Influence of Age on Decision-Making Process to Limit or Withdraw Life-Sustaining Treatment in the Intensive Care Unit - A Single Center Prospective Observational Study.

BACKGROUND: The increasing age in the industrialized countries places significant demands on intensive care unit (ICU) resources and this triggers debates about end-of-life care for the elderly. OBJECTIVES: We sought to determine the impact of age on the decision-making process to limit or withdraw life-sustaining treatment (DWLST) in an ICU in France. We hypothesized that there are differences in the decision-making process for young and old patients. DESIGN, SETTING, PARTICIPANTS: We prospectively studied end-of-life decision-making for all consecutive admissions (n=390) to a tertiary care university ICU in Toulouse, France over a period of 11 months between January and October 2011. RESULTS: Among the 390 patients included in the study (age ≥70yo, n=95; age <70yo, n=295) DWLST were more common for patients 70 years or older (43% for age ≥70yo vs. 16% for age <70yo, p <0.0001). Reasons for DWLST were different in the 2 groups, with the 'no alternative treatment options' and 'severity of illness' as the most frequent reasons cited for the younger group whereas it was 'severity of illness' for the older group. 'Advanced age' led to DWLSTs in 43% of the decisions in the group ≥70yo (vs. 0% in the group <70yo, p <0.0001). Multivariate logistic regression showed a high SAPS II score and age ≥70yo as independent risk factors for DWLSTs in the ICU. We did not find age ≥70yo as an independent risk factor for mortality in ICU. CONCLUSION: We found that age ≥70yo was an independent risk factor for DWLSTs for patients in the ICU, but not for their mortality. Reasons leading to DWLSTs are different according to the age of patients.

[Seasonal influenza vaccination coverage of general practitioners and their patients. Practice survey of French general practitioners after vaccination campaign 2011-2012]. / Couverture par le vaccin de la grippe saisonnière des médecins généralistes et de leurs patients. Enquête de pratique auprès de médecins généralistes français après la campagne de vaccination 2011-2012.

BACKGROUND: In France, vaccination coverage against seasonal influenza for risk groups was inadequate: 55.2% of people aged 65 and older, and 33% of the 16-64 year group with chronic targeted disorders were vaccinated in March 2012. Three quarters of general practitioners were vaccinated. Our objective was to estimate the influence of the vaccination status of general practitioners on vaccine coverage of their patients at risk. METHODS: A questionnaire was sent in March 2012 to a sample of 500 general practitioners. Their professional characteristics, vaccination status against seasonal influenza and the determinants of these vaccinations were collected and compared to the vaccine coverage of their patients obtained from the French healthcare fund. RESULTS: Self-reported vaccination coverage of the 225 general practitioners respondents was 81.3%. There was a positive correlation with age greater than 50 years, high activity level, rural practice and the absence of particular mode of exercise. The doctors wanted to be vaccinated to protect themselves and protect their patients or their family. Of the 42 doctors unvaccinated, 42.5% feared the side effects of the vaccine, 40% considered influenza to be a benign illness and 32.5% considered low risk of catching or spreading it. The vaccination rate for patients aged 65 and older was 62.3% among 147 doctors vaccinated versus 58.3% in unvaccinated 31 physicians (P<0.0001). These rates were 39% versus 36.7% (P=0.29) for patients with chronic targeted disorders. CONCLUSION: This study shows a positive association between the reported vaccination of general practitioners and effective influenza vaccination of their patients aged 65 years and older. This result is less clear for patients with chronic targeted disorders. All this findings argue in favor of promoting seasonal influenza vaccination among general practitioners.

Resistive Index or color-Doppler semi-quantitative evaluation of renal perfusion by inexperienced physicians: results of a pilot study.

BACKGROUND: Doppler-based renal resistive index (RI) calculation may help in the early detection of acute kidney injury (AKI). Its feasibility and reproducibility by inexperienced operators remain unknown. The main objective of this study was to compare performances of junior and senior operators in assessing renal perfusion using both the semiquantitative color-Doppler scale and RI calculation. METHODS: Prospective cohort study performed in 3 ICUs. Inexperienced juniors physicians attended a half-day course on renal perfusion assessment using RI calculation and color-Doppler (from 0, absence of renal perfusion; to 3, renal vessels identifiable in the entire field of view). Junior and senior operators used both methods in 69 mechanically ventilated patients, in blind fashion. RESULTS: Failure to obtain RI occurred for a junior operator in a single patient. RI and color-Doppler semi-quantitative values obtained by operators were correlated (r²=0.64 and r²=0.61, respectively). Systematic bias across operators as assessed using Bland-Altman plots was negligible (-0.001 and -0.29, respectively), although precision was limited (95% confidence intervals, +0.105 to -0.107 and +0.98 to -1.04, respectively). RI calculation and semi-quantitative assessment performed well for diagnosing persistent AKI (area under the receiver-operating characteristic curve, 0.84 [95% confidence interval, 0.73-0.97] and 0.87 [0.77-0.97], respectively). CONCLUSION: A brief course on renal Doppler allowed inexperienced operators to assess effectively renal perfusion with a good reliability when compared to senior operators. In addition, our results suggest the good diagnostic performance of both Doppler-based RI and semi-quantitative renal perfusion assessment in predicting short-term renal dysfunction reversibility.