resistance. In order to gain a better understanding of the interaction of these effects and their influence on excitability with I (h) modulation, we systematically analyze changes in neuronal properties associated with excitability during I (h) modulation in simplified, yet, biophysical neuron models based on a hippocampal pyramidal neuron. We simulate I (h) modulation by varying both its maximal conductance and its half-activation voltage, mimicking the effects of cAMP-linked neurotransmitters, through ranges of physiologically realistic parameter regimes. Of particular interest is the contribution of the different effects of I (h) up-regulation when membrane potentials are held at common levels and neuronal excitability is probed. Our modeling results suggest that, although holding potentials at common levels may compensate for changes in resting membrane potentials, this protocol may exaggerate the excitability-depressing influences of changes in input resistances with I (h) up-regulation.

The art and science of debriefing in simulation: Ideal and practice.

OBJECTIVES: Describing what simulation centre leaders see as the ideal debriefing for different simulator courses (medical vs. crisis resource management (CRM)-oriented). Describing the practice of debriefing based on interactions between instructors and training participants. METHODS: Study 1 - Electronic questionnaire on the relevance of different roles of the medical teacher for debriefing (facilitator, role model, information provider, assessor, planner, resource developer) sent to simulation centre leaders. Study 2 - Observation study using a paper-and-pencil tool to code interactions during debriefings in simulation courses for CRM for content (medical vs. CRM-oriented) and type (question vs. utterance). RESULTS: Study 1 - The different roles were seen as equally important for both course types with the exception of 'information provider' which was seen as more relevant for medical courses. Study 2 - There were different interaction patterns during debriefings: line - involving mostly the instructor and one course participant, triangle - instructor and two participants, fan - instructor and all participants in a dyadic form and net - all participants and the instructor with cross references. CONCLUSION: What simulation centre heads think is important for the role mix of simulation instructors is (at least partly) not reflected in debriefing practice.

Impact of triage-to-admission time on patient outcome in European intensive care units: A prospective, multi-national study.

PURPOSE: Ubiquitous bed shortages lead to delays in intensive care unit (ICU) admissions worldwide. Assessing the impact of delayed admission must account for illness severity. This study examined both the relationship between triage-to-admission time and 28-day mortality and the impact of controlling for Simplified Acute Physiology Score (SAPS) II scores on that relationship. METHODS: Prospective cross-sectional analysis of referrals to eleven ICUs in seven European countries between 2003 and 2005. Outcomes among patients admitted within versus after 4 h were compared using a Chi-square test. Triage-to-admission time was also analyzed as a continuous variable; outcomes were assessed using a non-parametric Kruskal-Wallis test. RESULTS: Among 3175 patients analyzed, triage-to-admission time was 2.1 ±â€¯3.9 h. Patients admitted within 4 h had higher SAPS II scores (33.6 versus 30.6, Pearson correlation coefficient -0.07, p < 0.0001). 28-day mortality was surprisingly higher among patients admitted earlier (29.6 vs 25.2%, OR 1.25, 95% CI 0.99-1.58, p = 0.06). Even after adjusting for SAPS II scores, delayed admission was not associated with higher mortality (OR 1.08, CI 0.83-1.41, p = 0.58). CONCLUSIONS: Even after accounting for quantifiable parameters of illness severity, delayed admission did not negatively impact outcome. Triage practices likely influence outcomes. Severity scores may not fully reflect illness acuity or trajectory.

Relieving suffering or intentionally hastening death: where do you draw the line?

OBJECTIVE: End-of-life practices vary worldwide. The objective was to demonstrate that there is no clear-cut distinction between treatments administered to relieve pain and suffering and those intended to shorten the dying process. DESIGN: Secondary analysis of a prospective, observational study. SETTING: Thirty-seven intensive care units in 17 European countries. PATIENTS: Consecutive patients dying or with any limitation of therapy. INTERVENTIONS: Evaluation of the type of end-of-life category; dates and times of intensive care unit admission, death, or discharge; and decisions to limit therapy, medication, and doses used for active shortening of the dying process and the intent of the doctors prescribing the medication. MEASUREMENTS AND MAIN RESULTS: Limitation of life-sustaining therapy occurred in 3,086 (72.6%) of 4,248 patients, and 94 (2.2%) underwent active shortening of the dying process. Medication for active shortening of the dying process included administration of opiates (morphine to 71 patients) or benzodiazepines (diazepam to 54 patients) alone or in combination. The median dosage for morphine was 25.0 mg/hr and for diazepam 20.8 mg/hr. Doses of opiates and benzodiazepines were no higher than mean doses used with withdrawal in previous studies in 20 of 66 patients and were within the ranges of doses used in all but one patient. Doctors considered that medications for active shortening of the dying process definitely led to the patient's death in 72 patients (77%), probably led to the patient's death in 11 (12%), and were unlikely to have led to death in 11 (12%) patients. CONCLUSIONS: There is a gray area in end-of-life care between treatments administered to relieve pain and suffering and those intended to shorten the dying process.

Reasons, considerations, difficulties and documentation of end-of-life decisions in European intensive care units: the ETHICUS Study.

OBJECTIVE: To evaluate physicians' reasoning, considerations and possible difficulties in end-of-life decision-making for patients in European intensive care units (ICUs). DESIGN: A prospective observational study. SETTING: Thirty-seven ICUs in 17 European countries. PATIENTS AND PARTICIPANTS: A total of 3,086 patients for whom an end-of-life decision was taken between January 1999 and June 2000. The dataset excludes patients who died after attempts at cardiopulmonary resuscitation and brain-dead patients. MEASUREMENTS AND RESULTS: Physicians indicated which of a pre-determined set of reasons for, considerations in, and difficulties with end-of-life decision-making was germane in each case as it arose. Overall, 2,134 (69%) of the decisions were documented in the medical record, with inter-regional differences in documentation practice. Primary reasons given by physicians for the decision mostly concerned the patient's medical condition (79%), especially unresponsive to therapy (46%), while chronic disease (12%), quality of life (4%), age (2%) and patient or family request (2%) were infrequent. Good medical practice (66%) and best interests (29%) were the commonest primary considerations reported, while resource allocation issues such as cost effectiveness (1%) and need for an ICU bed (0%) were uncommon. Living wills were considered in only 1% of cases. Physicians in central Europe reported no significant difficulty in 81% of cases, while in northern and southern regions there was no difficulty in 92-93% of cases. CONCLUSIONS: European ICU physicians do not experience difficulties with end-of-life decisions in most cases. Allocation of limited resources is a minor consideration and autonomous choices by patient or family remain unusual. Inter-regional differences were found.

[Review of Early Warning Score in preventing sudden critical illness and death].

Early Warning Score (EWS) are used extensively to identify patients at risk of deterioration during hospital admission. The validation of EWS has primarily focused on investigating predictive validity, i.e. the association between EWS and severe adverse events. Few studies have tested, whether EWS work in the clinical setting, and if it prevents severe adverse events from occurring. Many of these studies have methodological limitations, and their clinical relevance could be questioned. Currently, there is limited evidence to support, that the implementation of EWS reduces the occurrence of severe adverse events.