In some intensive care units (ICUs), fewer patients who die now undergo attempts at cardiopulmonary resuscitation (CPR), and many more have life support actively withdrawn prior to death than did a decade ago. To determine the frequency of withdrawal of life support, we contacted every American postgraduate training program with significant clinical exposure to critical care medicine, asking them prospectively to classify patients who died into one of five mutually exclusive categories. We received data from 131 ICUs at 110 institutions in 38 states. There were 6,303 deaths, of which 393 patients were brain dead. Of the remaining 5,910 patients who died, 1,544 (23%) received full ICU care including failed cardiopulmonary resuscitation (CPR); 1,430 (22%) received full ICU care without CPR; 797 (10%) had life support withheld; and 2,139 (38%) had life support withdrawn. There was wide variation in practice among ICUs, with ranges of 4 to 79%, 0 to 83%, 0 to 67%, and 0 to 79% in these four categories, respectively. Variation was not related to ICU type, hospital type, number of admissions, or ICU mortality. We conclude that limitation of life support prior to death is the predominant practice in American ICUs associated with critical care training programs. There is wide variation in end-of-life care, and efforts are needed to understand practice patterns and to establish standards of care for patients dying in ICUs.

OBJECTIVE: To characterize chronic obstructive pulmonary disease (COPD) over patients' last 6 months of life. STUDY DESIGN: A retrospective analysis of a prospective cohort from the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). SETTING:Hospitalization for exacerbation of COPD at five US teaching hospitals. PARTICIPANTS: COPD patients who died within 1 year (n = 416) among 1016 enrolled. METHODS: Interview and medical record data were organized into time windows beginning with death and ending 6 months earlier. OUTCOME MEASURES: Days in hospital, prognosis, illness severity, function, symptoms, patients' preferences, and impacts on families. RESULTS: One-year survival was 59%, 39% had 2 3 comorbidities, and 15 to 25% of the patients' last 6 months were in hospitals. Exacerbation etiologies included respiratory infection (47%) and cardiac problems (30%). Better quality of life predicted longer survival (ARR: 0.36; 95% CI, 0.19-0.87) as did heart failure etiology of exacerbation (ARR: 0.57; CI, 0.40,0.82). Estimates of survival by physicians and by prognostic model were well calibrated, although patients with the worst prognoses survived longer than predicted. Patients' estimates of prognosis were poorly calibrated. One-quarter of patients had serious pain throughout, and two-thirds had serious dyspnea. Patients' illnesses had a major impact on more than 25% of families. Patients' preferences for Do-Not-Resuscitate orders increased from 40% at 3 to 6 months before death to 77% within 1 month of From the 'Center to Improve Care of the Dying, The George Washington University, Washington, DC; tDivision of Allergy, Pulmonary, and Critical Care, death; their decisions not to use mechanical ventilation increased from 12 to 31%, and their preferences for resuscitation decreased from 52 to 23%. CONCLUSIONS: Patients with advanced COPD often die within 1 year and have substantial comorbidities and symptoms. Adequate description anchors improved care. J Am Geriatr SOC 48:S91-S100,2000. ~~~ hronic obstructive pulmonary disease (COPD) is the C fourth leading cause of death in the United States, with about 110,000 deaths annually.' COPD affects approximately 15 million people in the United state^,^,^ and its prevalence and mortality rates are in~reasing.~-~ COPD is slowly progressive and disabling, with quality of life and ability to perform activities of daily living often compromised for many years as a result of the severe dyspnea and deterioration of exercise ~a p a c i t y .~ For patients with advanced COPD, exacerbations are common and often lead to hospitalization, intubation, and mechanical ventilation. Hospitalization represents the largest component of the cost of care for COPD patient^.'^^ US medical care expenditures for COPD exceed 14.5 billion dollars annually." Despite the substantial health and economic burden of COPD on our society, little information in the literature details the experiences of patients dying with this illness.Clinical experience and research indi...

This work commenced during the 3rd European Society for Therapeutic Radiology and Oncology (ESTRO) physics workshop on 'Implementation/commissioning/QA of artificial intelligence techniques' in Budapest (2019) Radiotherapy and Oncology xxx (xxxx) xxx Contents lists available at ScienceDirect Radiotherapy and Oncology j o u r n a l h o m e p a g e : w w w. t h e g r e e n j o u r n a l. c o m Please cite this article as: L. Vandewinckele, M. Claessens, A. Dinkla et al., Overview of artificial intelligence-based applications in radiotherapy: Recommendations for implementation and quality assurance, Radiotherapy and Oncology,

CONTEXT: Many are calling for patients with advanced chronic obstructive pulmonary disease (COPD) to receive hospice care, but the traditional hospice model may be insufficient. OBJECTIVE: To compare the course of illness and patterns of care for patients with non-small cell lung cancer and severe COPD. DESIGN Prospective cohort study of seriously ill, hospitalized adults. SETTING: Five teaching hospitals in the United States. PATIENTS: Patients with Stage 111 or IV non-small cell lung cancer (n = 939) or acute exacerbation of severe COPD (n = 1008). MAIN OUTCOME MEASURES: Patients' preferences for pattern of care and for ventilator use; symptoms; lifesustaining interventions; and survival prognoses. RESULTS: Sixty percent in each group wanted comfortfocused care; 81% with lung cancer and 78% with COPD were extremely unwilling to have mechanical ventilation indefinitely. Severe dyspnea occurred in 32% of patients with lung cancer and 56% of patients with COPD and severe pain in 28% of patients with lung cancer and 21 % of patients with COPD. Patients with COPD who died during index hospitalization were more likely than patients with lung cancer to receive mechanical ventilation (70.4% vs 19.8%), tube feeding (38.7% vs 18.5%), and cardiopulmonary resuscitation (25.2% vs 7.8%). Mechanical ventilation had greater short term effectiveness in patients with COPD, based on survival From the 'Palliative Care Program, Marshfield Clinic and St. Joseph's Hospital, Marshfield, Wisconsin; tThe Center to Improve Care of the Dying, WI 54449. Address requests for reprints to Joanne Lynn, MD, Center to Improve Care of the Dying, Rand Health, 1200 S . Hayes St., Arlington, VA 22202.to hospital discharge (76% vs 38%). Patients with COPD maintained higher median 2-month and 6-month survival prognoses, even days before death. CONCLUSIONS: Hospitalized patients with lung cancer or COPD preferred comfort-focused care, yet dyspnea and pain were problematic in both groups. Patients with COPD were more often treated with life-sustaining interventions, and short-term effectiveness was comparatively better than in patients with lung cancer. In caring for patients with severe COPD, consideration should be given to implementing palliative treatments more aggressively, even while remaining open to provision of life-sustaining interventions. J Am Geriatr SOC 48:S146-S153,2000.