End-of-life in the ICU: moving from ‘withdrawal of care’ to a palliative care, patient-centred approach

Connolly, Catriona; Miskolci, Orsolya; Phelan, Dermot; Buggy, Donal J.

doi:10.1093/bja/aew109

Cited by 31 publications

(23 citation statements)

References 16 publications

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“…In practice, withholding preceded or accompanied withdrawal in >90% of patients [22], and was more likely to occur during on-call hours [24]. It is noteworthy that withholding and withdrawal reflect the limitation of life sustaining treatments, but it is essential in the communication with the team, the patient and the relatives that a change in goals of care does not mean the cessation of medical care [25]. …”

Section: Discussionmentioning

confidence: 99%

“…In everyday practice, adoption of the ‘ABCDs’ of EOL critical care is applicable: Attitudes, Behaviours, Compassion and Dialogue [27]. Presently, between 10% and 20% of the population at large now die in the ICU underlining the importance of EOL care to everyday practice and training [25], being extended to EOL orders (Q41) for continuing care after death for relatives (Q43) (Additional file 10: Figure S10). Many clinicians and families equate withholding or withdrawing as giving up [17].…”

Section: Discussionmentioning

confidence: 99%

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End-of-life perceptions among physicians in intensive care units managed by anesthesiologists in Germany: a survey about structure, current implementation and deficits

Weiß

Michalsen²,

Toenjes

et al. 2017

BMC Anesthesiol

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BackgroundStructural aspects and current practice about end-of-life (EOL) decisions in German intensive care units (ICUs) managed by anesthesiologists are unknown. A survey among intensive care anesthesiologists has been conducted to explore current practice, barriers and opinions on EOL decisions in ICU.MethodsIn November 2015, all members of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and the Association of German Anesthesiologists (BDA) were asked to participate in an online survey to rate the presence or absence and the importance of 50 items. Answers were grouped into three categories considering implementation and relevance: Category 1 reflects high implementation and high relevance, Category 2 low and low, and Category 3 low and high.ResultsFive-hundred and forty-one anesthesiologists responded. Only four items reached ≥90% agreement as being performed “yes, always” or “mostly”, and 29 items were rated “very” or “more important”. A profound discrepancy between current practice and attributed importance was revealed. Twenty-eight items attributed to Category 1, six to Category 2 and sixteen to Category 3. Items characterizing the most urgent need for improvement (Category 3) referred to patient outcome data, preparation of health care directives and interdisciplinary discussion, standard operating procedures, implementation of practical instructions and inclusion of nursing staff and families in the process.ConclusionThe present survey affirms an urgent need for improvement in EOL practice in German ICUs focusing on advanced care planning, distinct aspects of changing goals of care, implementation of standard operating procedures, continuing education and reporting of outcome data.Electronic supplementary materialThe online version of this article (doi:10.1186/s12871-017-0384-5) contains supplementary material, which is available to authorized users.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

End-of-life perceptions among physicians in intensive care units managed by anesthesiologists in Germany: a survey about structure, current implementation and deficits

Weiß

Michalsen²,

Toenjes

et al. 2017

BMC Anesthesiol

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“…Having an official, legally-binding, and nationwide framework for end-of-life practices allows both the patient to maintain their dignity and the clinician to follow the key concepts of medical ethics. All end-of-life decisions are difficult for everyone involved: the patient, the patient's family members, and the medical team; and they are becoming increasingly common (4). In these instances time can play an essential role.…”

Section: Discussionmentioning

confidence: 99%

ECCO2R as a bridge to a decision in type II respiratory failure

Grauslytė

Cerda

Jovaiša

2019

AML

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Introduction. End-of-life decisions are often time consuming and difficult for everyone involved. In some of these cases extracorporeal life support systems could potentially be used not only as a bridge to treatment but as a tool to buy time to allow patient’s participation in decision making and to avoid further futile invasive procedures. Case report. A previously healthy 53-year-old female patient presented with respiratory failure of unknown cause. In the course of treatment her condition was deemed irreversible and the only option for any chance of long-term survival was a lung transplant. During this whole time the patient’s condition was managed with extracorporeal carbon dioxide removal system (ECCO2R). She remained compos mentis and expressed the wish to stop all the treatment as the option of lung transplant was not acceptable to her. Treatment was withdrawn and she passed away. Discussion. In cases of end-of-life decisions, time can play an essential role. Even though extracorporeal life support systems have been conceptualised to be a bridge to treatment, they could be beneficial in a situation when time is needed to make a decision. ECCO2R has been used as a treatment method in different settings, however, in this case it served as a tool to maintain the patient alive and conscious for a sufficient time for her to participate in decision making. Conclusions. Our case report demonstrated that ECCO2R could serve as a bridge to decision in situations when time is limited and the decisions that need to be made are difficult.

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“…Delay in withdrawal may not only increase prognostic accuracy, but will also allow better shared decision making with the family, improve end of life care for the patient and their relatives, enable the incorporation of palliative care into the patient's ICU management, and facilitate the adoption of best practice in organ donation [10,16,17,[27][28][29]. These are all good reasons for adopting pathways for the management of devastating brain injury that follow the principles of those for OHCA, but unfortunately there are no robust outcome studies for devastating brain injury pathways as there are for OHCA.…”

Section: Editorialmentioning

confidence: 99%