Outcomes of Cancer Patients Discharged From ICU After a Decision to Forgo Life-Sustaining Therapies.

OBJECTIVES: Many cancer patients are admitted to an ICU and decisions to forgo life-sustaining therapies are frequent during ICU stay. A significant proportion of these patients are subsequently discharged from ICU, but their outcomes are unknown. DESIGN: Retrospective. SETTING: ICU of oncological hospital. PATIENTS: Adult cancer patients admitted to ICU, then with a decision to forgo life-sustaining therapies and that were discharged from ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Hospital mortality, long-term survival, recommencement of cancer treatment, and ICU readmission were recorded. Hospital mortality predictors were evaluated. The propensity score method was used to test the hypothesis that decision to forgo life-sustaining therapies was independently associated with hospital mortality. Among the 16,998 patients that were admitted to ICU, in 1,369 patients (8.1%) a decision to forgo life-sustaining therapies was made during ICU stay. Among the latter group, 507 were discharged from ICU and were examined in this study. The hospital mortality of this group was 80.1% and was independently predicted according to the occurrence of delirium or acute kidney injury during their ICU stay. Six-month and 12-month survival rates were 3.6% and 0.6%. Sixty-four patients (12.6%) resumed cancer treatment and had a longer survival (p < 0.01). Fifty-two patients (10.3%) were readmitted to ICU and had a longer survival (p < 0.01). The decision to forgo life-sustaining therapies was associated with higher hospital mortality (80.0% vs 26.3%, respectively; p < 0.01) and lower rates of survival (p < 0.01). CONCLUSIONS: Approximately 20% of cancer patients discharged from our ICU after a decision to forgo life-sustaining therapies were discharged from hospital. Delirium and acute kidney injury during ICU stay were predictors of hospital mortality. The decision to forgo life-sustaining therapies was independently associated with hospital mortality. Patients readmitted to the ICU and those that resumed cancer treatment had longer survival. Knowledge of these outcomes is important for providing proper therapeutic planning and counseling for patients and their relatives.

Limitación de tratamiento de soporte vital en una Unidad de Cuidado Intensivo pediátrica chilena: 2004-2014 / Limitation of Vital Support in a Chilean Pediatric Intensive Care Unit: 2004-2014

Resumen Objetivo: Describir las frecuencias y características del proceso de Limitación de Tratamiento de So porte Vital (LTSV) en pacientes de la Unidad de Cuidados Intensivos Pediátricos (UCI) entre 2004 2014. Pacientes y Método: Estudio retrospectivo, observacional descriptivo a partir de dos registros de la UCI del Hospital Roberto del Río: 1) ficha clínica individual de seguimiento y 2) ficha de registro de indicadores de calidad incluida LTSV, ambos actualizados diariamente al iniciar la visita clínica. Desde estos registros se analizaron los casos con dilemas bioéticos en los que se propuso LTSV du rante su hospitalización en UCI ("LTSV intra-UCI"). Se menciona la población rechazada de ingresar a UCI ("LTSV pre-UCI") y los fallecidos con LTSV en cama básica. Resultados: De 7.821 ingresos a UCI en el 1,51% (118 pacientes) se establece una LTSV: ONI (Orden de No Innovación) en 78,8% de los casos, retiro de medidas terapéuticas en 14,4% y suspensión de ventilación mecánica en 6,8%. En 23,7% el diagnóstico de base fue neurológico u oncológico, para cada uno. La condición fisiopatológica predominante para una LTSV fue neurológica (39%). El tiempo de estadía en UCI triplica el promedio de estada de los egresos totales de UCI, pero es de amplia variabilidad. Conclusiones: Es factible realizar una LTSV en UCI cuando el equipo incorpora esta perspectiva al trabajo diario junto a la familia. Hay una amplia variabilidad individual en las características del proceso de LTSV, propio del ámbito de la ética clínica.

Abstract Objective: Describe the frequency and characteristics of PICU patients who undergo a process of withholding or withdrawing life-sustaining treatment (LTSV), between 2004 y 2014. Patients and Method: A retrospective, observational descriptive study, using two documents for quality assessment in the PICU of Hospital Roberto del Río: 1) daily individual patient tracking log and 2) daily record of quality indicators, including LTSV, both updated daily at the morning visit. All PICU patients with an ethical dilemma during their PICU stay in which a LTSV was proposed were included. We men tion patients rejected for admission in the ICU and those who died in basic units of the hospital with LTSV. Results: In 118 patients of 7821 PICU admissions (1,5%) we determined a LTSV: ONR (Non Resuscitation Order) for all of them, ONI (Non Innovation Order) in 78,8%, withdrawal of some therapeutics in 14,4% and withdrawal of active mechanical ventilation in 6,8%. The basic diagnosis was 23,7% for each neurologic and oncologic diseases. The predominant pathophysiologic condition leading to a LTSV was severe chronic neurologic damage (39%). The length of stay was threefold the mean PICU stay, with a large variability due to expectable individual factors when ethic decisions are involved. Conclusion: LTSV is feasible when the team is involved and this perspective is part of daily clinical analysis. The wide individual variability in the LTSV process is expectable in ethical decisions.

[Limitation of Vital Support in a Chilean Pediatric Intensive Care Unit: 2004-2014]. / Limitación de tratamiento de soporte vital en una Unidad de Cuidado Intensivo pediátrica chilena: 2004-2014.

OBJECTIVE: Describe the frequency and characteristics of PICU patients who undergo a process of withholding or withdrawing life-sustaining treatment (LTSV), between 2004 y 2014. PATIENTS AND METHOD: A retrospective, observational descriptive study, using two documents for quality assessment in the PICU of Hospital Roberto del Río: 1) daily individual patient tracking log and 2) daily record of quality indicators, including LTSV, both updated daily at the morning visit. All PICU patients with an ethical dilemma during their PICU stay in which a LTSV was proposed were included. We men tion patients rejected for admission in the ICU and those who died in basic units of the hospital with LTSV. RESULTS: In 118 patients of 7821 PICU admissions (1,5%) we determined a LTSV: ONR (Non Resuscitation Order) for all of them, ONI (Non Innovation Order) in 78,8%, withdrawal of some therapeutics in 14,4% and withdrawal of active mechanical ventilation in 6,8%. The basic diagnosis was 23,7% for each neurologic and oncologic diseases. The predominant pathophysiologic condition leading to a LTSV was severe chronic neurologic damage (39%). The length of stay was threefold the mean PICU stay, with a large variability due to expectable individual factors when ethic decisions are involved. CONCLUSION: LTSV is feasible when the team is involved and this perspective is part of daily clinical analysis. The wide individual variability in the LTSV process is expectable in ethical decisions.

A survey of self-directed dying attended by proxies in the Dutch population.

Physicians may hasten death by medical decisions to end life (MDEL) that have been extensively researched. However, outside the medical domain, some individuals hasten their death by Voluntary Refusal of Food and Fluid while receiving some palliative care (VRFF) or by Independently taking Lethal Medication attended by a Confidant (ILMC). Both dying trajectories are more or less under the control of the individuals themselves. No survey data are available on how often these self-directed deaths occur in the Dutch population. We have isolated VRFF and ILMC from other dying trajectories in a population-based study employing after-death interviews with relatives, friends or nurses. Members of a research database that is representative of the Dutch population (n=31,516) were asked whether they had been a confidant in someone's decision to hasten death by VRFF or ILMC. In this sample, 144 deaths that conformed to our definitions were reported by proxies. We have computed an annual frequency of 2.1% VRFF deaths and of 1.1% ILMC deaths. The annual frequencies of VRFF and ILMC appear to be roughly the same as the yearly frequency of physician-assisted dying (1.8%). In seventy percent of those who had died by VRFF or ILMC, a diagnosis of cancer or a serious illness was reported by the informant. The proxies retrospectively described the self-directed hastening of death by both methods as a dignified death in about 75% of deaths. Both VRFF and ILMC require strenuous efforts and reflect a strong desire to control the process of dying. End-of-life research has shown that some control over the time of death is an important aspect of a 'good death' in western countries. We therefore presume that these self-directed methods for hastening death in consultation with proxies occur in other countries as well.

How patients die after intracerebral hemorrhage.

INTRODUCTION: Severity of illness scores predict all-cause mortality after intracerebral hemorrhage (ICH), but do not differentiate between proximate mechanisms or predict the timing. We hypothesized that death by neurologic criteria [brain death (BD)], withdrawal of life support, and cardiovascular death would be distinct after ICH. METHODS: We prospectively enrolled patients with spontaneous ICH without underlying vascular malformation or neoplasm. We recorded clinical data and the proximate mechanism of death (BD, withdrawal of life support, cardiovascular death, or other cause). Time to death was compared with Kaplan-Meier methods (log-rank test). Data are median (IQR). RESULTS: Among 89 patients, 15 had withdrawal of life support, 5 had BD, 2 died from cardiac arrest, and 3 died from other causes. Among patients who died, ICH score, age, Glasgow Coma Scale, NIH Stroke Scale, and proximate cause were not associated with the proximate mechanism of death. The time to death was different (P < 0.001) depending on the proximate mechanism. Patients with BD died 1 [0-1] 1 day after ICH, withdrawal of life support led to death 5 [1-13] days after ICH, cardiac death occurred 35 [35-85] days after ICH, and other causes led to death 33 [26-33] days after ICH. Among patients where life support was withdrawn, a higher ICH score on admission was related to earlier death (P = 0.002). CONCLUSIONS: Proximate mechanisms of death after ICH occur at distinct times. Withdrawal of life support leads to earlier death in patients with a higher severity of injury. Medical causes of death can be effectively prevented after ICH.

Eutanasia, calidad de vida y retiro de soporte vital: estudio en 5 Centros de cuidados críticos / Euthanasia, quality of life and retirement of vital support: study in 5 Centers of cares critics

Objetivos. Evaluar opiniones y conductas acerca de métodos de abstención y/o retiro de soporte vital y de la eutanasia, en profesionales que trabajan usualmente en el ámbito de Servicios de Terapia Intensiva. Métodos. Diseño prospectivo, observacional, transversal, analítico. Se encuestaron 130 profesionales de 5 unidades de Terapia Intensiva. Encuesta abierta/cerrada. Estadística descriptiva, regresión lineal y logistica. Resultados. El 86.92% considera que la abstención (A) y/o retiro (R) de los métodos de soporte vital implica límites en la atención médica, el 63.07% piensa que A y R no son equivalentes. El 78.46% no consigna en las historias sus decisiones. El 36.92% no discute con el resto del equipo sus decisiones. Las variables más relacionadas con A y R son: irreversibilidad del cuadro agudo (80.76%) e ineficacia de medidas terapeúticas (70.00%). A es más frecuente que R (47.69% y 40.76%). El 24.61% consensúa con la familia. El 31.53% investiga preferencias previas del paciente. Los R más comunes son: suspensión de inótropicos (50.00%) y de la ventilación mecánica (36.92%). El 15.38% está a favor de la eutanasia. De las variables mencionadas, no se hallaron predictores a favor de la eutanasia en el modelo multivariado. No se hallaron diferencias a favor de eutanasia entre Centros, ni entre médicos versus enfermeros, ni entre médicos experimentados versus en formación (p 0.05 o más en todos los casos). La antiguedad en terapia intensiva no fue predictora de eutanasia en regresión lineal (p0.6110). Conclusiones. La mayoría de los profesionales considera que abstención o retiro del soporte vital implica limitar la atención, sin consignar tal conducta en la historia, y basándose en general en la irreversibilidad del cuadro agudo, la minoría ésta a favor de la eutanasia, sin diferencias según profesión o antigüedad profesional.

The incidence and characteristics of end-of-life decisions by GPs in Belgium.

BACKGROUND: Medical end-of-life decisions (ELDs) have been discussed for several years in different countries, but little is known about the involvement of GPs in these ELDs. OBJECTIVES: The aim of the present study was to establish the incidence and characteristics of ELDs by GPs. METHOD: We selected 3999 deaths, a 20% random sample of all registered deaths during the first 4 months of 1998 in Flanders, Belgium, and mailed anonymous questionnaires to the attesting physicians. Here we focus exclusively on the 1647 deaths certified by GPs. RESULTS: The GPs returned 1067 questionnaires (response rate of 64.8%). At least one ELD was made in 39.5% [95% confidence interval (CI) 37.8-41.2] of all primary care deaths. The incidence of euthanasia (including physician-assisted suicide) was 1.5% (95% CI 0.9-2.3) (incidence higher among more educated patients and at home), of administration of lethal drugs without the patient's explicit request 3.8% (95% CI 2.9-5.0) (higher among cancer patients), of alleviation of pain and symptoms with possibly life-shortening effect 18.6% (95% CI 17.0-20.2) (higher among cancer patients and married patients) and of non-treatment decisions 15.6% (95% CI 14.2-17.2) (higher among cancer patients and in nursing homes). The decision was not discussed with the patient in three out of four of the ELDs. A colleague was consulted in one in four ELD cases. CONCLUSION: ELDs are common in general practice in Flanders, Belgium, despite the restrictive law concerning euthanasia at the time of this study. The incidence of these ELDs varies with cause and place of death, the patient's education and the GP's religion and age. Requirements of prudent practice regarding ELDs are rather poorly met by GPs. Further international research and debate is needed to highlight the GPs' important role in end-of-life care.

Attitudes towards euthanasia among physicians, nurses and the general public in Finland.

The object of this study was to investigate the attitudes of physicians, nurses and the general public to physician-assisted suicide (PAS), active voluntary euthanasia (AVE) and passive euthanasia (PE) in Finland. Respondents received a postal questionnaire to evaluate the acceptability of euthanasia in five scenarios, which were imaginary patient cases. Age, severity of pain and prognosis of the disease were presented as background factors in these scenarios. This work was carried out in Finland in 1998. The respondents include a random selection of 814 physicians (506 responded, 62%), 800 nurses (582 responded, 68%) and 1000 representatives of the general public (587 responded, 59%).Thirty-four percent of the physicians, 46% of the nurses and 50% of the general public agreed that euthanasia would be acceptable in some situations. Of the scenarios, PE was most often considered acceptable in cases of severe dementia (physicians 88%, nurses 79% and general public 64%). In the same scenario, 8% of physicians, 23% of nurses and 48% of general public accepted AVE. In the scenario of an incurable cancer, 20% of the physicians, 34% of the nurses and 42% of the general public accepted PAS. All forms of euthanasia were generally more acceptable in older, than in younger, scenario patients. This paper conclude that PE was largely accepted among Finnish medical professionals and the general public. Only a minority favored AVE and PAS.

Patient race and decisions to withhold or withdraw life-sustaining treatments for seriously ill hospitalized adults. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

PURPOSE: Patient race is associated with decreased resource use for seriously ill hospitalized adults. We studied whether this difference in resource use can be attributed to more frequent or earlier decisions to withhold or withdraw life-sustaining therapies. SUBJECTS AND METHODS: We studied adults with one of nine illnesses that are associated with an average 6-month mortality of 50% who were hospitalized at five geographically diverse teaching hospitals participating in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). We examined the presence and timing of decisions to withhold or withdraw ventilator support and dialysis, and decisions to withhold surgery. Analyses were adjusted for demographic characteristics, prognosis, severity of illness, function, and patients' preferences for life-extending care. RESULTS: The mean (+/- SD) age of the patients was 63 +/- 16 years; 16% were African-American, 44% were women, and 53% survived for 6 months or longer. Of the 9,076 patients, 5,349 (59%) had chart documentation that ventilator support had been considered in the event the patient's condition required such a treatment to sustain life, 2,975 charts (33%) had documentation regarding major surgery, and 1,293 (14%) had documentation of discussions about dialysis. There were no significant differences in the unadjusted rates of decisions to withhold or withdraw treatment among African-Americans compared with non-African-Americans: among African-Americans, 33% had a decision made to withhold or withdraw ventilator support compared with 35% among other patients, 14% had a decision made to withhold major surgery compared with 12% among other patients, and 25% had a decision made to withhold or withdraw dialysis compared with 30% among other patients (P >0.05 for all comparisons). After adjustment for demographic characteristics, prognosis, illness severity, function, and preferences for care, there were no differences in the timing or rate of decisions to withhold or withdraw treatments among African-Americans compared with non-African-American patients. CONCLUSION: Patient race does not appear to be associated with decisions to withhold or withdraw ventilator support or dialysis, or to withhold major surgery, in seriously ill hospitalized adults.

Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995.

BACKGROUND: In 1991 a new procedure for reporting physician-assisted deaths was introduced in the Netherlands that led to a tripling in the number of reported cases. In 1995, as part of an evaluation of this procedure, a nationwide study of euthanasia and other medical practices concerning the end of life was begun that was identical to a study conducted in 1990. METHODS: We conducted two studies, the first involving interviews with 405 physicians (general practitioners, nursing home physicians, and clinical specialists) and the second involving questionnaires mailed to the physicians attending 6060 deaths that were identified from death certificates. The response rates were 89 percent and 77 percent, respectively. RESULTS: Among the deaths studied, 2.3 percent of those in the interview study and 2.4 percent of those in the death-certificate study were estimated to have resulted from euthanasia, and 0.4 percent and 0.2 percent, respectively, resulted from physician-assisted suicide. In 0.7 percent of cases, life was ended without the explicit, concurrent request of the patient. Pain and symptoms were alleviated with doses of opioids that may have shortened life in 14.7 to 19.1 percent of cases, and decisions to withhold or withdraw life-prolonging treatment were made in 20.2 percent. Euthanasia seems to have increased in incidence since 1990, and ending of life without the patient's explicit request to have decreased slightly. For each type of medical decision except those in which life-prolonging treatment was withheld or withdrawn, cancer was the most frequently reported diagnosis. CONCLUSIONS: Since the notification procedure was introduced, end-of-life decision making in the Netherlands has changed only slightly, in an anticipated direction. Close monitoring of such decisions is possible, and we found no signs of an unacceptable increase in the number of decisions or of less careful decision making.

Community attitudes on the family of issues surrounding the death of terminal patients.

In two studies, respondents made recommendations for the medical treatment of a terminally ill elderly woman. The woman was or was not experiencing intractable pain, and had requested either heroic medical efforts or euthanasia. Respondents' recommendations were influenced by both the specific wishes of the patient and the pain the person was experiencing. However, participants were not completely swayed by the patient's wishes: only about half of the sample recommended euthanasia even when the patient was in intractable pain and had requested death; also, many subjects would not resuscitate the patient whose heart or lungs failed, even though she had requested heroic measures. Respondent attitudes toward euthanasia predicted recommendations in the expected directions. We suggest that there is less dissent on the issues that arise for medical treatments at the end of life than has been widely assumed.

Withholding and withdrawal of life support from surgical neonates with life-threatening congenital anomalies.

We evaluated why and how life support was withheld or withdrawn in surgical neonates. During the study period, January 1988 through December 1991, 529 neonates were admitted, 52 of whom died (10%). Twenty-eight deaths were due to the underlying disease. The other 24 patients died because treatment was withheld or withdrawn. In 15 of 24 (group A, mean stay 9.2 +/- 9.1 days) treatment was initially started but later withdrawn (13/15) because of the severity of congenital anomalies alone (7/12) or congenital anomalies associated with chromosomal anomalies (5/12). In 9 of 24 (group B, mean stay 20.3 +/- 17.3 days) treatment was withdrawn because of serious complications. In all cases often lengthy discussions have led the doctors and nurses together with the parents to chose unanimously for withdrawal of treatment. Mechanical ventilation was the intervention most frequently withdrawn (10/15 group A, 9/9 group B). Vasoactive and other drugs were withheld in 5 patients of group A. Sedatives and analgetics were administrated as supportive care permitting the child to die in a humane way, 17 in the lap of a parent and 7 in the lap of a nurse. We conclude that life-sustaining care is withheld or withdrawn relatively frequently from patients at our ICU. Such decisions are ethical ones, taken in the light of professional and technical expertise. Evaluation of withholding or withdrawal of treatment is difficult but necessary to evolve appropriate decision-making procedures and to formulate humane standards of intensive care.(ABSTRACT TRUNCATED AT 250 WORDS)

Euthanasia and other medical decisions concerning the end of life.

This article presents the first results of the Dutch nationwide study on euthanasia and other medical decisions concerning the end of life (MDEL). The study was done at the request of the Dutch government in preparation for a discussion about legislation on euthanasia. Three studies were undertaken: detailed interviews with 405 physicians, the mailing of questionnaires to the physicians of a sample of 7000 deceased persons, and the collecting of information about 2250 deaths by a prospective survey among the respondents to the interviews. The alleviation of pain and symptoms with such high dosages of opioids that the patient's life might be shortened was the most important MDEL in 17.5% of all deaths. In another 17.5% a non-treatment decision was the most important MDEL. Euthanasia by administering lethal drugs at the patient's request seems to have been done in 1.8% of all deaths. Since MDEL were taken in 38% of all deaths (and in 54% of all non-acute deaths) we conclude that these decisions are common medical practice and should get more attention in research, teaching, and public debate.