RESUMO
BACKGROUND: Discussing goals of care with heart failure patients is recommended but is not done systematically, due to factors such as time and personal beliefs. A recent survey showed that one-fifth of clinicians believe that implantable cardioverter defibrillator deactivation (ICDD) is unethical or constitutes physician-assisted suicide. We investigated whether individuals' characteristics are associated with these beliefs. METHODS: The Decision-Making About Goals of Care for Hospitalized Patients With Heart Failure (DECIDE-HF) survey was given to healthcare providers at 9 hospitals to assess their perceived barriers to goals-of-care discussions. The association between respondent characteristics and their beliefs was examined using 2 adjusted logistic regression models. RESULTS: We included 760 clinicians (459 nurses, 94 fellows, and 207 cardiologists). The responses varied among professions, with the belief that ICDD is unethical considered to be important barrier by nurses (24%), fellows (10%), and staff (7%); P < 0.001). After adjusting for site, spirituality being more important in life (odds ratio [OR]: 2.21; 95% confidence interval [CI]:1.37-3.56; P = 0.001, compared to less important), region of training (Asia [OR: 5.88; 95% CI: 2.12-16.31; P = 0.001] and Middle East [OR: 5.55; 95% CI:1.57-19.63; P = 0.008] compared to Canada), and years in practice (OR: 1.32; 95% CI: 1.07-1.63; P = 0.01 per decade) influenced beliefs about ICDD being unethical, with similar results for the belief that ICDD represents physician-assisted suicide. CONCLUSIONS: Sociocultural factors, region of training, and profession influence clinicians' beliefs about ICDD being unethical and representing physician-assisted suicide. These factors and beliefs must be acknowledged when facing the delicate issue of end-of-life discussion.
CONTEXTE: Une discussion sur les objectifs de soins avec les patients atteints d'insuffisance cardiaque est recommandée, mais elle n'est pas systématiquement menée en raison de facteurs tels que les contraintes de temps et les croyances personnelles. Selon une enquête récente, un cinquième des cliniciens croient qu'une désactivation d'un défibrillateur cardioverteur implantable (DDCI) est contraire à l'éthique ou représente un suicide assisté par le médecin. Nous avons vérifié si des caractéristiques individuelles sont associées à ces croyances. MÉTHODOLOGIE: L'enquête DECIDE-HF ( Deci sion-Making About Goals of Care for Hospitalize d Pati e nts With H eart F ailure) a été réalisée chez des professionnels de la santé de neuf hôpitaux dans le but d'évaluer les obstacles qu'ils percevaient face à la discussion sur les objectifs de soins. Le lien entre les caractéristiques des répondants et leurs croyances a été analysé à l'aide de deux modèles ajustés de régression logistique. RÉSULTATS: Nous avons interrogé 760 cliniciens (459 infirmières, 94 médecins associés et 207 cardiologues). Les réponses ont varié d'une profession à l'autre, la croyance qu'une DDCI est contraire à l'éthique étant considérée comme un obstacle important par 24 % des infirmières, 10 % des médecins associés et 7 % des membres du personnel (p < 0,001). Après ajustement selon l'établissement, l'importance de la spiritualité dans la vie (très important [rapport de cotes {RC}] = 2,21; intervalle de confiance [IC] à 95 % : 1,37-3,56; p = 0,001 comparativement à moins important), la région d'obtention du diplôme (Asie [RC = 5,88; IC à 95 % : 2,12-16,31; p = 0,001] et Moyen-Orient [RC = 5,55; IC à 95 % : 1,57-19,63; p = 0,008] comparativement au Canada) et le nombre d'années d'exercice (RC = 1,32; IC à 95 % : 1,07-1,63; p = 0,01 par tranche de 10 ans) ont influencé les croyances voulant qu'une DDCI soit contraire à l'éthique, et les résultats ont été similaires pour la croyance selon laquelle une DDCI représente un suicide assisté par le médecin. CONCLUSIONS: Des facteurs socioculturels, la région de formation et la profession influencent les croyances des cliniciens sur la DDCI et le fait qu'ils la considèrent comme étant une démarche contraire à l'éthique ou un suicide assisté par un médecin. Ces facteurs et croyances doivent être reconnus lorsque vient le temps d'aborder la délicate question de la discussion sur la fin de vie.
RESUMO
OBJECTIVES: The Pediatric Logistic Organ Dysfunction-2 is a validated score that quantifies organ dysfunction severity and requires complex data collection that is time-consuming and subject to errors. We hypothesized that a computer algorithm that automatically collects and calculates the Pediatric Logistic Organ Dysfunction-2 (aPELOD-2) score would be valid, fast and at least as accurate as a manual approach (mPELOD-2). DESIGN: Retrospective cohort study. SETTING: Single center tertiary medical and surgical pediatric critical care unit (Sainte-Justine Hospital, Montreal, Canada). PATIENTS: Critically ill children participating in four clinical studies between January 2013 and August 2018, a period during which mPELOD-2 data were manually collected. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The aPELOD-2 was calculated for all consecutive admissions between 2013 and 2018 (n = 5,279) and had a good survival discrimination with an area under the receiver operating characteristic curve of 0.84 (95% CI, 0.81-0.88). We also collected data from four single-center studies in which mPELOD-2 was calculated (n = 796, 57% medical, 43% surgical) and compared these measurements to those of the aPELOD-2. For those patients, median age was 15 months (interquartile range, 3-73 mo), median ICU stay was 5 days (interquartile range, 3-9 d), mortality was 3.9% (n = 28). The intraclass correlation coefficient between mPELOD-2 and aPELOD-2 was 0.75 (95% CI, 0.73-0.77). The Bland-Altman showed a bias of 1.9 (95% CI, 1.7-2) and limits of agreement of -3.1 (95% CI, -3.4 to -2.8) to 6.8 (95% CI, 6.5-7.2). The highest agreement (Cohen's Kappa) of the Pediatric Logistic Organ Dysfunction-2 components was noted for lactate level (0.88), invasive ventilation (0.86), and creatinine level (0.82) and the lowest for the Glasgow Coma Scale (0.52). The proportion of patients with multiple organ dysfunction syndrome was higher for aPELOD-2 (78%) than mPELOD-2 (72%; p = 0.002). The aPELOD-2 had a better survival discrimination (area under the receiver operating characteristic curve, 0.81; 95% CI, 0.72-0.90) over mPELOD-2 (area under the receiver operating characteristic curve, 0.70; 95% CI, 0.59-0.82; p = 0.01). CONCLUSIONS: We successfully created a freely available automatic algorithm to calculate the Pediatric Logistic Organ Dysfunction-2 score that is less labor intensive and has better survival discrimination than the manual calculation. Use of an automated system could greatly facilitate integration of the Pediatric Logistic Organ Dysfunction-2 score at the bedside and within clinical decision support systems.
