Defining Futile and Potentially Inappropriate Interventions: A Policy Statement From the Society of Critical Care Medicine Ethics Committee

Kon, Alexander A.; Shepard, Eric K.; Sederstrom, Nneka; Swoboda, Sandra M.; Marshall, Mary Faith; Birriel, Barbara; Rincón, Fred

doi:10.1097/ccm.0000000000001965

Cited by 222 publications

(70 citation statements)

References 57 publications

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“…They also introduced the concept of potentially inappropriate treatment (PIT) for the more value-laden situations when there is doubt about whether goals were achievable or in the patient’s best interest [10]. There is an ongoing discussion about how potentially inappropriate interventions should be understood in TBI [37, 38]. The Society of Critical Care Medicine Ethics Committee has suggested that “ ICU interventions should generally be considered inappropriate when there is no reasonable expectation that the patient will improve sufficiently to survive outside the acute care setting, or when there is no reasonable expectation that the patient’s neurologic function will improve sufficiently to allow the patient to perceive the benefit of treatment” [38].…”

Section: Discussionmentioning

confidence: 99%

Treatment-limiting decisions in patients with severe traumatic brain injury in a Norwegian regional trauma center

Robertsen

Førde

Skaga

et al. 2017

Scand J Trauma Resusc Emerg Med

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BackgroundTreatment-limiting decisions (TLD) for severe traumatic brain injury (sTBI) have been sparsely studied. This study determine prevalence, main reason for, categories and timing of TLDs in a Norwegian regional trauma setting.MethodsA retrospective study of a 2-year cohort of 579 sTBI patients admitted to Oslo University Hospital (OUH). Prospectively collected data in the OUH Trauma Registry were combined with retrospective data from a chart review regarding TLDs.ResultsTLDs were documented for 101/579 sTBI patients (17%). The situation was evaluated as futile in 59 cases and as potentially inappropriate in 42 cases. The three most frequent types of TLDs were withholding of neurosurgery, do not resuscitate orders and withdrawing of organ support. In 70% of cases, the first TLD was made within 2 days after injury, while in 14%, the first TLD was made later than day 7. Twenty percent (20/101) of the first TLDs were later adjusted, revoked in 4 patients and broadening of TLDs in 16 patients. The median time from the decision to death was 2 days (range 1–652). TLDs were documented in 93% of in-hospital death cases (n = 79). In-hospital deaths occurred in 73% of TLD group cases and 1% of non-TLD group cases. Family interaction and multi-team discussions were documented in >88% of cases, but no advanced directives were found, and notifications of patients’ preferences were found in only 7% of cases.DiscussionClinicians should consider limiting treatment if continued treatment is not in the patients best interest. A range of different types of TLDs were applied for patients after sTBI in the trauma hospital setting.ConclusionTLDs were found in 17% of sTBI patients. Value considerations behind TLDs in this care context need to be further explored.

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Section: Discussionmentioning

confidence: 99%

Treatment-limiting decisions in patients with severe traumatic brain injury in a Norwegian regional trauma center

Robertsen

Førde

Skaga

et al. 2017

Scand J Trauma Resusc Emerg Med

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“…Critical care management has been understood for more than two decades to be a trial of management, with ethically justified, beneficence-based criteria for its initiation and discontinuation (Consensus statement of the Society of Critical Care Medicine's Ethics Committee regarding futile and other possibly inadvisable treatment 1997; Kon et al 2016). Critical care management should be initiated when, in deliberative (evidence-based, rigorous, transparent, and accountable) clinical judgment, it is reliably predicted to result in the clinical benefit of reducing the risk of mortality and preserving at least some interactive capacity, that is, when initiating critical care management is medically reasonable.…”

Section: Guest Editorialmentioning

confidence: 99%

In Response to COVID-19 Pandemic Physicians Already Know What to Do

McCullough

2020

The American Journal of Bioethics

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“…( 3 , 5 ) Even in patients with severe, advanced diseases, ICU utilization during terminal hospitalization may occur in up to 50% of cases, ( 6 ) and much of that care may be seen as nonbeneficial or inconsistent with patients' values and preferences. ( 7 ) Moreover, potentially inappropriate ICU admissions ( 8 ) may increase the strain on the allocation of scarce critical care resources. ( 9 - 11 )…”

Section: Introductionmentioning

confidence: 99%

Effect of a palliative care program on trends in intensive care unit utilization and do-not-resuscitate orders during terminal hospitalizations. An interrupted time series analysis

Ramos¹,

Tourinho²,

Borrione³

et al. 2018

Revista Brasileira De Terapia Intensiva

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ObjectiveTo assess the effect of the implementation of a palliative care program on do-not-resuscitate orders and intensive care unit utilization during terminal hospitalizations.MethodsData were retrospectively collected for all patients who died in a tertiary hospital in Brazil from May 2014 to September 2016. We analyzed the frequency of do-not-resuscitate orders and intensive care unit admissions among in-hospital deaths. Interrupted time series analyses were used to evaluate differences in trends of do-not-resuscitate orders and intensive care unit admissions before (17 months) and after (12 months) the implementation of a palliative care program.ResultsWe analyzed 48,372 hospital admissions and 1,071 in-hospital deaths. Deaths were preceded by do-not-resuscitate orders in 276 (25.8%) cases and admissions to the intensive care unit occurred in 814 (76%) cases. Do-not-resuscitate orders increased from 125 (20.4%) to 151 (33%) cases in the pre-implementation and post-implementation periods, respectively (p < 0.001). Intensive care unit admissions occurred in 469 (76.5%) and 345 (75.3%) cases in the pre-implementation and post-implementation periods, respectively (p = 0.654). Interrupted time series analyses confirmed a trend of increased do-not-resuscitate order registrations, from an increase of 0.5% per month pre-implementation to an increase of 2.9% per month post-implementation (p < 0.001), and demonstrated a trend of decreased intensive care unit utilization, from an increase of 0.6% per month pre-implementation to a decrease of -0.9% per month in the post-implementation period (p = 0.001).ConclusionThe implementation of a palliative care program was associated with a trend of increased registration of do-not-resuscitate orders and a trend of decreased intensive care unit utilization during terminal hospitalizations.

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Defining Futile and Potentially Inappropriate Interventions: A Policy Statement From the Society of Critical Care Medicine Ethics Committee

Abstract: The Society of Critical Care Medicine supports the seven-step process presented in the multiorganization statement. This statement provides added guidance to clinicians in the ICU environment.

Cited by 222 publications

References 57 publications

Treatment-limiting decisions in patients with severe traumatic brain injury in a Norwegian regional trauma center

Treatment-limiting decisions in patients with severe traumatic brain injury in a Norwegian regional trauma center

In Response to COVID-19 Pandemic Physicians Already Know What to Do

Effect of a palliative care program on trends in intensive care unit utilization and do-not-resuscitate orders during terminal hospitalizations. An interrupted time series analysis

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