Conflict associated with decisions to limit life-sustaining treatment in intensive care units.

OBJECTIVE: To determine the incidence and nature of interpersonal conflicts that arise when patients in the intensive care unit are considered for limitation of life-sustaining treatment. DESIGN: Qualitative analysis of prospectively gathered interviews. SETTING: Six intensive care units at a university medical center. PARTICIPANTS: Four hundred six physicians and nurses who were involved in the care of 102 patients for whom withdrawal or withholding of treatment was considered. MEASUREMENTS: Semistructured interviews addressed disagreements during life-sustaining treatment decision making. Two raters coded transcripts of the audiotaped interviews. MAIN RESULTS: At least 1 health care provider in 78% of the cases described a situation coded as conflict. Conflict occurred between the staff and family members in 48% of the cases, among staff members in 48%, and among family members in 24%. In 63% of the cases, conflict arose over the decision about life-sustaining treatment itself. In 45% of the cases, conflict occurred over other tasks such as communication and pain control. Social issues caused conflict in 19% of the cases. CONCLUSIONS: Conflict is more prevalent in the setting of intensive care decision making than has previously been demonstrated. While conflict over the treatment decision itself is most common, conflict over other issues, including social issues, is also significant. By identifying conflict and by recognizing that the treatment decision may not be the only conflict present, or even the main one, clinicians may address conflict more constructively.

Measuring patient expectations: does the instrument affect satisfaction or expectations?

BACKGROUND: Fulfillment of patients' expectations may influence health care utilization, affect patient satisfaction, and be used to indicate quality of care. Several different instruments have been used to measure expectations, yet little is known about how different assessment methods affect outcomes. OBJECTIVE: The object of the study was to determine whether different measurement instruments elicit different numbers and types of expectations and different levels of patient satisfaction. DESIGN: Patients waiting to see their physician were randomly assigned to receive 1 of 2 commonly used instruments assessing expectations or were assigned to a third (control) group that was not asked about expectations. After the visit, patients in all 3 groups were asked about their satisfaction and services they received. SUBJECTS: The study subjects were 290 male, primary care outpatients in a VA general medicine clinic. MEASURES: A "short" instrument asked about 3 general expectations for tests, referrals, and new medications, while a "long" instrument nested similar questions within a more detailed list. Wording also differed between the 2 instruments. The short instrument asked patients what they wanted; the long instrument asked patients what they thought was necessary for the physician to do. Satisfaction was measured with a visit-specific questionnaire and a more general assessment of physician interpersonal skills. RESULTS: Patients receiving the long instrument were more likely to express expectations for tests (83% vs. 28%, P <0.001), referrals (40% vs. 18%, P <0.001), and new medications (45% vs. 28%, P <0.001). The groups differed in the number of unmet expectations: 40% of the long instrument group reported at least 1 unmet expectation compared with 19% of the short instrument group (P <0.001). Satisfaction was similar among the 3 groups. CONCLUSIONS: These different instruments elicit different numbers of expectations but do not affect patient satisfaction.

Families looking back: one year after discussion of withdrawal or withholding of life-sustaining support.

OBJECTIVE: To identify critical psychosocial supports and areas of conflict for families of intensive care unit (ICU) patients during decisions to withdraw or withhold life-sustaining treatment. DESIGN: Cross-sectional survey. SETTING: Six intensive care units in a tertiary care academic medical center. PARTICIPANTS: Forty-eight family members, one per case, of patients previously hospitalized in the ICU who had been considered for withdrawal or withholding of life-sustaining treatment. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Two raters coded transcripts of audiotaped interviews with family members about their experiences in the ICU and the decision-making process for withdrawing or withholding life-sustaining treatment. Codes identified sources of conflict and personal, institutional, and staff supports on which families relied during the decision-making process. Forty-six percent of respondents perceived conflict during their family member's ICU stay; the vast majority of conflicts were between themselves and the medical staff and involved communication or perceived unprofessional behavior (such as disregarding the primary caregiver in treatment discussions). Sixty-three percent of family members previously had spoken with the patient about his or her end-of-life treatment preferences, which helped to lessen the burden of the treatment decision. Forty-eight percent of family members reported the reassuring presence of clergy, and 27% commented on the need for improved physical space to have family discussion and conferences with physicians. Forty-eight percent of family members singled out their attending physician as the preferred source of information and reassurance. CONCLUSIONS: Many families perceived conflict during end-of-life treatment discussions in the ICU. Conflicts centered on communication and behavior of staff. Families identified pastoral care and prior discussion of treatment preferences as sources of psychosocial support during these discussions. Families sought comfort in the identification and contact of a "doctor-in-charge." ICU policies such as family conference rooms and lenient visitation accommodate families during end-of-life decision-making.

Activity of amoxicillin-clavulanate against penicillin-resistant Streptococcus pneumoniae in an experimental respiratory infection model in rats.

High doses of amoxicillin, equivalent to those produced by 500- and 750-mg oral doses in humans (area under the plasma concentration-time curve), were effective against a penicillin-resistant strain of Streptococcus pneumoniae in an experimental respiratory tract infection in immunocompromised rats; this superior activity confirms the results of previous studies. An unexpected enhancement of amoxicillin's antibacterial activity in vivo against penicillin-resistant and -susceptible S. pneumoniae strains was observed when subtherapeutic doses of amoxicillin were coadministered with the beta-lactamase inhibitor potassium clavulanate. The reason for this enhancement was unclear since these organisms do not produce beta-lactamase. The differential binding of clavulanic acid and amoxicillin to penicillin-binding proteins may have contributed to the observed effects.

Development of experimental respiratory infections in neutropenic rats with either penicillin-resistant Streptococcus pneumoniae or beta-lactamase-producing Haemophilus influenzae.

Acute respiratory infections with penicillin-resistant strains of Streptococcus pneumoniae and a beta-lactamase-producing strain of Haemophilus influenzae were established in neutropenic weanling rats. By use of nonsurgical intrabronchial instillation of the bacteria suspended in molten agar, reproducible, acute respiratory infections suitable for experimental antibiotic efficacy studies were established.

Bactericidal effects of co-amoxiclav (amoxycillin clavulanic acid) against a Legionella pneumophila pneumonia in the immunocompromised weanling rat.

To evaluate the activity of co-amoxiclav (amoxycillin/clavulanic acid) against Legionella pneumophila in vivo, a model of L. pneumophila pneumonia was developed in weanling rats rendered leukopenic by pre-administration of cyclophosphamide. Assessment of therapy was by lung bacterial counts and histological examination. Amoxycillin was ineffective in reducing bacterial counts in the lungs of infected rats, whereas erythromycin, the standard agent, was significantly more effective (P < 0.01). Co-amoxiclav and erythromycin, administered parenterally, produced significant bactericidal effects (P < 0.01), reducing the counts of L. pneumophila strain 1624 at 96 h to 1.2 log10 cfu/lungs compared with counts of 6 log10 cfu/lungs in the untreated animals. Clavulanic acid was also highly effective in preventing development of the infection, and was as efficacious as co-amoxiclav. Because of the significant reduction in bacterial numbers, a marked reduction in inflammation and consolidation of lung tissue was seen in rats treated with erythromycin, clavulanic acid or co-amoxiclav. The activity of co-amoxiclav was no greater than clavulanic acid alone, and no synergy was noted between the two components. When therapy was delayed until 48 h after infection, co-amoxiclav was as effective as erythromycin, with both treatments reducing bacterial numbers to 3.3 and 3.6 log10 cfu/lungs by 96 h, after only two days of therapy, in comparison with non-treated rats (5.6 log10 cfu/lungs). In a prolonged infection, produced by extending the period of leucopenia, co-amoxiclav and erythromycin were equally effective in preventing growth of the organism, with 1.5 and 1.6 log10 cfu/lungs, respectively, present at 96 h, in contrast to the non-treated rats with 5.7 log10 cfu/lungs (P < 0.01). After cessation of therapy, regrowth of L. pneumophila occurred in the erythromycin-treated group to such a degree that by 168 h, lung viable counts from these rats were significantly higher (4.8 log10 cfu/lungs) than in co-amoxiclav-treated rats (2.1 log10 cfu/lungs) (P < 0.05). Oral therapy of this infection with erythromycin or clavulanic acid, either alone or in combination with amoxycillin, resulted in counts of 3.3, 3.6 and 3.5 log10 cfu/lungs at 96 h, respectively. Although oral therapy was significantly less effective than parenteral therapy (P < 0.05), the bacterial counts in the treated groups were significantly lower than in the non-treated animals. The data show that co-amoxiclav displayed bactericidal activity consistently against intracellular L. pneumophila in vivo.

Bactericidal effects of ticarcillin-clavulanic acid against Legionella pneumophila pneumonia in immunocompromised weanling rats.

A model of acute Legionella pneumophila pneumonia in neutropenic weanling rats was developed as a means of assessing the efficacies in vivo of the beta-lactams ticarcillin, ticarcillin-clavulanic acid, and clavulanic acid, agents active against the organism in vitro. Weanling rats were dosed with cyclophosphamide 3 days before and immediately prior to infection by intrabronchial intubation with L. pneumophila. The bacteria persisted in the lungs of untreated animals at high counts (5.0 to 7.0 log10 CFU/g of lung tissue) for up to 168 h after infection, and the histological characteristics of the infection were similar to those of the disease in humans. Transmission electron micrography revealed the presence of L. pneumophila multiplying within alveolar macrophages. Therapy with ticarcillin was ineffective in reducing the bacterial numbers in the lung tissue, whereas ticarcillin-clavulanic acid and clavulanic acid were active, producing bactericidal effects similar to those of erythromycin. The ticarcillin-clavulanic acid combination was significantly more efficacious (P less than 0.01) than corresponding doses of clavulanic acid alone. Synergistic activity between ticarcillin and clavulanic acid against L. pneumophila has been demonstrated in vivo, and the combination showed activity similar to that of erythromycin.

Bactericidal effects of amoxycillin/clavulanic acid against a Legionella pneumophila pneumonia in the weanling rat.

Amoxycillin/clavulanic acid and clavulanic acid have been previously reported to demonstrate bactericidal activity in tissue culture studies against intracellular Legionella pneumophila. A rat model of legionellosis was therefore developed for the purpose of assessing the efficacy of these agents against L. pneumophila in vivo. Therapy by the subcutaneous route was started 12 h after infection when the majority of the bacteria observed in lavage fluid were residing in alveolar macrophages. Treatment with amoxycillin was ineffective in reducing the bacterial counts of L. pneumophila in lung homogenates whereas amoxycillin/clavulanic acid displayed bactericidal effects of the same order as the control antibiotic, erythromycin. Further in-vivo studies are planned to assess the clinical relevance of these findings.