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3.
Med. intensiva (Madr., Ed. impr.) ; 44(2): 101-112, mar. 2020. ilus, tab
Artigo em Espanhol | IBECS | ID: ibc-188659

RESUMO

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


Assuntos
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
4.
J Med Syst ; 43(6): 155, 2019 Apr 25.
Artigo em Inglês | MEDLINE | ID: mdl-31025119

RESUMO

The 30-day surgical mortality metric is endorsed by the National Quality Forum for value-based purchasing purposes. However, its integrity has been questioned, as there is documented evidence of hospital manipulation of this measure, by way of inappropriate palliative care designation and changes in patient selection. To determine if there is evidence of potential manipulation, we retrospectively analyzed 1,725,291 surgical admissions from 158 United States hospitals participating in the National Inpatient Sample from 2010 to 2011. As a way of evaluating unnecessary life-prolonging measures, we determined that a significant increase in mortality rate after post-operative day 30 (day 31-35) would indicate manipulation. We compared the post-operative mortality rates for each hospital between Post-Operative Day 26-30 and Post-Operative Day 31-35 using Wilcoxon signed-rank tests. After application of the Bonferroni correction, the results showed that none of the hospitals had a statistically significant increase in mortality after post-operative day 30. This analysis fails to impugn the integrity of this measure, as we did not identify any evidence of potential manipulation of the 30-day surgical mortality metric.


Assuntos
Qualidade da Assistência à Saúde/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/mortalidade , Feminino , Humanos , Estimativa de Kaplan-Meier , Cuidados para Prolongar a Vida/estatística & dados numéricos , Masculino , Propriedade , Características de Residência , Medição de Risco , Fatores de Tempo , Estados Unidos/epidemiologia
5.
Medicine (Baltimore) ; 98(4): e13990, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30681557

RESUMO

Prehospital use of ventilators by emergency medical services (EMS) during 911 calls is increasing. This study described the impact of prehospital mechanical ventilation on prehospital time intervals and on mortality.This retrospective matched-cohort study used 4 consecutive public releases of the US National Emergency Medical Services Information System dataset (2011-2014). EMS activations with recorded ventilator use were randomly matched with activations without ventilator use (1 to 1) on age (range ±â€Š2 years), gender, provider's primary impression, urbanicity, and level of service.A total of 5740 EMS activations were included (2870 patients per group). Patients in the ventilator group had a mean age of 69.1 (±17.3) years with 49.4% males, similar to the non-ventilator group. Activations were mostly in urban settings (83.8%) with an advanced life support level of care (94.5%). Respiratory distress (77.8%) and cardiac arrest (6.8%) were the most common provider's primary impressions. Continuous positive airway pressure was the most common mode of ventilation used (79.2%).Mortality was higher at hospital discharge (29.0% vs 21.1%, P = .01) but not at emergency department (ED) discharge (8.4% vs 7.4%, P = .19) with prehospital ventilator use. Both total on-scene time and total prehospital time intervals increased with reported ventilator use (4.10 minutes (95% confidence interval [CI]: 2.71-5.49) and 3.59 minutes (95% CI: 3.04-4.14), respectively).Ventilator use by EMS agencies in 911 calls in the US is associated with higher prehospital time intervals without observed impact on survival to ED discharge. More EMS outcome research is needed to provide evidence-based prehospital care guidelines and targeted resource utilization.


Assuntos
Serviços Médicos de Emergência/estatística & dados numéricos , Respiração Artificial/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Cuidados para Prolongar a Vida/normas , Cuidados para Prolongar a Vida/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Alta do Paciente/estatística & dados numéricos , Características de Residência/estatística & dados numéricos , Estudos Retrospectivos , Fatores Sexuais , Estados Unidos
6.
Burns ; 45(2): 322-327, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30442381

RESUMO

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.


Assuntos
Queimaduras/terapia , Grupos Étnicos/estatística & dados numéricos , Cuidados para Prolongar a Vida/estatística & dados numéricos , Suspensão de Tratamento/estatística & dados numéricos , Adulto , Afro-Americanos/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Queimaduras por Inalação/terapia , Comorbidade , Tomada de Decisões , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Feminino , Hispano-Americanos/estatística & dados numéricos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Estudos Retrospectivos , Fatores Sexuais , Assistência Terminal
7.
Pediatr Neurol ; 91: 20-26, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30559002

RESUMO

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.


Assuntos
Hipotermia Induzida/estatística & dados numéricos , Hipóxia-Isquemia Encefálica/terapia , Doenças do Recém-Nascido/terapia , Unidades de Terapia Intensiva Neonatal/estatística & dados numéricos , Cuidados para Prolongar a Vida/estatística & dados numéricos , Suspensão de Tratamento/estatística & dados numéricos , Estudos de Coortes , Feminino , Humanos , Hipotermia Induzida/economia , Hipóxia-Isquemia Encefálica/economia , Hipóxia-Isquemia Encefálica/epidemiologia , Recém-Nascido , Doenças do Recém-Nascido/economia , Doenças do Recém-Nascido/epidemiologia , Unidades de Terapia Intensiva Neonatal/economia , Cuidados para Prolongar a Vida/economia , Masculino , Estudos Prospectivos , Fatores Socioeconômicos , Estados Unidos/epidemiologia , Suspensão de Tratamento/economia
8.
Eur J Clin Invest ; 48(12): e13026, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30215851

RESUMO

BACKGROUND: In elder patients after out-of-hospital cardiac arrest, diminished neurologic function as well as reduced neuronal plasticity may cause a low response to targeted temperature management (TTM). Therefore, we investigated the association between TTM (32-34°C) and neurologic outcome in cardiac arrest survivors with respect to age. MATERIAL AND METHODS: This retrospective cohort study included patients 18 years of age or older suffering a witnessed out-of-hospital cardiac arrest with presumed cardiac cause, which remained comatose after return of spontaneous circulation. Patients were a priori split by age into four groups (<50 years (n = 496); 50-64 years (n = 714); 65-74 years (n = 395); >75 years (n = 280)). Subsequently, within these groups, patients receiving TTM were compared to those not treated with TTM. RESULTS: Out of 1885 patients, 921 received TTM for 24 hours. TTM was significantly associated with good neurologic outcome in patients <65 years of age whereas showing no effect in elders (65-74 years: OR: 1.49 (95% CI: 0.90-2.47); > 75 years: OR 1.44 (95% CI 0.79-2.34)). CONCLUSION: In our cohort, it seems that TTM might not be able to achieve the same benefit for neurologic outcome in all age groups. Although the results of this study should be interpreted with caution, TTM was associated with improved neurologic outcome only in younger individuals, patients with 65 years of age or older did not benefit from this treatment.


Assuntos
Hipotermia Induzida/estatística & dados numéricos , Parada Cardíaca Extra-Hospitalar/terapia , Adulto , Fatores Etários , Idoso , Humanos , Hipotermia Induzida/mortalidade , Cuidados para Prolongar a Vida/estatística & dados numéricos , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/mortalidade , Estudos Prospectivos , Estudos Retrospectivos , Resultado do Tratamento
9.
Rev. clín. esp. (Ed. impr.) ; 218(6): 285-292, ago.-sept. 2018. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-176209

RESUMO

Antecedentes y objetivo: El lugar en que se produce la muerte varía ampliamente en las distintas sociedades. El objetivo del estudio fue describir la evolución del porcentaje de muertes en hospitales (PMH) en España a lo largo de 20años, así como su distribución por provincias en un periodo más reciente y explorar su relación con posibles variables explicativas. Métodos: El estudio fue ecológico. Las muertes poblacionales se obtuvieron del Movimiento Natural de la Población, y las muertes en hospitales, del Sistema de Información en Atención Especializada, que incluye información de todos los hospitales del país. Se estimaron las muertes de pacientes no censados y se calculó el PMH a nivel nacional entre 1996 y 2015 y por provincias entre 2013 y 2015. La relación entre la distribución provincial del PMH y diversas variables de tipo demográfico, socioeconómico y asistencial se analizó mediante regresión lineal simple y múltiple. Resultados: El PMH ascendió en España desde el 49% en 1996 hasta el 56% en 2007, habiendo permanecido estable desde entonces hasta 2015. Su variación entre provincias fue del 40 al 70%. El análisis multivariante mostró un PMH superior en las provincias menos rurales y en aquellas con mayor dotación de camas hospitalarias. Conclusiones: En España existe una gran heterogeneidad provincial en cuanto a la probabilidad de morir en un hospital o en el domicilio. Esto se justifica en parte por razones sociodemográficas (porcentaje de población rural) y de la estructura sanitaria (número de camas hospitalarias por población)


Background and objective: The location where death occurs varies widely among societies. The aim of this study was to describe the evolution in the hospital mortality rate (HMR) in Spain over the course of 20years and its distribution by province during a more recent period and to explore its relationship with potential explanatory variables. Methods: This was an ecological study. The population mortality rates were obtained from the Natural Population Movement (Movimiento Natural de la Población), and the hospital mortality rates were obtained from the Specialised Care Information System (Sistema de Información en Atención Especializada), which includes information from all hospitals in Spain. We calculated the mortality rates for patients who were not surveyed and the HMR at the national level between 1996 and 2015 and for provinces between 2013 and 2015. The relationship between the provincial distribution of HMR and various demographic, socioeconomic and healthcare variables were analysed through simple and multiple linear regression. Results: The HMR in Spain increased from 49% in 1996 to 56% in 2007, having remained stable from 1996 to 2015. The variation among provinces was 40% to 70%. The multivariate analysis showed a higher HMR in the less rural provinces and in those with a larger availability of hospital beds. Conclusions: There is considerable provincial heterogeneity in Spain in terms of the probability of dying in hospital or at home. This result could be partly explained by demographics (percentage of rural population) and the healthcare structure (number of hospital beds per population)


Assuntos
Humanos , Mortalidade Hospitalar , Causas de Morte , Geografia Médica/estatística & dados numéricos , Cuidados Paliativos na Terminalidade da Vida/estatística & dados numéricos , Cuidados para Prolongar a Vida/estatística & dados numéricos , Medicalização/tendências
10.
J Palliat Care ; 33(3): 159-166, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29807480

RESUMO

AIM: Little is known regarding the extent to which dying patients with chronic obstructive pulmonary disease (COPD) receive life-sustaining procedures and palliative care in US hospitals. We examined temporal trends and the impact of palliative care on the use of life-sustaining procedures in this population. MATERIALS AND METHODS: A retrospective nationwide cohort analysis was performed using weighted National Inpatient Sample (NIS) data obtained from 2010 to 2014. Decedents ≥18 years of age at the time of death and with a principal diagnosis of COPD were included. We examined the receipt of life-sustaining procedures, defined as1 ventilation (intubation, mechanical ventilation, and noninvasive ventilation),2 vasopressor use (infusion and intravascular monitoring),3 nutrition (enteral and parenteral infusion of concentrated nutrition),4 dialysis, and5 cardiopulmonary resuscitation as well as palliative care consultation and do not resuscitate (DNR). We used compound annual growth rates (CAGRs) and the Rao-Scott correction of the χ2 statistic to determine the statistical significance of temporal trends of life-sustaining procedures, palliative care utilization, and DNR status. RESULTS: Among 37 312 324 hospitalizations, 38 425 patients were examined. The CAGRs of life-sustaining procedures were 6.61% and -9.73% among patients who underwent multiple procedures and patients who did not undergo any procedure, respectively (both P < .001). The CAGRs of palliative consultation and DNR were 5.25% and 36.62%, respectively (both P < .001). CONCLUSIONS: Among adults with COPD dying in US hospitals between 2010 and 2014, the utilization of life-sustaining procedures, palliative care, and DNR status increased.


Assuntos
Cuidados para Prolongar a Vida/estatística & dados numéricos , Cuidados para Prolongar a Vida/tendências , Cuidados Paliativos/estatística & dados numéricos , Cuidados Paliativos/tendências , Doença Pulmonar Obstrutiva Crônica/terapia , Ordens quanto à Conduta (Ética Médica) , Assistência Terminal/estatística & dados numéricos , Assistência Terminal/tendências , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Previsões , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos , Adulto Jovem
11.
J Fam Pract ; 67(4): 249-251, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29614148

RESUMO

Quite well, for cardiopulmonary resuscitation (CPR). Most patients (91%-100%) who select "do not resuscitate" (DNR) on their physician's orders for life-sustaining treatment (POLST) forms are allowed a natural death without attempted CPR across a variety of settings (community, skilled nursing facilities, emergency medical services, and hospice). Few patients (6%) who select "comfort measures only" die in the hospital, whereas more (22%) who choose "limited interventions," and still more (34%) without a POLST form, die in the hospital (strength of recommendation [SOR]: B, large, consistent cross-sectional and cohort studies).


Assuntos
Planejamento Antecipado de Cuidados/normas , Diretivas Antecipadas/estatística & dados numéricos , Assistência à Saúde/normas , Fidelidade a Diretrizes/normas , Cuidados para Prolongar a Vida/normas , Assistência Terminal/normas , Planejamento Antecipado de Cuidados/estatística & dados numéricos , Idoso , Estudos de Coortes , Estudos Transversais , Assistência à Saúde/estatística & dados numéricos , Feminino , Fidelidade a Diretrizes/estatística & dados numéricos , Humanos , Cuidados para Prolongar a Vida/estatística & dados numéricos , Masculino , Assistência Terminal/estatística & dados numéricos , Estados Unidos
12.
Clin Respir J ; 12(7): 2249-2256, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29660241

RESUMO

BACKGROUND: In-hospital outcomes following decisions of withholding or withdrawing in Intensive Care Unit (ICU) patients have been previously assessed, little is known about outcomes after ICU and hospital discharge. Our objective was to report the 6-month outcomes of discharged patients who had treatment limitations in a general ICU and to identify prognostic factors of survival. METHODS: We retrospectively collected the data of patients discharged from the ICU for whom life support was withheld from 2009 to 2011. We assessed the survival status of all patients at 6 months post-discharge and their duration of survival. Survivors and non-survivors were compared using univariate and multivariate analyses by Cox's proportional hazard model. RESULTS: One hundred fourteen patients were included. The survival rate at 6 months was 58.8%. Survival was associated with acute respiratory failure (48% vs 19%, P = .006), a history of COPD (40% vs 21%, P = .03) and a lower SAPS II score (44 vs 49, P = .006). We identified a history of COPD as a prognostic factor for survival in the multivariate analysis (HR = 2.1; IC 95% 1.02-4.36, P = .04). CONCLUSION: A total of 58.8% of patients for whom life-sustaining therapies were withheld in the ICU survived for at least 6 months after discharge. Patients with COPD appeared to have a significantly higher survival rate. The decision to withhold life support in patients should not lead to a cessation of post-ICU care and to non-readmission of COPD patients.


Assuntos
Cuidados Críticos/estatística & dados numéricos , Doença Pulmonar Obstrutiva Crônica/terapia , Suspensão de Tratamento/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Cuidados para Prolongar a Vida/estatística & dados numéricos , Masculino , Alta do Paciente , Prognóstico , Estudos Retrospectivos , Análise de Sobrevida , Taxa de Sobrevida
13.
Palliat Med ; 32(3): 622-630, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29343186

RESUMO

BACKGROUND: The association between palliative care and life-sustaining treatments for patients with dementia is unclear in Asian countries. AIM: To analyse the use of palliative care and its association with aggressive treatments based on Taiwanese national data. DESIGN: A matched cohort study was conducted. The association between intervention and outcome was evaluated using conditional logistic regression analyses. SETTING/PARTICIPANTS: The source population comprised 239,633 patients with dementia diagnosed between 2002 and 2013. We selected patients who received palliative care between 2009 and 2013 (the treatment cohort; N = 1996) and assembled a comparative cohort ( N = 3992) through 1:2 matching for confounding factors. RESULTS: After 2009, palliative care was provided to 3928 (1.64%) patients of the dementia population. The odds ratio for undergoing life-sustaining treatments in the treatment cohort versus the comparative cohort was <1 for most treatments (e.g. 0.41 for mechanical ventilation (95% confidence interval: 0.35-0.48)). The odds ratio was >1 for some treatments (e.g. 1.73 for tube feeding (95% confidence interval: 1.54-1.95)). Palliative care was more consistently associated with fewer life-sustaining treatments for those with cancer. CONCLUSIONS: Palliative care is related to reduced life-sustaining treatments for patients with dementia. However, except in the case of tube feeding, which tended to be provided alongside palliative care regardless of cancer status, having cancer possibly had itself a protective effect against the use of life-sustaining treatments. Modifying the eligibility criteria for palliative care in dementia, improving awareness on the terminal nature of dementia and facilitating advance planning for dementia patients may be priorities for health policies.


Assuntos
Demência/terapia , Enfermagem de Cuidados Paliativos na Terminalidade da Vida/métodos , Cuidados para Prolongar a Vida/métodos , Cuidados Paliativos/métodos , Qualidade de Vida/psicologia , Assistência Terminal/métodos , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Enfermagem de Cuidados Paliativos na Terminalidade da Vida/estatística & dados numéricos , Humanos , Cuidados para Prolongar a Vida/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Cuidados Paliativos/estatística & dados numéricos , Taiwan
14.
Health Serv Res ; 53(3): 1644-1661, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-28097649

RESUMO

OBJECTIVE: To determine between-hospital variation in interventions provided to patients with do not resuscitate (DNR) orders. DATA SOURCES/SETTING: United States Agency of Healthcare Research and Quality, Healthcare Cost and Utilization Project, California State Inpatient Database. STUDY DESIGN: Retrospective cohort study including hospitalized patients aged 40 and older with potential indications for invasive treatments: in-hospital cardiac arrest (indication for CPR), acute respiratory failure (mechanical ventilation), acute renal failure (hemodialysis), septic shock (central venous catheterization), and palliative care. Hierarchical logistic regression to determine associations of hospital "early" DNR rates (DNR order placed within 24 hours of admission) with utilization of invasive interventions. DATA COLLECTION/EXTRACTION METHODS: California State Inpatient Database, year 2011. PRINCIPAL FINDINGS: Patients with DNR orders at high-DNR-rate hospitals were less likely to receive invasive mechanical ventilation for acute respiratory failure or hemodialysis for acute renal failure, but more likely to receive palliative care than DNR patients at low-DNR-rate hospitals. Patients without DNR orders experienced similar rates of invasive interventions regardless of hospital DNR rates. CONCLUSIONS: Hospitals vary widely in the scope of invasive or organ-supporting treatments provided to patients with DNR orders.


Assuntos
Estado Terminal/epidemiologia , Hospitais/estatística & dados numéricos , Cuidados para Prolongar a Vida/estatística & dados numéricos , Ordens quanto à Conduta (Ética Médica) , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Revisão da Utilização de Seguros , Masculino , Pessoa de Meia-Idade , Cuidados Paliativos/estatística & dados numéricos , Preferência do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos
15.
Am J Hosp Palliat Care ; 35(5): 767-771, 2018 May.
Artigo em Inglês | MEDLINE | ID: mdl-29179574

RESUMO

BACKGROUND: Substantial variability exists among countries regarding the modes of death in pediatric intensive care units (PICUs). However, there is limited information on end-of-life care in Japanese PICUs. Thus, this study aimed to elucidate the characteristics of end-of-life care practice for children in a Japanese PICU. METHODS: We examined life-sustaining treatment (LST) status at the time of death based on medical chart reviews from 2010 to 2014. All deaths were classified into 3 groups: limitation of LST (limitation group, death after withholding or withdrawal of LST or a do not attempt resuscitation order), no limitation of LST (no-limitation group, death following failed resuscitation attempts), or brain death (brain death group). RESULTS: Of the 62 patients who died, 44 (71%) had limitation of LST, 18 (29%) had no limitation of LST, and none had brain death. In the limitation group, the length of PICU stay was longer than that in the no-limitation group (13.5 vs 2.5 days; P = .01). The median time to death after the decision to limit LST was 2 days (interquartile range: 1-5.5 days), and 94% of the patients were on mechanical ventilation at the time of death in the limitation group. CONCLUSIONS: Although limiting LST was a common practice in end-of-life care in a Japanese PICU, a severe limitation of LST such as withdrawal from the ventilator was hardly practiced, and a considerable LST was still provided at the time of death.


Assuntos
Tomada de Decisões , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Cuidados para Prolongar a Vida/estatística & dados numéricos , Assistência Terminal/estatística & dados numéricos , Adolescente , Morte Encefálica/diagnóstico , Criança , Pré-Escolar , Feminino , Humanos , Tempo de Internação , Cuidados para Prolongar a Vida/psicologia , Masculino , Respiração Artificial , Ordens quanto à Conduta (Ética Médica) , Estudos Retrospectivos , Assistência Terminal/psicologia , Fatores de Tempo , Suspensão de Tratamento/estatística & dados numéricos
16.
Patient ; 11(1): 97-106, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-28825182

RESUMO

BACKGROUND: Seriously ill people at high risk of death face difficult decisions, especially concerning the extent of medical intervention. Given the inherent difficulty and complexity of these decisions, the care they receive often does not align with their preferences. Patient decision aids that educate individuals about options and help them construct preferences about life-sustaining care may reduce the mismatch between the care people say they want and the care they receive. The quantity and quality of patient decision aids for those at high risk of death, however, are unknown. OBJECTIVE: This protocol describes an approach for conducting an environmental scan of life-sustaining treatment patient decision aids for seriously ill patients, identified online and through informant analysis. We intend for the outcome to be an inventory of all life-sustaining treatment patient decision aids for seriously ill patients currently available (either publicly or proprietarily) along with information about their content, quality, and known use. METHODS: We will identify patient decision aids in a three-step approach (1) mining previously published systematic reviews; (2) systematically searching online and in two popular app stores; and (3) undertaking a key informant survey. We will screen and assess the quality of each patient decision aid identified using the latest published draft of the U.S. National Quality Forum National Standards for the Certification of Patient Decision Aids. Additionally, we will evaluate readability via readable.io and content via inductive content analysis. We will also use natural language processing to assess the content of the decision aids. DISCUSSION: Researchers increasingly recognize the environmental scan as an optimal method for studying real-world interventions, such as patient decision aids. This study will advance our understanding of the availability, quality, and use of decision aids for life-sustaining interventions targeted at seriously ill patients. We also aim to provide patients, their families, and friends, along with their clinicians, a broad set of resources for making life-sustaining treatment decisions. Although we intend to capture all patient decision aids for the seriously ill in our review, we anticipate the possibility that we may miss some decision aids. In addition to publishing our findings in an academic journal, we plan to post our inventory online in an easy-to-read format for public and clinical consumption.


Assuntos
Estado Terminal/psicologia , Técnicas de Apoio para a Decisão , Cuidados para Prolongar a Vida/estatística & dados numéricos , Participação do Paciente , Preferência do Paciente , Comportamento de Escolha , Tomada de Decisões , Família , Humanos , Alfabetização , Educação de Pacientes como Assunto , Pacientes , Reprodutibilidade dos Testes , Projetos de Pesquisa , Fatores de Risco
17.
An. sist. sanit. Navar ; 40(3): 339-349, sept.-dic. 2017. tab
Artigo em Espanhol | IBECS | ID: ibc-169771

RESUMO

Fundamento: Evaluar la calidad de la atención clínica de los pacientes fallecidos en unidades de cuidados intensivos (UCI) españolas a través de las historias clínicas. Metodología: Estudio de cohorte, observacional, retrospectivo, de pacientes que fallecieron en la UCI de una muestra de UCI españolas. El criterio de inclusión fue pacientes mayores de 18 años fallecidos en UCI tras ingreso mínimo de 24h. Se analizaron ingresos consecutivos, sin exclusiones. Se valoraron criterios de excelencia específicos para la UCI mediante los indicadores y medidas de calidad desarrollados por el Robert Wood Johnson Foundation Critical Care Workgroup. Resultados: Se incluyeron 282 pacientes de 15 UCI españolas. Se observó una mediana de 13% de cumplimiento de los indicadores. Casi todas las historias clínicas documentaron la capacidad de decisión del paciente (96%) y la comunicación con la familia (98%) pero solo el 50% contenían un plan u objetivo del cuidado. Sólo dos UCI tenían régimen abierto de visitas de familiares. Estaba mejor documentada la valoración de la disnea (48%) que la del dolor (28%). En trece UCI no había protocolos de retirada de medidas de soporte. En los indicadores de apoyo emocional y apoyo espiritual se observó un cumplimiento inferior al 10%. Conclusiones: La calidad del cuidado del final de vida en las UCI estudiadas puede mejorar. El estudio identifica déficits y señala recursos reales de la práctica clínica a partir de los cuales se puede diseñar un plan de mejora gradual adaptado a cada realidad hospitalaria. El análisis, poco costoso en su realización, coincide con la recomendación unánime de las sociedades profesionales de cuidados intensivos (AU)


Background: To assess the quality of clinical care given to patients who die in intensive care units (ICU) in Spain. Methodos: A retrospective observational cohort study of patients who died in the ICU based on a Spanish sample. Inclusion criteria were patients older than 18 years who died in ICU after a minimum stay of 24 hours. Consecutive admissions without exclusions were analyzed. Excellence criteria in intensive care were assessed by quality indicators and measures, related to end-of-life care, developed by the Robert Wood Johnson Foundation Critical Care Workgroup. Results: Two hundred and eighty-two patients from 15 Spanish ICU were included. A median of 13% was observed in the achievement of the indicators. Almost all clinical records assessed both the patients' decision making capacity (96%) and their communication with families (98%), while a plan of care goals was achieved in only 50% of them. Only two ICU had open visiting policies. Distress assessment (48%) was better than that of pain assessment (28%). The absence of protocol for the withdrawal of life-sustaining treatments was observed in thirteen ICU. The indicators of emotional and spiritual support were achieved in less than 10%. Conclusions: The quality of end-of-life care in the participating ICU needs to be improved. The study identifies shortcomings and indicates existing resources in clinical practice from which a gradual improvement plan, adapted to the situation in each hospital, can be designed. The analysis, inexpensive in its implementation, offers an opportunity for improvement, a goal recommended by most professional societies of intensive care medicine (AU)


Assuntos
Humanos , Qualidade da Assistência à Saúde/estatística & dados numéricos , Resultados de Cuidados Críticos , Cuidados Paliativos na Terminalidade da Vida/estatística & dados numéricos , Melhoria de Qualidade/tendências , Cuidados Críticos/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , Cuidados para Prolongar a Vida/estatística & dados numéricos , Estudos Retrospectivos , Planejamento de Assistência ao Paciente
18.
J Frailty Aging ; 6(3): 148-153, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28721432

RESUMO

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.


Assuntos
Tomada de Decisões , Fragilidade , Cuidados para Prolongar a Vida , Assistência Terminal , Suspensão de Tratamento , Fatores Etários , Idoso , Feminino , Fragilidade/diagnóstico , Fragilidade/mortalidade , Fragilidade/psicologia , França/epidemiologia , Humanos , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Cuidados para Prolongar a Vida/psicologia , Cuidados para Prolongar a Vida/estatística & dados numéricos , Masculino , Estudos Prospectivos , Fatores de Risco , Índice de Gravidade de Doença , Escala Psicológica Aguda Simplificada , Assistência Terminal/psicologia , Assistência Terminal/estatística & dados numéricos , Populações Vulneráveis/psicologia , Populações Vulneráveis/estatística & dados numéricos
19.
J Pediatr ; 190: 118-123.e4, 2017 11.
Artigo em Inglês | MEDLINE | ID: mdl-28647272

RESUMO

OBJECTIVES: To describe the frequency of postnatal discussions about withdrawal or withholding of life-sustaining therapy (WWLST), ensuing WWLST, and outcomes of infants surviving such discussions. We hypothesized that such survivors have poor outcomes. STUDY DESIGN: This retrospective review included registry data from 18 centers of the National Institute of Child Health and Human Development Neonatal Research Network. Infants born at 22-28 weeks of gestation who survived >12 hours during 2011-2013 were included. Regression analysis identified maternal and infant factors associated with WWLST discussions and factors predicting ensuing WWLST. In-hospital and 18- to 26-month outcomes were evaluated. RESULTS: WWLST discussions occurred in 529 (15.4%) of 3434 infants. These were more frequent at 22-24 weeks (27.0%) compared with 27-28 weeks of gestation (5.6%). Factors associated with WWLST discussion were male sex, gestational age (GA) of ≤24 weeks, birth weight small for GA, congenital malformations or syndromes, early onset sepsis, severe brain injury, and necrotizing enterocolitis. Rates of WWLST discussion varied by center (6.4%-29.9%) as did WWLST (5.2%-20.7%). Ensuing WWLST occurred in 406 patients; of these, 5 survived to discharge. Of the 123 infants for whom intensive care was continued, 58 (47%) survived to discharge. Survival after WWLST discussion was associated with higher rates of neonatal morbidities and neurodevelopmental impairment compared with babies for whom WWLST discussions did not occur. Significant predictors of ensuing WWLST were maternal age >25 years, necrotizing enterocolitis, and days on a ventilator. CONCLUSIONS: Wide center variations in WWLST discussions occur, especially at ≤24 weeks GA. Outcomes of infants surviving after WWLST discussions are poor. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00063063.


Assuntos
Tomada de Decisões , Cuidados para Prolongar a Vida/estatística & dados numéricos , Suspensão de Tratamento/estatística & dados numéricos , Feminino , Humanos , Lactente , Mortalidade Infantil , Recém-Nascido , Recém-Nascido Prematuro , Masculino , Morbidade , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Sistema de Registros , Estudos Retrospectivos , Taxa de Sobrevida
20.
Geriatr Gerontol Int ; 17(12): 2545-2551, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28620978

RESUMO

AIM: Little is known about the pattern of healthcare services for end-of-life patients with dementia (PwD) in East Asia. We compared this pattern between PwD and cancer patients in their last year of life in Taiwan. METHODS: Taiwan's National Health Insurance Research Database was applied for this case-control analysis. The records of patients who had dementia and died between 2002 and 2011 were reviewed. The control group was decedents with cancer. The utilization of hospitalization, emergency department visits and life-sustaining interventions during the last year of life between the two groups were compared. RESULTS: Of the 2724 patients enrolled, 908 had dementia and 1816 had cancer. PwD were more likely to have a higher frequency of admission to hospital and intensive care unit, and longer stays compared with cancer patients. PwD had a higher risk of enteral tube insertion and feeding, endotracheal intubation and tracheostomy, mechanical ventilation, hemodialysis and cardiopulmonary resuscitation (OR 4.36, 95% CI 3.51-5.41), which was the highest among the selected procedures. CONCLUSIONS: PwD in their last year of life in Taiwan underwent aggressive interventions significantly more frequently than did their counterparts in Western countries. Providing comfort-centered care for better quality of life for end-of-life PwD is a priority of Taiwan's national health policy. Geriatr Gerontol Int 2017; 17: 2545-2551.


Assuntos
Demência/epidemiologia , Demência/terapia , Cuidados para Prolongar a Vida/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias , Qualidade de Vida , Taiwan , Assistência Terminal
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