Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 8.060
PLoS One ; 15(9): e0238567, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32898165


There is limited evidence on the relationships of preference for end-of-life life-sustaining treatments [LSTs] and diagnostic contexts like heart failure [HF] or cancer, and patient attitudes toward and perceived susceptibility to use advance directives [ADs]. Thus, this study aimed to compare attitudes and perceived susceptibility between HF patients and community-dwelling patients with cancer, and examine the associations of these variables with their preference for each LST (cardiopulmonary resuscitation [CPR], ventilation support, hemodialysis, and hospice care). Secondary data were obtained from 36 outpatients with HF (mean age, 65.44 years; male, 69.4%) and 107 cancer patients (mean age, 67.39 years; male, 32.7%). More patients with HF preferred CPR than cancer patients (41.7% and 15.9%, χ2 = 8.88, P = 0.003). Attitudes and perceived susceptibility were similar between the two diagnostic cohorts. HF patients and those with more positive attitudes had greater odds of preferring CPR (odds ratio [OR] = 3.02, confidence interval [CI] = 1.19, 7.70) and hospice care (OR = 1.14, CI = 1.06, 1.23), respectively. HF diagnosis and AD attitudes increased the preference for CPR and hospice care, respectively. This suggests that it is important to gain positive attitudes toward ADs and consider diagnostic context to facilitate informed decision-making for LSTs.

Insuficiência Cardíaca/terapia , Neoplasias/terapia , Preferência do Paciente , Assistência Terminal , Diretivas Antecipadas/legislação & jurisprudência , Idoso , Feminino , Humanos , Cuidados para Prolongar a Vida/legislação & jurisprudência , Masculino , Pessoa de Meia-Idade , Preferência do Paciente/legislação & jurisprudência , Assistência Terminal/legislação & jurisprudência
Rev. esp. med. legal ; 46(3): 119-126, jul.-sept. 2020.
Artigo em Espanhol | IBECS | ID: ibc-192313


La pandemia por COVID-19 ha suscitado problemas éticos y médico-legales, entre los que destaca la asignación equitativa de recursos sanitarios, sobre todo en relación a la priorización de pacientes y el racionamiento de recursos. El establecimiento de prioridades está siempre presente en los sistemas sanitarios y depende de la teoría de justicia aplicable en cada sociedad. El racionamiento de recursos ha sido necesario en la pandemia por COVID-19, por lo que se han publicado documentos de consenso para la toma de decisiones sustentadas en cuatro valores éticos fundamentales: maximización de los beneficios, tratar a las personas igualmente, contribuir en la creación de valor social y dar prioridad a la situación más grave. De ellos derivan recomendaciones específicas: maximizar beneficios; priorizar a los trabajadores de la salud; no priorizar la asistencia por orden de llegada; ser sensible a la evidencia científica; reconocer la participación en la investigación y aplicar los mismos principios a los pacientes COVID-19 que a los no-COVID-19

The COVID-19 pandemic has raised ethical and medico-legal problems, which include the equitable allocation of health resources, especially in relation to the prioritization of patients and the rationing of resources. Priority setting is always present in healthcare systems and depends on the theory of justice applicable in each society. Resource rationing has been necessary in the COVID-19 pandemic, and therefore consensus documents have been published for decision-making based on four fundamental ethical values: maximization of benefits, treating people equally, contributing to creating social value and giving priority to the worst off, from which specific recommendations derive: maximize benefits; prioritize health workers; do not prioritize attendance on a first-come, first-served basis; be sensitive to scientific evidence; recognize participation in research and apply the same principles to COVID-19 patients as to non-COVID-19 patients

Humanos , Valor da Vida , Administração dos Cuidados ao Paciente/legislação & jurisprudência , Seleção de Pacientes/ética , Infecções por Coronavirus , Cuidados Paliativos na Terminalidade da Vida/ética , Cuidados para Prolongar a Vida/ética , Pandemias/legislação & jurisprudência , Tomada de Decisões/ética , Temas Bioéticos , Revisão da Utilização de Recursos de Saúde/legislação & jurisprudência , Alocação de Recursos/legislação & jurisprudência , Recusa do Médico a Tratar/ética , Recusa do Médico a Tratar/legislação & jurisprudência
Artigo em Inglês | MEDLINE | ID: mdl-32635499


BACKGROUND: Satisfactory experience about basic life support (BLS) is crucial to ensure rapid and efficient delivery of essential life-saving care during emergency situations. OBJECTIVES: To assess BLS experience among health profession students at King Khalid University (KKU), Southwestern Saudi Arabia. METHODS: A cross-sectional study was conducted on a representative sample of male and female health profession students, during the academic year 2019-2020. A self-reported questionnaire was utilized to collect data about BLS experiences, which included receiving BLS training, reasons for not having BLS training, suggestions to improve BLS training, encountering a situation that required the use of BLS, practicing BLS when needed and reasons for not practicing BLS when needed. RESULTS: Out of 1261 health profession students, 590 received formal BLS training with a prevalence rate of 46.8% (95% CI: 44.0-49.6), and 46.0% of them trained at the university. Important obstacles for non-attendance included busy academic schedule (54.7%) and high cost of the training course (18%). Overall, 84.1% supported integration of BLS training into their college curricula. Almost 26% encountered a situation that required BLS; however, only 32.4% responded. Through multivariate regression, the significant determinant of response was having formal BLS training (aOR = 4.24, 95% CI: 2.38-7.54). The frequent reasons for non-response were lack of adequate BLS knowledge (35.0%), nervousness (22.8%), and that the victim was of opposite sex (9.0%). CONCLUSION: It is recommended that more emphasis should be given to BLS training among undergraduates of health profession colleges in Southwestern Saudi Arabia. It is recommended that BLS training be integrated into health profession college curricula. Including BLS training as a graduation requirement for health profession students might motivate students to attain BLS training courses.

Reanimação Cardiopulmonar/educação , Conhecimentos, Atitudes e Prática em Saúde , Ocupações em Saúde/educação , Cuidados para Prolongar a Vida/métodos , Estudantes de Ciências da Saúde/psicologia , Adulto , Reanimação Cardiopulmonar/estatística & dados numéricos , Estudos Transversais , Feminino , Humanos , Masculino , Parada Cardíaca Extra-Hospitalar/terapia , Arábia Saudita , Estudantes de Ciências da Saúde/estatística & dados numéricos , Inquéritos e Questionários , Universidades
Scand J Trauma Resusc Emerg Med ; 28(1): 52, 2020 Jun 08.
Artigo em Inglês | MEDLINE | ID: mdl-32513282


BACKGROUND: Decisions of withholding or withdrawing life sustaining-treatments in emergency department are part of current practice but the decision-making process remains poorly described in the literature. STUDY OBJECTIVE: We conducted a study in two phases, the first comprising a retrospective chart review study of patients dying in the ED and the second comprising survey study of health care workers at 10 urban emergency departments in France. METHOD: In a first step, we analyzed medical records based on fifteen criteria of the decision-making process grouped into four categories: the collegiality, the traceability, the management and the communication as recommended by the international guidelines. In a second step, we conducted an auto-administrated survey to assess how the staff members (medical, paramedical) feel with the decision-making process. RESULTS: There were 273 deaths which occurred in the ED over the study period and we included 145 (53.1%) patients. The first-step analysis revealed that the traceability of the decision and the information given to patient or the relatives were the most reported points according to the recommendations. Three of the ten emergency departments had developed a written procedure. The collegial discussion and the traceability of the prognosis assessment were significantly increased in emergency department with a written procedure as well as management of pain, comfort care, and the communication with the patient or the relatives. In the second-step analysis, among the 735 staff members asked to take part in the survey, 287 (39.0%) answered. The medical and paramedical staff expressed difficult experience regarding the announcement and the communication with the patient and the relatives. CONCLUSION: The management of the decision to withhold or withdraw life-sustaining treatments must be improved in emergency departments according to the guidelines. A standard written procedure could be useful in clinical practice despite the lack of experienced difference between centers with and without procedures.

Tomada de Decisão Clínica , Serviço Hospitalar de Emergência , Cuidados para Prolongar a Vida , Suspensão de Tratamento , Adulto , Feminino , França , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Inquéritos e Questionários
J Clin Ethics ; 31(2): 111-125, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32585654


INTRODUCTION: In highly developed countries, as many as 16 percent of children are physically abused each year. Traumatic brain injury (TBI) is the most common injury in non-accidental trauma (NAT) and is responsible for 80 percent of fatal NAT cases, with most deaths occurring in children younger than three years old. Cases of abusers who refuse withdrawal of life-sustaining medical treatment (LSMT) to avoid criminal charges have previously been reported. Therefore, we hypothesized that NAT is associated with a lower risk for withdrawal LSMT in pediatric TBI. METHODS: The pediatric Trauma Quality Improvement Program database was analyzed (2014 to 2016) for patients aged 16 and younger with TBI and Glasgow Coma Scale (GCS) of 8 and lower on admission. Patients with a head Abbreviated Injury Scale (AIS) of 2 or less or who died within 48 hours were excluded. A multivariable logistic regression model was used for analysis. RESULTS: Of 2,209 TBI patients, 92 (4.2 percent) had withdrawal of LSMT. Compared to those without withdrawal of LMST, those with LMST had statistically similar median age (three years of age versus seven years) and a higher rate of NAT (33.7 percent versus 13.5 percent). The most common specified perpetrator was a father/stepfather/male partner (70 percent). After adjusting for covariates, factors associated with higher risk for withdrawal of LSMT included age of less than three years (OR 2.38, CI 1.34-4.23) and NAT (OR 1.86, CI 1.02-3.41). CONCLUSION: NAT is associated with increased risk for withdrawal of LSMT in pediatric TBI. Age of less than three years is similarly associated with a higher risk for withdrawal of LSMT. Future research in this population is needed to determine what other factors predict withdrawal of LSMT and what resources, such as social workers and/or ethics consults, are utilized.

Lesões Encefálicas Traumáticas , Lesões Encefálicas , Cuidados para Prolongar a Vida , Suspensão de Tratamento , Adolescente , Criança , Pré-Escolar , Escala de Coma de Glasgow , Humanos , Cuidados para Prolongar a Vida/ética , Masculino , Estudos Retrospectivos , Suspensão de Tratamento/ética
Artigo em Inglês | MEDLINE | ID: mdl-32526979


Practicing the algorithms of basic life support (BLS) is essential in order to take adequate measures to save lives, and future nursing staff should be advanced when it comes to performing lifesaving activities. The purpose of the study was to analyse the theoretical and practical knowledge of nursing students (within the undergraduate course) with regards to the basic life support (BLS). The study has a prospective, comparative and descriptive nature. Three countries that educate nursing students within the undergraduate course participated in the project. Data was collected with the use of a questionnaire based on the guidelines of the European Resuscitation Council (ERC 2015). The study was carried out among a total of 748 respondents from three countries: Poland (n = 189, 25.3%), Lithuania (n = 500, 66.8%) and Spain (n = 59; 7.9%). The average age of respondents was 23.41 (SD ± 5.90). The average score obtained by the respondents who answered the questions was 11.13 with a standard deviation of SD ± 2.29. The conducted study revealed that a substantial number of the respondents who participated in the study obtained an average result concerning theoretical and practical knowledge of BLS. It was also confirmed that the additional education in the form of first aid training courses has a major impact on improving the levels of knowledge among the students in each of the analysed country.

Reanimação Cardiopulmonar , Bacharelado em Enfermagem , Cuidados para Prolongar a Vida , Estudantes de Enfermagem , Adolescente , Adulto , Atitude , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Lituânia , Masculino , Polônia , Estudos Prospectivos , Espanha , Inquéritos e Questionários , Adulto Jovem
Rev. bioét. derecho ; (48): 5-21, mar. 2020.
Artigo em Espanhol | IBECS | ID: ibc-192075


La medicina en general, y la medicina intensiva (SMI) en particular, han presentado grandes cambios a lo largo de los últimos años, en especial en relación a la toma de decisiones sobre las actuaciones a realizar en pacientes efectos de enfermedades crónicas. De esta manera, tanto la enfermedad oncológica como las enfermedades crónicas no oncológicas, en la mayoría de casos, tienen un curso evolutivo mucho más largo, con episodios de descompensación que pueden requerir la instauración de medicina intensiva. Es por ello que actualmente enfermedades que cursan con insuficiencia de un solo órgano, como pueden ser la cirrosis hepática o la miocardiopatía dilatada, por ejemplo, se pueden considerar terminales según su grado de evolución. Esto obliga a los equipos asistenciales a tener no solo conocimientos científico-técnicos sino también bioéticos, para decidir la correcta adecuación diagnóstico-terapéutica en cada caso concreto. En este trabajo se pretenden dar algunas nociones básicas para tomar decisiones clínicas en este grupo de pacientes

Medicine in general and the intensive medicine (ICM) in particular, have presented major changes in recent years, especially in relation to decision-making on the actions to be taken in patients with chronic diseases. Thus, both oncological and non-oncological chronic diseases, in most cases, have a much longer evolutionary course, with decompensation episodes that may require the establishment of intensive medicine. That is why currently diseases with a single organ failure, such as liver cirrhosis or dilated cardiomyopathy, for example, can be considered terminal according to their degree of evolution. This requires health care teams to have not only scientifictechnical knowledge but also bioethical knowledge in order to decide on the correct diagnostic-therapeutic approach in each specific case. In this work, we intend to give some basic notions to make clinical decisions in this group of patients

La medicina en general, I la medicina intensiva (SMI) en particular, han presentat grans canvis al llarg dels últims anys, especialment en relació a la presa de decisions sobre les actuacions que cal dur a terme en pacients afectats de malalties cròniques. Tant la malaltia oncològica com les malalties cròniques no oncològiques, en la majoria de casos, tenen un curs evolutiu molt més llarg, amb episodis de descompensació que poden requerir la instauració de medicina intensiva. És per això que actualment malalties que cursen amb insuficiència d'un sol òrgan, com pot ser la cirrosi hepàtica o la miocardiopatia dilatada, per exemple, es poden considerar terminals segons el seu grau d'evolució. Això obliga els equips assistencials a tenir no només coneixements cientificotècnics sinó també bioètics per decidir la correcta adequació diagnòstic-terapèutica en cada cas concret. En aquest treball es preté aportar algunes nocions bàsiques per a prende decisions clíniques en aquest grup de pacients

Humanos , Cuidados Paliativos na Terminalidade da Vida/ética , Unidades de Cuidados Coronarianos , Cuidados para Prolongar a Vida/ética , Hospitalização , Tomada de Decisões/ética , Doença Crônica , Demência
Rev. bioét. derecho ; (48): 81-93, mar. 2020.
Artigo em Espanhol | IBECS | ID: ibc-192079


La misión de los cuidados intensivos es restaurar la situación basal de salud libre de discapacidad severa atendiendo al principio bioético de beneficencia, respetando la dignidad y voluntad del paciente de ser tratado lo que vendría a ser atender al principio bioético de autonomía, y realizando todo esto de una forma adecuada a la mejor evidencia actual, justa y sostenible atendiendo a los principios de no maleficencia y de justicia. Cuando no es posible es cuando los profesionales tienen la obligación ética de iniciar un diálogo de manera respetuosa y prudente con el  paciente y/o la familia y el resto de profesionales implicados (atención primaria, enfermería, especialistas...etc.) de cara a llegar a un consenso sobre limitar los tratamientos de soporte vital y/o adecuar  los cuidados y continuar el tratamiento con un plan terapéutico de cuidados dirigidos al confort, control de síntomas y a mejorar la calidad de vida (Plan de cuidados paliativos) para preservar la dignidad del paciente, evitar el sufrimiento y proporcionar un tratamiento compasivo de soporte y acompañamiento durante el proceso de muerte si se diera el mismo atendiendo al paciente y a la familia con el máximo cuidado y respeto en un marco de humanización de la salud. Atender de forma excelente el final de la vida significa dignificar a las personas que están pasando por ese proceso, aportar un valor extraordinario de humanidad y debe ser un objetivo prioritario actual en nuestro quehacer diario en las unidades de cuidados intensivos

The mission of intensive care is to restore the baseline health situation free of severe disability by following the bioethical principle of beneficence, respecting the dignity and willingness of the patient to be treated what would be to attend to the bioethical principle of autonomy, and doing all this in a manner appropriate to the best current, fair and sustainable evidence, taking into account the principles of non-maleficence and justice. When it is not possible, it is when professionals have the ethical obligation to initiate a dialogue in a respectful and prudent manner with the patient and / or the family and the rest of the professionals involved (primary care, nursing, specialists ... etc.) Face to reach a consensus on limiting life support treatments and / or adapt care and continue treatment with a therapeutic plan of care aimed at comfort, symptom control and improving the quality of life (Palliative Care Plan) to preserve the dignity of the patient, avoid suffering and provide a compassionate support and support during the death process if the same were given to the patient and the family with the utmost care and respect in a framework of humanization of health. Addressing the end of life in an excellent way means dignifying the people who are going through this process, providing an extraordinary value of humanity and must be a current priority in our daily work in the intensive care units

La finalitat de la vigilància intensiva és restaurar la situació basal de salut lliure de discapacitat severa atenent al principi bioètic de beneficència, respectant la dignitat I voluntat del pacient de ser tractat, cosa que vindria a ser atendre al principi bioètic d'autonomia, I realitzant tot això d'una forma adequada a la millor evidència actual, justa I sostenible, atesos els principis de no maleficència I de justícia. Quan tot això no és possible és quan els professionals tenen l'obligació ètica d'iniciar un diàleg de manera respectuosa I prudent amb el pacient i/o la família I amb la resta de professionals implicats (atenció primària, infermeria, especialistes...etc.) de cara a arribar a un consens sobre limitar els tractaments de suport vital i/o adequar les cures I continuar el tractament amb un pla terapèutic de cures dirigides al confort, el control de símptomes I a millorar la qualitat de vida (Pla de Cures Pal·liatives) per a preservar la dignitat del pacient, evitar el sofriment I proporcionar-li un tractament compassiu de suport I acompanyament durant el procés de mort, atenent el pacient I a la família amb la màxima cura I respecte en un marc d'humanització de la salut. Atendre de forma excel·lent el final de la vida significa dignificar les persones que están passant per aquest procés, aportar un valor extraordinari d'humnaitat I ha de ser un objectiu prioritari actual en el nostre qufer diari en les unitats de vigilancia intensiva

Humanos , Cuidados para Prolongar a Vida/ética , Cuidados Paliativos na Terminalidade da Vida/ética , Cuidados Paliativos na Terminalidade da Vida/legislação & jurisprudência , Tomada de Decisões/ética , Cuidados para Prolongar a Vida/classificação , Cuidados para Prolongar a Vida/métodos , Unidades de Terapia Intensiva
Med. intensiva (Madr., Ed. impr.) ; 44(2): 101-112, mar. 2020. ilus, tab
Artigo em Espanhol | IBECS | ID: ibc-188659


El Grupo de Trabajo de Bioética de la SEMICYUC ha elaborado las recomendaciones en la toma de decisiones de limitación de tratamientos de soporte vital con la aspiración de disminuir la variabilidad en la práctica clínica observada y de contribuir a la mejora de los cuidados al final de la vida del paciente crítico. Además de abordar el marco conceptual de la limitación de tratamientos de soporte vital y de la futilidad, desarrolla las nuevas formas de limitación extendiéndola a la adecuación de otros tratamientos y métodos diagnósticos, además de planificar los posibles cursos evolutivos tras la decisión de limitación de tratamientos de soporte vital. Se enfatiza la importancia de la planificación compartida de la asistencia sanitaria en la toma de decisiones, se presentan los cuidados intensivos orientados a la donación y se promueve la integración de los cuidados paliativos en el tratamiento del paciente crítico en estadios del final de la vida en UCI

The Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) Bioethics Working Group has developed recommendations on the Limitation of Advanced Life Support Treatment (LLST) decisions, with the aim of reducing variability in clinical practice and of improving end of life care in critically ill patients. The conceptual framework of LLST and futility are explained. Recommendations referred to new forms of LLST encompassing also the adequacy of other treatments and diagnostic methods are developed. In addition, planning of the possible clinical courses following the decision of LLST is commented. The importance of advanced care planning in decision-making is emphasized, and intensive care oriented towards organ donation at end of life in the critically ill patient is described. The integration of palliative care in the critical patient treatment is promoted in end of life stages in the Intensive Care Unit

Humanos , Tomada de Decisões , Cuidados para Prolongar a Vida/normas , Cuidados Críticos/normas , Cuidados para Prolongar a Vida/estatística & dados numéricos , Cuidados Paliativos na Terminalidade da Vida/ética , Cuidados Paliativos na Terminalidade da Vida/normas , Unidades de Terapia Intensiva
J Trauma Acute Care Surg ; 89(1): 160-166, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32218021


BACKGROUND: Although several trauma centers have developed direct to operating room (DOR) trauma resuscitation programs, there is little published data on optimal patient selection, practices, and outcomes. We sought to analyze triage criteria and interventions associated with optimal DOR outcomes and resource utilization. METHODS: Retrospective review of all adult DOR resuscitations for a 6-year period was performed. Triage criteria were analyzed individually and grouped into categories: mechanism, physiology, anatomy/injury, or other. The best univariate and multivariate predictors of requiring lifesaving interventions (LSIs) or emergent surgery (ES) were analyzed. Actual and predicted mortality were compared for all patients and for predefined time-sensitive subgroups. RESULTS: There were 628 DOR patients (5% of all admissions) identified; the majority were male (79%), penetrating mechanism (70%), severely injured (40% ISS >15), and 17% died. Half of patients required LSI and 23% required ES, with significantly greater need for ES and lower need for LSI after penetrating versus blunt injury (p < 0.01). Although injury mechanism criteria triggered most DOR cases and best predicted need for ES, the physiology and anatomy/injury criteria were associated with greater need for LSI and mortality. Observed mortality was significantly lower than predicted mortality with DOR for several key subgroups. Triage schemes for both ES and LSI could be simplified to four to six independent predictors by regression analysis. CONCLUSION: The DOR program identified severely injured trauma patients at increased risk for requiring LSI and/or ES. Different triage variable categories drive the need for ES versus LSI and could be simplified or optimized based on local needs or preferences. Direct to operating room was associated with better than expected survival among specific time-sensitive subgroups. LEVEL OF EVIDENCE: Therapeutic/Care Management, Level IV.

Salas Cirúrgicas , Seleção de Pacientes , Ressuscitação/métodos , Ferimentos e Lesões/terapia , Adulto , Feminino , Humanos , Escala de Gravidade do Ferimento , Cuidados para Prolongar a Vida , Masculino , Oregon , Sistema de Registros , Estudos Retrospectivos , Tempo para o Tratamento , Centros de Traumatologia , Triagem , Ferimentos e Lesões/mortalidade
Medicina (B Aires) ; 80(1): 48-53, 2020.
Artigo em Espanhol | MEDLINE | ID: mdl-32044741


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.

Cuidados para Prolongar a Vida/legislação & jurisprudência , Estado Vegetativo Persistente , Direito a Morrer/legislação & jurisprudência , Suspensão de Tratamento/legislação & jurisprudência , Argentina , Humanos
JAMA ; 323(10): 950-960, 2020 03 10.
Artigo em Inglês | MEDLINE | ID: mdl-32062674


Importance: Patients with chronic illness frequently use Physician Orders for Life-Sustaining Treatment (POLST) to document treatment limitations. Objectives: To evaluate the association between POLST order for medical interventions and intensive care unit (ICU) admission for patients hospitalized near the end of life. Design, Setting, and Participants: Retrospective cohort study of patients with POLSTs and with chronic illness who died between January 1, 2010, and December 31, 2017, and were hospitalized 6 months or less before death in a 2-hospital academic health care system. Exposures: POLST order for medical interventions ("comfort measures only" vs "limited additional interventions" vs "full treatment"), age, race/ethnicity, education, days from POLST completion to admission, histories of cancer or dementia, and admission for traumatic injury. Main Outcomes and Measures: The primary outcome was the association between POLST order and ICU admission during the last hospitalization of life; the secondary outcome was receipt of a composite of 4 life-sustaining treatments: mechanical ventilation, vasopressors, dialysis, and cardiopulmonary resuscitation. For evaluating factors associated with POLST-discordant care, the outcome was ICU admission contrary to POLST order for medical interventions during the last hospitalization of life. Results: Among 1818 decedents (mean age, 70.8 [SD, 14.7] years; 41% women), 401 (22%) had POLST orders for comfort measures only, 761 (42%) had orders for limited additional interventions, and 656 (36%) had orders for full treatment. ICU admissions occurred in 31% (95% CI, 26%-35%) of patients with comfort-only orders, 46% (95% CI, 42%-49%) with limited-interventions orders, and 62% (95% CI, 58%-66%) with full-treatment orders. One or more life-sustaining treatments were delivered to 14% (95% CI, 11%-17%) of patients with comfort-only orders and to 20% (95% CI, 17%-23%) of patients with limited-interventions orders. Compared with patients with full-treatment POLSTs, those with comfort-only and limited-interventions orders were significantly less likely to receive ICU admission (comfort only: 123/401 [31%] vs 406/656 [62%], aRR, 0.53 [95% CI, 0.45-0.62]; limited interventions: 349/761 [46%] vs 406/656 [62%], aRR, 0.79 [95% CI, 0.71-0.87]). Across patients with comfort-only and limited-interventions POLSTs, 38% (95% CI, 35%-40%) received POLST-discordant care. Patients with cancer were significantly less likely to receive POLST-discordant care than those without cancer (comfort only: 41/181 [23%] vs 80/220 [36%], aRR, 0.60 [95% CI, 0.43-0.85]; limited interventions: 100/321 [31%] vs 215/440 [49%], aRR, 0.63 [95% CI, 0.51-0.78]). Patients with dementia and comfort-only orders were significantly less likely to receive POLST-discordant care than those without dementia (23/111 [21%] vs 98/290 [34%], aRR, 0.44 [95% CI, 0.29-0.67]). Patients admitted for traumatic injury were significantly more likely to receive POLST-discordant care (comfort only: 29/64 [45%] vs 92/337 [27%], aRR, 1.52 [95% CI, 1.08-2.14]; limited interventions: 51/91 [56%] vs 264/670 [39%], aRR, 1.36 [95% CI, 1.09-1.68]). In patients with limited-interventions orders, older age was significantly associated with less POLST-discordant care (aRR, 0.93 per 10 years [95% CI, 0.88-1.00]). Conclusions and Relevance: Among patients with POLSTs and with chronic life-limiting illness who were hospitalized within 6 months of death, treatment-limiting POLSTs were significantly associated with lower rates of ICU admission compared with full-treatment POLSTs. However, 38% of patients with treatment-limiting POLSTs received intensive care that was potentially discordant with their POLST.

Diretivas Antecipadas , Cuidados Críticos , Cuidados para Prolongar a Vida , Planejamento Antecipado de Cuidados , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Doença Crônica/terapia , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Médicos , Ordens quanto à Conduta (Ética Médica) , Estudos Retrospectivos , Assistência Terminal
Ann Emerg Med ; 75(5): 559-567, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31983499


STUDY OBJECTIVE: Out-of-hospital naloxone has been championed as a lifesaving solution during the opioid epidemic. However, the long-term outcomes of out-of-hospital naloxone recipients are unknown. The objectives of this study are to describe the 1-year mortality of presumed opioid overdose victims identified by receiving out-of-hospital naloxone and to determine which patient factors are associated with subsequent mortality. METHODS: This was a regional retrospective cohort study of out-of-hospital records from 7 North Carolina counties from January 1, 2015 to February 28, 2017. Patients who received out-of-hospital naloxone were included. Out-of-hospital providers subjectively assessed patients for improvement after administering naloxone. Naloxone recipients were cross-referenced with the North Carolina death index to examine mortality at days 0, 1, 30, and 365. Naloxone recipient mortality was compared with the age-adjusted, at-large population's mortality rate in 2017. Generalized estimating equations and Cox proportional hazards models were used to assess for mortality-associated factors. RESULTS: Of 3,085 out-of-hospital naloxone encounters, 72.7% of patients (n=2,244) improved, whereas 27.3% (n=841) had no improvement with naloxone. At day 365, 12.0% (n=269) of the improved subgroup, 22.6% (n=190) of the no improvement subgroup, and 14.9% (n=459) of the whole population were dead. Naloxone recipients who improved were 13.2 times (95% confidence interval 13.0 to 13.3) more likely to be dead at 1 year than a member of the general populace after age adjusting of the at-large population to match this study population. Older age and being black were associated with 1-year mortality, whereas sex and multiple overdoses were not. CONCLUSION: Opioid overdose identified by receiving out-of-hospital naloxone with clinical improvement carries a 13-fold increase in mortality compared to the general population. This suggests that this is a high-risk population that deserves attention from public health officials, policymakers, and health care providers in regard to the development of long-term solutions.

Analgésicos Opioides/envenenamento , Overdose de Drogas/tratamento farmacológico , Serviços Médicos de Emergência , Mortalidade/tendências , Naloxona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Adolescente , Adulto , Criança , Pré-Escolar , Overdose de Drogas/mortalidade , Feminino , Humanos , Lactente , Recém-Nascido , Cuidados para Prolongar a Vida/métodos , Masculino , Pessoa de Meia-Idade , North Carolina/epidemiologia , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Adulto Jovem