ANZICS guiding principles for complex decision making during the COVID-19 pandemic.

The global 2019 coronavirus disease (COVID-19) pandemic has led to major challenges in clinical decision making when the demand for intensive care exceeds local capacity. In order to promote consistent, transparent, objective and ethical decision making, the Australian and New Zealand Intensive Care Society (ANZICS) formed a committee to urgently develop guidelines outlining key principles that should be utilised during the pandemic. This guidance is intended to support the practice of intensive care specialists during the COVID-19 pandemic and to promote the development of local admission policies that should be endorsed by health care organisations and relevant local authorities.

Admission to ICU "solely for possible organ donation"-audit of current New Zealand practice.

AIM: Admission of patients with likely fatal illness to ICU "solely for possible organ donation" has been a long-standing practice in New Zealand. This is advocated as a means of increasing the availability of organs for transplant. We sought to determine the extent and characteristics of current clinical practice. METHOD: We identified patients admitted "solely for possible organ donation" from a total of 2,686 patients who died in the 24 public hospital ICUs in New Zealand between 1 July 2017 and 30 June 2019. We determined their characteristics, resource utilisation and organ and tissue donation outcomes. RESULTS: There were 49 patients (F26, M23; age range 9 days to 79 years, median 57 years, European 36, Maori 11, Pacific 1, Asian 1). On 26 occasions (57%) ICU admission was preceded by a "preliminary family discussion about donation". Eighteen of the 24 ICUs admitted at least one patient (range 1 to 13, median 2) over the two-year period. All 49 patients had evidence of catastrophic brain damage at the time of ICU admission; they used a total of 60 ICU days, including 15.5 days for one patient who was actively treated after spontaneous improvement. Death occurred between 5 minutes and 15 days, median 18.7 hours after ICU admission; all but one death occurred by 82 hours. Distribution of ICU stay was similar for the 20 patients who donated and for those 29 who did not. Brain death developed in 22 patients, 20 of whom donated 63 organs, 15% of the total 430 organs donated by all deceased donors over the period. Organs from 20 donors were transplanted into 58 recipients, 14% of the total 417 recipients of deceased-donor organs over the period. Nine of the 49 patients also donated tissues for transplantation. CONCLUSION: There are already a small number of patients being admitted to ICUs in New Zealand "solely for possible organ donation", the majority following prior family discussion of donation. These patients occupy a small number of ICU bed-days and contribute ~15% of the deceased donation activity. Organ Donation New Zealand has developed and recently promulgated recommended best practice guidelines for clinicians in the ICU and emergency departments and is supporting expansion of the practice within the scope of these guidelines.

Attitudes to Organ Donation and Knowledge of Donation and Transplantation among University of Auckland Medical Students.

AIMS: •To explore organ donation and transplantation knowledge and attitudes among medical students at the University of Auckland.•To understand students' perception of the extent of training received prior to and during the medical program. METHOD: A validated web-based questionnaire consisting of 42 questions in five categories was anonymously administered to all enrolled medical students at the Faculty of Medical and Health Sciences, University of Auckland, in September 2012. RESULTS: In all, 419 out of 989 (42%) Year 2-6 students responded. A total of 99.3% of medical students supported organ donation, but knowledge was limited (mean score 7.54/15±2.26). A total of 38% of students reported having participated in organ donation learning. A total of 96% of students believed that organ donation information should be available in primary care settings. A total of 69% of students reported that if a patient asked a question about organ donation that they did not know the answer to, they also would not know where to source the correct information from. CONCLUSION: This study demonstrates that although medical students support organ donation, they lack the knowledge required to facilitate informative discussions with patients. Enhanced organ donation education in medical programs may enable students to develop skills and knowledge allowing them to better discuss donation with patients.

End points for phase II trials in intensive care: recommendations from the Australian and New Zealand Clinical Trials Group consensus panel meeting.

BACKGROUND: There is uncertainty about which end points should be used for Phase II trials in critically ill patients. OBJECTIVE: To systematically evaluate potential end points for Phase II trials in critically ill patients. DESIGN AND SETTING: A report outlining a process of literature review and recommendations from a consensus meeting conducted on behalf of the Australian and New Zealand Intensive Care Society Clinical Trials Group (ANZICS CTG) in October 2011. RESULTS AND CONCLUSIONS: The consensus panel concluded that there are no adequately validated end points for Phase II trials in critically ill patients. However, the following were identified as potential Phase II end points: hospital-free days to Day 90, ICU-free days to Day 28, ventilator-free days to Day 28, cardiovascular support-free days to Day 28, and renal replacement therapy-free days to Day 28. We recommend that these end points be evaluated further.

Health economics and health technology assessment: perspectives from Australia and New Zealand.

Formal health economics and health technology assessment (HTA)processes, including cost-effectiveness and cost-utility analysis, are variably used to inform decisions about public and private health service funding and service provision. In general, pharmaceuticals have been subject to more sophisticated health economic analyses and HTAs and for a longer time than either devices or procedures. HTA has been performed by a number of different entities. While HTA shares many common features across the world, its uses, approaches, applications,and impact differ throughout the world. This article will discuss some of the general attributes of HTA and will focus on its specific applications in Australia and New Zealand.

Pro/con ethics debate: when is dead really dead?

Contemporary intensive care unit (ICU) medicine has complicated the issue of what constitutes death in a life support environment. Not only is the distinction between sapient life and prolongation of vital signs blurred but the concept of death itself has been made more complex. The demand for organs to facilitate transplantation promotes a strong incentive to define clinical death in a manner that most effectively supplies that demand. We consider the problem of defining death in the ICU as a function of viable organ availability for transplantation.

Clinical review: moral assumptions and the process of organ donation in the intensive care unit.

The objective of the present article is to review moral assumptions underlying organ donation in the intensive care unit. Data sources used include personal experience, and a Medline search and a non-Medline search of relevant English-language literature. The study selection included articles concerning organ donation. All data were extracted and analysed by the author. In terms of data synthesis, a rational, utilitarian moral perspective dominates, and has captured and circumscribed, the language and discourse of organ donation. Examples include "the problem is organ shortage", "moral or social duty or responsibility to donate", "moral responsibility to advocate for donation", "requesting organs" or "asking for organs", "trained requesters", "pro-donation support persons", "persuasion" and defining "maximising donor numbers" as the objective while impugning the moral validity of nonrational family objections to organ donation. Organ donation has recently been described by intensivists in a morally neutral way as an "option" that they should "offer", as "part of good end-of-life care", to families of appropriate patients. In conclusion, the review shows that a rational utilitarian framework does not adequately encompass interpersonal interactions during organ donation. A morally neutral position frees intensivists to ensure that clinical and interpersonal processes in organ donation are performed to exemplary standards, and should more robustly reflect societal acceptability of organ donation (although it may or may not "produce more donors").

Drotrecogin alfa (recombinant human activated protein C) in severe sepsis--a New Zealand viewpoint.

AIM: Sepsis is a serious and increasing worldwide intensive care problem. In response to intensivists' concerns over the benefits, risks and financial implications of the use of drotrecogin alfa (recombinant human activated protein C), the first adjunctive therapy for sepsis licensed in New Zealand, the New Zealand Region of the Australian and New Zealand Intensive Care Society (ANZICS) requested an advisory statement from a working party of New Zealand intensivists. METHODS: We reviewed (a) the PROWESS study of drotrecogin alfa recombinant; (b) the submission made by the sponsoring company to the FDA; (c) recent discussions and an economic evaluation of the use of the agent; (d) Australian pharmaceutical benefits scheme positive recommendations; (e) guidelines produced by the Eli Lilly Australian Advisory Board; (f) Australian hospital decisions on availability; and (g) New Zealand pricing and payment arrangements. We then formulated suggested New Zealand guidelines. RESULTS: We recommend that hospital pharmacy and therapeutics committees review the agent now. If the agent is made available for use, we recommend that: (a) specialists prescribing the agent be required to contribute clinical data to a national register of patients, (b) patients considered for treatment should first be treated with all appropriate surgical and medical therapy for severe sepsis with high illness severity in an intensive care unit by an intensivist; (c) patients considered for treatment should not have severe comorbidity or predetermined treatment limitations or contraindications to the agent in the original phase III study; and (d) patients should be considered only if seen to be not clearly improving after a six-hour period of intensive treatment. Once a decision has been made to treat with drotrecogin alfa, treatment should commence as soon as possible and within 24 hours of meeting criteria. Although the agent is recommended for use in adults, it may be reasonable to treat some older children. CONCLUSIONS: Despite high cost and moderate benefit, it may be reasonable to treat highly selected New Zealand patients with drotrecogin alfa.

Ethics roundtable debate: should a sedated dying patient be wakened to say goodbye to family?

Intensivists have the potential to maintain vital signs almost indefinitely, but not necessarily the potential to make moribund patients whole. Current ethical and legal mandates push patient autonomy to the forefront of care plans. When patients are incapable of expressing their preferences, surrogates are given proxy. It is unclear how these preferences extend to the very brink of inevitable death. Some say that patients should have the opportunity and authority to direct their death spiral. Others say it would be impossible for them to do so because an inevitable death spiral cannot be effectively palliated. Humane principles dictate they be spared the unrelenting discomfort surrounding death. The present case examines such a patient and the issues surrounding a unique end-of-life decision.

Surgeons, intensivists, and the covenant of care: administrative models and values affecting care at the end of life--Updated.

CONTEXT: End-of-life care remains a challenging and complex activity in critical care units. There is little information concerning the influence of administrative models of care delivery on end-of-life care. OBJECTIVE: To compare and contrast end-of-life care delivery in intensive care units using "semiclosed," "open," and "closed" administrative models. DESIGN: Ethnographic study of three critical care units. SETTING: University hospitals in the United States and New Zealand. SUBJECTS: Approximately 600 physicians, nurses, allied health personnel, patients, family members, and friends. MEASUREMENTS AND MAIN RESULTS: Ethnographic observations were made at three sites for 75, 3, and 10 wks, respectively. Eighty end-of-life care episodes were observed. The interactions among care personnel and families varied according to the administrative model, depending on whether surgeons or intensivists had primary patient responsibility. This led to differential timing on the shift from "cure" to "comfort," and differential decision-making power for families. CONCLUSIONS: End-of-life care varies according to the administrative model. When surgeons have primary responsibility for the patient, the most important goal is defeating death. When intensivists have sole patient responsibility, scarce resources are considered and quality of life is a significant variable. Discussions about improving the way end-of-life decisions are carried out in intensive care units rarely consider the administrative models and personal, professional, and national values affecting such decisions. To improve care at the end of life, we must critically examine these features.

Surgeons, intensivists, and the covenant of care: administrative models and values affecting care at the end of life.

CONTEXT: End-of-life care remains a challenging and complex activity in critical care units. There is little information concerning the influence of administrative models of care delivery on end-of-life care. OBJECTIVE: To compare and contrast end-of-life care delivery in intensive care units using "semiclosed," "open," and "closed" administrative models. DESIGN: Ethnographic study of three critical care units. SETTING: University hospitals in the United States and New Zealand. SUBJECTS: Approximately 600 physicians, nurses, allied health personnel, patients, family members, and friends. MEASUREMENTS AND MAIN RESULTS: Ethnographic observations were made at three sites for 75, 3, and 10 wks, respectively. Eighty end-of-life care episodes were observed. The interactions among care personnel and families varied according to the administrative model, depending on whether surgeons or intensivists had primary patient responsibility. This led to differential timing on the shift from "cure" to "comfort," and differential decision-making power for families. CONCLUSIONS: End-of-life care varies according to the administrative model. When surgeons have primary responsibility for the patient, the most important goal is defeating death. When intensivists have sole patient responsibility, scarce resources are considered and quality of life is a significant variable. Discussions about improving the way end-of-life decisions are carried out in intensive care units rarely consider the administrative models and personal, professional, and national values affecting such decisions. To improve care at the end of life, we must critically examine these features.