Prioritizing direct heart procurement in organ donors after circulatory death does not jeopardize lung transplant outcomes.

Background: Controlled donation after circulatory death (cDCD) has become a standard in liver, kidney, and lung transplantation (LTx). Based on recent innovations in ex vivo heart preservation, heart transplant centers have started to accept cDCD heart allografts. Because the heart has very limited tolerance to warm ischemia, changes to the cDCD organ procurement procedures are needed. These changes entail delayed ventilation and prolonged warm ischemia for the lungs. Whether this negatively impacts lung allograft function is unclear. Methods: A retrospective analysis of cDCD lungs transplanted between 2012 and February 2022 at the Medical University of Vienna was performed. The heart + lung group consisted of cases in which the heart was procured by a cardiac team for subsequent normothermic ex vivo perfusion. A control group (lung group) was formed by cases where only the lungs were explanted. In heart + lung group cases, the heart procurement team placed cannulas after circulatory death and a hands-off time, collected donor blood for ex vivo perfusion, and performed rapid organ perfusion with Custodiol solution, after which the heart was explanted. Up to this point, the lung procurement team did not interfere. No concurrent lung ventilation or pulmonary artery perfusion was performed. After the cardiac procurement team left the table, ventilation was initiated, and lung perfusion was performed directly through both stumps of the pulmonary arteries using 2 large-bore Foley catheters. This study analyzed procedural explant times, postoperative outcomes, primary graft dysfunction (PGD), duration of mechanical ventilation, length of intensive care unit (ICU) stay, and early survival after LTx. Results: A total of 56 cDCD lungs were transplanted during the study period. In 7 cases (12.5%), the heart was also procured (heart + lung group); in 49 cases (87.5%), only the lungs were explanted (lung group). Basic donor parameters were comparable in the 2 groups. The median times from circulatory arrest to lung perfusion (24 minutes vs 13.5 minutes; P = .002) and from skin incision to lung perfusion (14 minutes vs 5 minutes; P = .005) were significantly longer for the heart + lung procedures. However, this did not affect post-transplantation PGD grade at 0 hours (P = .851), 24 hours (P = .856), 48 hours (P = .929), and 72 hours (P = .874). At 72 hours after transplantation, none of the lungs in the heart + lung group but 1 lung (2.2%) in lung group was in PGD 3. The median duration of mechanical ventilation (50 hours vs 41 hours; P = .801), length of ICU stay (8 days vs 6 days; P = .951), and total length of hospital stay (27 days vs 25 days; P = .814) were also comparable in the 2 groups. In-hospital mortality occurred in only 1 patient of the lung group (2.2%). Conclusions: Although prioritized cDCD heart explantation is associated with delayed ventilation and significantly longer warm ischemic time to the lungs, post-LTx outcomes within the first year are unchanged. Prioritizing heart perfusion and explantation in the setting of cDCD procurement can be considered acceptable.

Hospital to Hospital Transfers of Cerebral Hemorrhage: Characteristics of Early Withdrawal of Life-Sustaining Treatment.

BACKGROUND: Large intracerebral hemorrhages (ICHs) are associated with significant morbidity and mortality. Patient transfer to higher level centers is common, but care in these centers rarely demonstrably improves morbidity or reduces mortality. Patients may rapidly progress to brain death, but a large number die shortly after transferring because of withdrawal of life-sustaining treatment (WOLST). This outcome may result in poor resource use and unnecessary cost to patients, families, and institutions. We sought to determine clinical and radiographic predictors of early death or WOLST that may alter potential transfer. METHODS: We performed a retrospective review of patients admitted from outside medical centers to the neurosciences intensive care unit at Saint Marys Mayo Clinic Hospital in Rochester, MN, from January 2014 to December 2019. Patients ≥ 18 years old with a spontaneous ICH were included. Exclusion criteria included trauma, subarachnoid hemorrhage, and subdural hematoma. We identified patients who died or underwent WOLST within 24 h of transfer. Descriptive characteristics of patients and ICH were collected. Data were analyzed with univariable, multivariable, and logistic regression. Predictive modeling was performed. An additional case-matched study was completed to evaluate for characteristics further. RESULTS: A total of 317 consecutive patients were identified. Forty-two patients were found with early death or WOLST within 24 h of transfer. Do not resuscitate/do not intubate (DNR/DNI) code status (odds ratio [OR] 5.23, confidence interval [CI] 3.31-8.28), anticoagulation use (OR 2.11, CI 1.09-4.09), and lower level of consciousness at presentation based on Glasgow Coma Score (OR 1.41, CI 1.29-1.54) and Full Outline of Unresponsiveness (FOUR) score (OR 1.34, CI 1.26-1.46) were associated with WOLST. Associated characteristics on the computed tomography scan included midline shift (OR 4.64, CI 2.32-9.29), hydrocephalus (OR 9.30, CI 4.56-18.96), and intraventricular extension (OR 5.27, CI 2.60-10.68). Case matching restricted to midline shift demonstrated similarity between patients with aggressive care and WOLST. DNR/DNI code status, warfarin use, ICH score, and composite FOUR score were the best predictive characteristics (area under the curve 0.942). CONCLUSIONS: Early death or WOLST after ICH within 24 h of presentation was most associated with DNR/DNI code status, warfarin use, ICH score, and lower level of consciousness at presentation. These characteristics may be used by clinicians to guide conversations prior to transfer to tertiary care centers.

Withdrawal of life-sustaining therapy in intensive care unit patients following out-of-hospital cardiac arrest: An Australian metropolitan ICU experience.

BACKGROUND: Withdrawal of life-sustaining therapy is a common phenomenon following out-of-hospital cardiac arrest. The clinical practices surrounding withdrawal of life-sustaining therapy remain unclear and warrant further inspection due to their reported impact on post-cardiac arrest mortality. OBJECTIVES: To determine factors associated with withdrawal of life-sustaining therapy (WLST) in intensive care unit (ICU) patients following out-of-hospital cardiac arrest (OHCA). METHODS: A retrospective review of ICU patients' clinical records following OHCA was conducted from January 2010 to December 2015. Demographic features, cardiac arrest characteristics, and targeted temperature management practices were compared between patients with and without WLST. We dichotomised WLST into early (ICU length of stay <72 h) and late (ICU length of stay ≥72 h). Factors independently associated with WLST were determined by multivariable binary logistic regression. RESULTS: The study cohort included 260 post-OHCA ICU patients. The mean age was 58 years, and majority were males (178, 68%); 145 (56%) underwent WLST, with the majority undergoing early WLST (89, 61%). Status myoclonus was the strongest independent factor associated with early WLST (OR 42.53, 95% CI 4.97-363.60; p < 0.001). Glasgow Coma Scale (GCS) motor response of <4 on day three post-OHCA was the strongest factor associated with delayed WLST (OR 48.76, 95% CI 11.87-200.27; p < 0.0001). CONCLUSION: The majority of deaths in ICU patients post-OHCA occurred following early WLST. Status myoclonus and a GCS motor response of <4 on day three post-OHCA are independently associated with WLST.

Predictors of treatment limitations in Finnish intensive care units.

BACKGROUND: Few studies have examined the factors that predict the limitations of life-sustaining treatment (LST) to patients in intensive care units (ICUs). We aimed to identify variables associated with the decision of withholding of life support (WHLS) at admission, WHLS during ICU stay and the withdrawal of ongoing life support (WDLS). METHODS: This retrospective observational study comprised 17,772 adult ICU patients who were included in the nationwide Finnish ICU Registry in 2016. Factors associated with LST limitations were identified using hierarchical logistic regression. RESULTS: The decision of WHLS at admission was made for 822 (4.6%) patients, WHLS during ICU stay for 949 (5.3%) patients, and WDLS for 669 (3.8%) patients. Factors strongly predicting WHLS at admission included old age (adjusted odds ratio [OR] for patients aged 90 years or older in reference to those younger than 40 years was 95.6; 95% confidence interval [CI], 47.2-193.5), dependence on help for activities of daily living (OR, 3.55; 95% CI, 3.01-4.2), and metastatic cancer (OR, 4.34; 95% CI, 3.16-5.95). A high severity of illness predicted later decisions to limit LST. Diagnoses strongly associated with WHLS at admission were cardiac arrest, hepatic failure and chronic obstructive pulmonary disease. Later decisions were strongly associated with cardiac arrest, hepatic failure, non-traumatic intracranial hemorrhage, head trauma and stroke. CONCLUSION: Early decisions to limit LST were typically associated with old age and chronic poor health whereas later decisions were related to the severity of illness. Limitations are common for certain diagnoses, particularly cardiac arrest and hepatic failure.

Withdrawal of Temporary Mechanical Circulatory Support in Patients With Capacity.

CONTEXT: Little is known about the real-time decision-making process of patients with capacity to choose withdrawal of temporary mechanical circulatory support (MCS). OBJECTIVES: To assess how withdrawal of temporary MCS occurs when patients possess the capacity to make this decision themselves. METHODS: This retrospective case series included adults supported by CentriMag Acute Circulatory Support or Veno-Arterial Extracorporeal Membrane Oxygenation from February 2, 2007 to May 27, 2020 at a tertiary academic medical center who possessed capacity to participate in end-of-life discussions. Authors performed chart review to determine times between "initiation of temporary MCS," "determination of 'bridge to nowhere,'" "patient expressing desire to withdraw," "agreement to withdraw," "withdrawal," and "death," as well as reasons for withdrawal and the role of ethics, psychiatry, and palliative care. RESULTS: A total of 796 individuals were included. MCS was withdrawn in 178 (22.4%) of cases. Six of these 178 patients (3.4%) possessed the capacity to decide to withdraw MCS. Time between "patient expressing desire to withdraw" and "agreement to withdraw" ranged from 0 to 3 days; time between "agreement to withdraw" and "withdrawal" ranged from 0 to 6 days. Common reasons for withdrawal include perceived decline in quality of life or low probability of recovery. Ethics and psychiatry were consulted in 3 of 6 cases and palliative care in 5 of 6 cases. CONCLUSION: While it is rare for patients on MCS to request withdrawal, such cases provide insight into reasons for withdrawal and the important roles of multidisciplinary teams in helping patients and families through end-of-life decision-making.

Postcardiotomy Extracorporeal Membrane Oxygenation: Narrative Review Navigating the Ethical Issues.

Postcardiotomy shock (PCS) is an uncommon and life-threatening surgical complication. Extracorporeal membrane oxygenation (ECMO) is the first line of mechanical circulatory support for treating PCS when medical therapies are insufficient. Reaching a "therapeutic ceiling" or a "bridge to nowhere" is a common clinical scenario in which medical avenues for recovery have been exhausted. These situations pose emotional and ethical challenges for patients, their surrogates, and clinicians. To shed light on these ethically challenging situations in PCS and potential approaches, the authors conducted a narrative review of the literature. Publications were utilized to describe current trends in the diagnosis and management of the patient with PCS, with particular emphasis on the therapeutic ceiling for life support. Most of the recommendations came from practice parameters or expert opinions to support specific interventions. The authors proposed a stepwise multidisciplinary approach to reduce PCS-associated ethical and emotional challenges. Their proposed algorithm was based on the likelihood of the need for ECMO support based on the mortality risk stratification of cardiac surgery. They suggested focused discussions around the commencement of ECMO or other life-sustaining therapies-ideally preoperatively at the time of consent-through shared decision-making and, subsequently, proactive multidisciplinary education and updates to the surrogate decision-makers relying on realistic prognosis and consideration of the patient wishes during the ECMO run.

Prognostication of patients in coma after cardiac arrest: Public perspectives.

AIM: To elicit preferences for prognostic information, attitudes towards withdrawal of life-sustaining treatment (WLST) and perspectives on acceptable quality of life after post-anoxic coma within the adult general population of Germany, Italy, the Netherlands and the United States of America. METHODS: A web-based survey, consisting of questions on respondent characteristics, perspectives on quality of life, communication of prognostic information, and withdrawal of life-sustaining treatment, was taken by adult respondents recruited from four countries. Statistical analysis included descriptive analysis and chi2-tests for differences between countries. RESULTS: In total, 2012 respondents completed the survey. In each country, at least 84% indicated they would prefer to receive early prognostic information. If a poor outcome was predicted with some uncertainty, 37-54% of the respondents indicated that WLST was not to be allowed. A conscious state with severe physical and cognitive impairments was perceived as acceptable quality of life by 17-44% of the respondents. Clear differences between countries exist, including respondents from the U.S. being more likely to allow WLST than respondents from Germany (OR = 1.99, p < 0.001) or the Netherlands (OR = 1.74, p < 0.001) and preferring to stay alive in a conscious state with severe physical and cognitive impairments more than respondents from Italy (OR = 3.76, p < 0.001), Germany (OR = 2.21, p < 0.001), or the Netherlands (OR = 2.39, p < 0.001). CONCLUSIONS: Over one-third of the respondents considered WLST unacceptable when there is any remaining prognostic uncertainty. Respondents had a more positive perspective on acceptable quality of life after coma than what is currently considered acceptable in medical literature. This indicates a need for a closer look at the practice of WLST based on prognostic information, to ensure responsible use of novel prognostic tests.

End-Of-Life (EOL) Comfort Care And Withdrawal Of Life Support (WLS) Of Severely Burned Patients: A Review Of The Literature.

Ensuring burn patients get appropriate care without pursuing futile treatment has always constituted a challenging balance for burn surgeons. Patients with no prospect of cure who eventually die should potentially experience more comfortable and peaceful end-of-life (EoL) care. Recognizing that death for some patients is inevitable and can only be postponed but not avoided would open the way to a more humane comfort care for such patients. Though comfort EoL services are still not universal in burns intensive care units (ICU) and disparities still exist in access, and use of palliative care appears underutilized, its integration in the burns ICU has increased over the past decade with undeniable benefits. Palliative care consultations should be considered in select burn patients for whom survival is highly unlikely.

Assurer des soins adaptés sans obstination déraisonnable a toujours représenté un équilibre subtil pour les brûlologues. Les patients à qui il ne peut être proposé de traitement curatif mourront et nous devons leur assurer une fin de vie confortable et apaisée. Ainsi, reconnaître que certains patients mourront inéluctablement, un traitement agressif ne faisant que reculer l'échéance, doit nous amener à leur prescrire des soins de confort. La culture des SP semble insuffisamment développée et leur prescription aléatoire au sein des CTB, alors que leur développement dans les décennies passées a indubitablement représenté un progrès. Des consultations de SP au profit des patients au-delà de toute ressource thérapeutique devraient être développées.

Ethical dilemmas due to the Covid-19 pandemic.

The devastating pandemic that has stricken the worldwide population induced an unprecedented influx of patients in ICUs, raising ethical concerns not only surrounding triage and withdrawal of life support decisions, but also regarding family visits and quality of end-of-life support. These ingredients are liable to shake up our ethical principles, sharpen our ethical dilemmas, and lead to situations of major caregiver sufferings. Proposals have been made to rationalize triage policies in conjunction with ethical justifications. However, whatever the angle of approach, imbalance between utilitarian and individual ethics leads to unsolvable discomforts that caregivers will need to overcome. With this in mind, we aimed to point out some critical ethical choices with which ICU caregivers have been confronted during the Covid-19 pandemic and to underline their limits. The formalized strategies integrating the relevant tools of ethical reflection were disseminated without deviating from usual practices, leaving to intensivists the ultimate choice of decision.

[Withdrawal of life support in the permanent vegetative state, and a dignified death]. / Suspensión de soporte vital en el estado vegetativo permanente y muerte digna.

Patient relatives often request withdrawal of life support, especially artificial nutrition and hydration, in cases of permanent vegetative or minimally conscious state, and resort to court in case of disagreement. Two recent cases of withdrawal authorized by the courts concerned, one from abroad and one from Argentina, have been controversial. Although it may appear inhuman to stop feeding and hydrating such patients, to continue it only prolongs a state of irreversible biological subsistence. Families tend to increasingly accept withdrawal if the patient status remains unchanged. However, concern persists regarding the suffering that patients may undergo from onset of withdrawal till death, even though such suffering is little conceivable in the absence of cortical function and conscience content. While doctors and the layman consider ethical to withdraw life support, a nonnegligible proportion of doctors consider that vegetative state patients, even more minimally conscious state patients, do experience hunger, thirst and pain. In some countries, like the United Kingdom, strict withdrawal criteria were proposed, together with pharmacological treatment schemes for the distress arising during the withdrawal period, even though its benefit is controversial. In Argentina, two scientific societies have publicly advocated withdrawal, but not issued formal guidelines. In any case, both "dignified death" Law 26.742 and the Civil Code consent withdrawal of life support, if accompanied by appropriate relief of clinical symptoms indicating suffering.

Es frecuente que familiares directos soliciten la suspensión de soporte vital, en particular de la hidratación y nutrición asistidas, en pacientes con estado vegetativo o de mínima conciencia permanente, y que recurran a la justicia en caso de desacuerdo. Dos casos recientes de suspensión, uno del exterior y otro argentino, autorizados por los tribunales respectivos, han sido motivo de controversia. Si bien puede parecer inhumano dejar de alimentar e hidratar, continuar haciéndolo solo prolonga un estado de supervivencia biológica irreversible. Las familias tienden a aceptar la suspensión si el paciente se mantiene sin cambios. Sin embargo, persiste preocupación por el posible sufrimiento desde la suspensión hasta la muerte, aunque el mismo es poco concebible en ausencia de función cortical y de conciencia. Si bien médicos y profanos consideran ético suspender el soporte vital, una cierta proporción de médicos considera que en el estado vegetativo, o más aún, en mínima conciencia, efectivamente se experimenta hambre, sed y dolor. En países como el Reino Unido, se han propuesto criterios de suspensión de soporte vital, y esquemas de tratamiento para el malestar durante el período de suspensión, aunque su beneficio efectivo es controvertido. La Argentina cuenta con recomendaciones de dos sociedades científicas, pero no con criterios reglamentados. Pero tanto la Ley 26.742 de "muerte digna" como el Código Civil consienten la suspensión del soporte vital en el estado vegetativo o de mínima conciencia, si se acompaña de medidas de alivio de los síntomas clínicos que puedan significar sufrimiento.

Suspensión de soporte vital en el estado vegetativo permanente y muerte digna / Withdrawal of life support in the permanent vegetative state, and a dignified death

Es frecuente que familiares directos soliciten la suspensión de soporte vital, en particular de la hidratación y nutrición asistidas, en pacientes con estado vegetativo o de mínima conciencia permanente, y que recurran a la justicia en caso de desacuerdo. Dos casos recientes de suspensión, uno del exterior y otro argentino, autorizados por los tribunales respectivos, han sido motivo de controversia. Si bien puede parecer inhumano dejar de alimentar e hidratar, continuar haciéndolo solo prolonga un estado de supervivencia biológica irreversible. Las familias tienden a aceptar la suspensión si el paciente se mantiene sin cambios. Sin embargo, persiste preocupación por el posible sufrimiento desde la suspensión hasta la muerte, aunque el mismo es poco concebible en ausencia de función cortical y de conciencia. Si bien médicos y profanos consideran ético suspender el soporte vital, una cierta proporción de médicos considera que en el estado vegetativo, o más aún, en mínima conciencia, efectivamente se experimenta hambre, sed y dolor. En países como el Reino Unido, se han propuesto criterios de suspensión de soporte vital, y esquemas de tratamiento para el malestar durante el período de suspensión, aunque su beneficio efectivo es controvertido. La Argentina cuenta con recomendaciones de dos sociedades científicas, pero no con criterios reglamentados. Pero tanto la Ley 26.742 de "muerte digna" como el Código Civil consienten la suspensión del soporte vital en el estado vegetativo o de mínima conciencia, si se acompaña de medidas de alivio de los síntomas clínicos que puedan significar sufrimiento.

Patient relatives often request withdrawal of life support, especially artificial nutrition and hydration, in cases of permanent vegetative or minimally conscious state, and resort to court in case of disagreement. Two recent cases of withdrawal authorized by the courts concerned, one from abroad and one from Argentina, have been controversial. Although it may appear inhuman to stop feeding and hydrating such patients, to continue it only prolongs a state of irreversible biological subsistence. Families tend to increasingly accept withdrawal if the patient status remains unchanged. However, concern persists regarding the suffering that patients may undergo from onset of withdrawal till death, even though such suffering is little conceivable in the absence of cortical function and conscience content. While doctors and the layman consider ethical to withdraw life support, a nonnegligible proportion of doctors consider that vegetative state patients, even more minimally conscious state patients, do experience hunger, thirst and pain. In some countries, like the United Kingdom, strict withdrawal criteria were proposed, together with pharmacological treatment schemes for the distress arising during the withdrawal period, even though its benefit is controversial. In Argentina, two scientific societies have publicly advocated withdrawal, but not issued formal guidelines. In any case, both "dignified death" Law 26.742 and the Civil Code consent withdrawal of life support, if accompanied by appropriate relief of clinical symptoms indicating suffering.

Intensive care nurses' experiences of withdrawal of life-sustaining treatments in intensive care patients: A qualitative study.

OBJECTIVE: To explore the experience of intensive care nurses when participating in the withdrawal of life-sustaining treatments from intensive care unit patients. DESIGN AND METHODS: A qualitative descriptive and explorative design. Data were collected in 2017 and 2018 by interviewing nine intensive care nurses. The data were analysed by using systematic text condensation. SETTING: The nine intensive care nurses interviewed worked in four different intensive care units located in one university hospital and one local hospital. MAIN OUTCOME MEASURES: Experiences when participating in the process of withdrawing life-sustaining treatments. FINDINGS: Three categories emerged from the data analysis: ICU nurses' experiences of stress in the process of treatment withdrawal; a requirement for interdisciplinary support and cooperation; and elements to achieve a dignified treatment withdrawal process. CONCLUSION: The intensive care nurses experienced challenges and emotional reactions when patients were overtreated or when they had to participate in treatments they did not agree with. They considered debriefings to be helpful in dealing with emotions. Thorough planning, good communication, pain relief, and the creation of a peaceful environment were perceived as important elements in achieving a dignified treatment withdrawal process.

Ethical Considerations for Mechanical Support.

Extracorporeal life support can support patients with severe forms of cardiac and respiratory failure. Uncertainty remains about its optimal use owing in large part to its resource-intensive nature and the high acuity illness in supported patients. Specific issues include the identification of patients most likely to benefit, the appropriate duration of support when prognosis is uncertain, and what to do when patients become dependent on extracorporeal life support but no longer have hope for recovery or transplantation. Careful deliberation of ethical principles and potential dilemmas should be made when considering the use of extracorporeal life support in advanced cardiopulmonary failure.

Evoked potentials improve multimodal prognostication after cardiac arrest.

AIM: Predicting recovery in comatose post-cardiac arrest patients requires multiple modalities of prognostic assessment. In isolation, absent N20 cortical responses in somatosensory evoked potentials (SSEPs) are a specific predictor of poor outcome. It is unknown whether SSEP results, when assessed in the context of prior knowledge (demographic and clinical information), change the pretest predicted probability of recovery. METHODS: In a single center retrospective study, a cohort of 323 patients admitted to post-cardiac arrest service at a tertiary care center were classified into a group based on SSEP testing. We built adjusted logistic regression models including clinical examination findings on the day SSEPs were recorded to generate a pre-test outcome probability for awakening, withdrawal of life-sustaining therapy (WLST) and survival to discharge. We then added the upper extremity N20 cortical response results to the model to obtain updated outcome probabilities. ROC curve was used to determine the additive effect of using SSEPs to the model. Survival to discharge, awakening, and WLST due to neurological reasons were designated as primary, secondary and tertiary outcomes, respectively. RESULTS: Analyses showed that evoked potentials are ordered in sicker patients. Adding SSEP to the model increased the proportion of patients with less than 1% and 5% chance of survival, as well as the proportion of patients with over 95% chance of WLST. AUC for survival increased from 0.85 to 0.93 when SSEP was included (p = 0.006). CONCLUSION: Adding the N20 SSEP response results to prior knowledge changed the predicted probability of WLST and survival to discharge in comatose post-arrest patients.

End-of-life decisions: A retrospective study in a tertiary care teaching hospital in India.

Background & objectives: In developing countries like India, there is a lack of clarity regarding the factors that influence decisions pertaining to life supports at the end-of-life (EOL). The objectives of this study were to assess the factors associated with EOL-care decisions in the Indian context and to raise awareness in this area of healthcare. Methods: This retrospectively study included all patients admitted to the medical unit of a tertiary care hospital in southern India, over one year and died. The baseline demographics, economic, physiological, sociological, prognostic and medical treatment-related factors were retrieved from the patient's medical records and analysed. Results: Of the 122 decedents included in the study whose characteristics were analyzed, 41 (33.6%) received full life support and 81 (66.4%) had withdrawal or withholding of some life support measure. Amongst those who had withdrawal or withholding of life support, 62 (76.5%) had some support withheld and in 19 (23.5%), it was withdrawn. The documentation of the disease process, prognosis and the mention of imminent death in the medical records was the single most important factor that was associated with the EOL decision (odds ratio - 0.08; 95% confidence interval, 0.01-0.74; P=0.03). Interpretation & conclusions: The documentation of poor prognosis was the only factor found to be associated with EOL care decisions in our study. Prospective, multicentric studies need to be done to evaluate the influence of various other factors on the EOL care.

Withdrawal of Life-Support in Neonatal Hypoxic-Ischemic Encephalopathy.

PURPOSE: We describe the frequency and timing of withdrawal of life-support (WLS) in moderate or severe hypoxic-ischemic encephalopathy (HIE) and examine its associations with medical and sociodemographic factors. PROCEDURES: We undertook a secondary data analysis of a prospective multicenter data registry of regional level IV Neonatal Intensive Care Units participating in the Children's Hospitals Neonatal Database. Infants ≥36 weeks gestational age with HIE admitted to a Children's Hospitals Neonatal Database Neonatal Intensive Care Unit between 2010 and 2016, who underwent therapeutic hypothermia were categorized as (1) infants who died following WLST and (2) survivors with severe HIE (requiring tube feedings at discharge). RESULTS: Death occurred in 267/1,925 (14%) infants with HIE, 87.6% following WLS. Compared to infants with WLS (n = 234), the survived severe group (n = 74) had more public insurance (73% vs 39.3%, P = 0.00001), lower household income ($37,020 vs $41,733, P = 0.006) and fewer [20.3% vs 35.0%, P = 0.0212] were from the South. Among infants with WLS, electroencephalogram was performed within 24 hours in 75% and was severely abnormal in 64% cases; corresponding rates for MRI were 43% and 17%, respectively. Private insurance was independently associated with WLS, after adjustment for HIE severity and center. CONCLUSIONS: In a multicenter cohort of infants with HIE, WLS occurred frequently and was associated with sociodemographic factors. The rationale for decision-making for WLS in HIE require further exploration.

Predictors of withdrawal of life support after burn injury.

INTRODUCTION: Discussions regarding withdrawal of life support after burn injury are challenging and complex. Often, providers may facilitate this discussion when the extent of injury makes survival highly unlikely or when the patient's condition deteriorates during resuscitation. Few papers have evaluated withdrawal of life support in burn patients. We therefore sought to determine the predictor of withdrawal of life support (WLS) in a regional burn center. METHODS: We conducted a retrospective analysis of all burn patients from 2002 to 2012. Patient characteristics included age, gender, burn mechanism, percentage total body surface area (%TBSA) burned, presence of inhalation injury, hospital length of stay, and pre-existing comorbidities. Patients <17years of age and patients with unknown disposition were excluded. Patients were categorized into three cohorts: Alive till discharge (Alive), death by withdrawal of life support (WLS), or death despite ongoing life support (DLS). DLS patients were then excluded from the study population. Multivariate logistic regression was used to estimate predictors of WLS. RESULTS: 8,371 patients were included for analysis: 8134 Alive, 237 WLS. Females had an increased odd of WLS compared to males (OR 2.03, 95% CI 1.18-3.48; p=0.010). Based on higher CCI, patients with pre-existing comorbidities had an increased odd of WLS (OR 1.28, 95% CI 1.08-1.52; p=0.005). There was a significantly increased odds for WLS (OR 1.09, 95% CI 1.06-1.12; p<0.001) with increasing age. Similarly, there was an increased odd for WLS (OR 1.08, 95% CI 1.07-1.51; p<0.001) with increasing %TBSA. An increased odd of WLS (OR 2.47, 95% CI 1.05-5.78; p=0.038) was also found in patients with inhalation injury. CONCLUSION: The decision to withdraw life support is a complex and difficult decision. Our current understanding of predictors of withdrawal of life support suggests that they mirror those factors which increase a patient's risk of mortality. Further research is needed to fully explore end-of-life decision making in regards to burn patients. The role of patient's sex, particularly women, in WLS decision making needs to be further explored.

Making a case for controlled organ donation after cardiac death: the story of Italy's first experience.

Donation after circulatory death (DCD) is a valuable option for the procurement of organs for transplantation. In Italy, organ procurement after controlled DCD is legally and ethically conceivable within the current legislative framework. However, although formal impediments do not exist, the health care team is faced with many obstacles that may hinder the implementation of such programs. We report the case of Italy's first controlled DCD, specifically discussing the role of the patient's family in the shared decision-making process. In our case, the death of the patient subsequent to the withdrawal of life-sustaining therapies was consistent with the patient's wishes, showing respect for his dignity and honoring his autonomy, as expressed to his family previously. By making donation possible, the medical team was able to fulfill the family's last request on behalf of the patient. This case should stimulate deliberation regarding the potential to shorten the 20-minute no-touch period currently in place in Italy. Such an action would not have injured this patient and would certainly have increased the quality of the procured organs.

End-of-life care beliefs among Hindu physicians in the United States.

Several studies from the United States and Europe showed that physicians' religiosity is associated with their approach to end-of-life care beliefs. No such studies have focused exclusively on Hindu physicians practicing in the United States. A 34-item questionnaire was sent to 293 Hindu physicians in the United States. Most participants believed that their religious beliefs do not influence their practice of medicine and do not interfere with withdrawal of life support. The US practice of discussing end-of-life issues with the patient, rather than primarily with the family, seems to have been adopted by Hindu physicians practicing in the United States. It is likely that the ethical, cultural, and patient-centered environment of US health care has influenced the practice of end-of-life care by Hindu physicians in this country.

Life, death, and the bridges in-between.

Remarkable advances in the technological capacity of modern medicine now permit the use of mechanical organ failure support deployed primarily to save life. Such technology serves as a bridge to either recovery or, when feasible, organ transplantation. However, when effective treatment options are exhausted, technological advances can be burdensome bridges to death. This paper briefly reviews the principles of management of life-threatening critical illness and the corresponding biological aspects of life, death, and organ donation, which are both informed and complicated by these technological and scientific achievements.