Incorporating palliative care into critical care education: Principles, challenges, and opportunities

Danis, Marion; Federman, Daniel D.; Fins, Joseph J.; Fox, Ellen; Kastenbaum, Beatrice; Lanken, Paul N.; Long, Karen; Lowenstein, Edward; Lynn, Joanne; Rouse, Fenella; Tulsky, James A.

doi:10.1097/00003246-199909000-00047

Cited by 156 publications

(69 citation statements)

References 33 publications

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“…3-6,10,16,29 -32 This survey revealed that with the exception of 1 case, the physician responsible for writing DNR orders was actually the intensivist, frequently a stranger to the families, rather than the child's referring physician. 7,[33][34][35] The patients in the study who had LST forgone were older and had a longer PICU stay. 11 The end-of-life process more frequently involved LST removal, because only 18% (7 of 39) of the W/LT group had limitation or no escalation of therapy as the mode of choice.…”

Section: Modes and Time Of Deathmentioning

confidence: 99%

“…43 Our survey clearly demonstrated that decision making at the end of life in the PICU is a dynamic process. 31,33,37,39,44 In almost half of the W/LT group, limitation in the level of support was considered in the earlier stages. Subsequently, 1 or more modes of LST were actually withdrawn.…”

Section: Why and How Decisions Are Madementioning

confidence: 99%

“…11 The residents' presence in the formal meetings was poor and needs to be encouraged. 33 Family conferences about end of life should be seen as an effective 58 "teachable moment" for staff in training. 59,60 In 50% of the cases, 2 or more formal meetings with families were necessary to reach consensus about forgoing therapy, perhaps indicating a more complex process or the existence of different goals regarding additional management.…”

Section: Approaching the Familiesmentioning

confidence: 99%

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Circumstances Surrounding End of Life in a Pediatric Intensive Care Unit

2003

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ABSTRACT.Objective. Approximately 60% of deaths in pediatric intensive care units follow limitation or withdrawal of life-sustaining treatment (LST). We aimed to describe the circumstances surrounding decision making and end-of-life care in this setting.Methods. We conducted a prospective, descriptive study based on a survey with the intensivist after every consecutive death during an 8-month period in a single multidisciplinary pediatric intensive care unit. Summary statistics are presented as percentage, mean ؎ standard deviation, or median and range; data are compared using the Mantel-Haenszel test and shown as survival curves.Results. Of the 99 observed deaths, 27 involved failed cardiopulmonary resuscitation; of the remaining 72, 39 followed withdrawal/limitation (W/LT) of LST, 20 were do not resuscitate (DNR), and 13 were brain deaths (BDs). Families initiated discussions about forgoing LST in 24% (17 of 72) of cases. Consensus between caregivers and staff about forgoing LST as the best approach was reached after the first meeting with 51% (35 of 68) of families; 46% (31 of 68) required >2 meetings (4 not reported). In the DNR group, the median time to death after consensus was 24 hours and for W/LT was 3 hours. LST was later withdrawn in 11 of 20 DNR cases. The family was present in 76% (45 of 59) of cases when LST was forgone. The dying patient was held by the family in 78% (35 of 45) of these occasions.Conclusions. More than 1 formal meeting was required to reach consensus with families about forgoing LST in almost half of the patients. Families often held their child at the time of death. The majority of children died quickly after the end-of-life decision was made. In pediatric ICUs (PICUs), retrospective studies done during the past decade indicate that 40% to 60% of all deaths follow such a decision. [3][4][5][6][7] However, few of these reports describe how these decisions were reached. 7-10 A more recent study analyzed 53 deaths in 3 PICUs in the United States in which LST was forgone. The author's focus was on the medications given at the end of life and the physicians' and nurses' levels of satisfaction with the care provided. 11 The revelation about the presence of paralyzing agents in some patients at the time of withdrawal of LST and that 2% of the involved professionals believed that hastening death is an acceptable goal in itself generated great controversy. 12-14 Consequently, more information about pediatric intensivists' actual practices regarding forgoing LST in children 8,10,15,16 is warranted. Some details about these events, such as timing of decision making, terminal sedation, barriers to achieve consensus with families, and their participation in the process, remain topics that need additional exploration. 17,18 The purpose of this study was not only to determine the modes of death in a single large multidisciplinary PICU in Canada but also to describe the decision-making process and the end-of-life care. We also examined the level of difficulty to reach consensus with families or ...

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Section: Modes and Time Of Deathmentioning

confidence: 99%

Section: Why and How Decisions Are Madementioning

confidence: 99%

Section: Approaching the Familiesmentioning

confidence: 99%

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Circumstances Surrounding End of Life in a Pediatric Intensive Care Unit

2003

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“…49 Outside of Canada there is a body of evidence to suggest that end of life care in the ICU falls short of these standards, leading to calls for better palliation. 50,51 The situation in Canada appears more encouraging with families reporting that most patients die in comfort in the ICU 17 and that the families themselves feel supported during the dying process. 37 However, inconsistencies in end of life care practices may affect where patients die, how they die, the quality of that death 52,53 and whether or not patients are considered for organ and tissue donation in the ICU.…”

Section: Withdrawal Of Mechanical Ventilationmentioning

confidence: 99%

Brief review: Practice variation in end of life care in the ICU: implications for patients with severe brain injury

Rocker

Cook

Shemie

2006

Can J Anesth/J Can Anesth

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“…1 Subsequently there have been many calls for better defined goals for, and better care of, dying patients in the intensive care units (ICUs). [2][3][4][5][6][7] Improvements to care in the ICU could take many forms: attention to communication strategies, better understanding of cultural issues, use of ethical committees in difficult cases or process issues within the ICU to improve consistency in care delivery. Regarding consistency, we recently reported tenfold variations in prescribed doses of morphine during the last 12 hr of life in dying ICU patients.…”

Section: Conclusion : Des Changements Simples Au Processus De Rmfv Pementioning

confidence: 99%

Simple changes can improve conduct of end-of-life care in the intensive care unit

Hall

Rocker

Murray

2004

Can J Anesth/J Can Anesth

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P Pu ur rp po os se e: : To describe changes to the conduct of withdrawal of life support (WOLS) in two teaching hospital tertiary care medical surgical intensive care units (ICUs) in a single centre over two distinct time periods. M Me et th ho od ds s: :We used a retrospective chart review with a before and after comparison. We assessed aspects of end-of-life care for ICU patients dying after a WOLS before and after we introduced instruments to clarify do not resuscitate (DNR) orders and to standardize the WOLS process, sought family input into the conduct of end-of-life care, and modified physicians' orders regarding use of analgesia and sedation.R Re es su ul lt ts s: : One hundred thirty-eight patients died following life support withdrawal in the ICUs between July 1996 and June 1997 (PRE) and 168 patients died after a WOLS between May 1998 and April 1999 (POST). Time from ICU admission to WOLS (mean ± SD) was shorter in the POST period (191 ± 260 hr PRE vs 135 ± 205 hr POST, P = 0.05). Fewer patients in the POST group received cardiopulmonary resuscitation in the 12-hr interval prior to death (PRE = 7; POST = 0: P < 0.05). Fewer comfort medications were used (PRE: 1.7 ± 1.0 vs POST: 1.4 ± 1.0; P < 0.05). Median cumulative dose of diazepam (PRE: 20.0 vs POST: 10.0 mg; P < 0.05) decreased. Documented involvement of physicians in WOLS discussions was unchanged but increased for pastoral care (PRE: 10/138 vs POST: 120/168 cases; P < 0.05). The majority of nurses (80%) felt that the DNR and WOLS checklists led to improved process around WOLS.C Co on nc cl lu us si io on n: : Simple changes to the process of WOLS can improve conduct of end-of-life care in the ICU. (PRE = 7 ; POST = 0 : P < 0,05). Moins de médicaments de confort ont été utilisés (PRE : 1,7 ± 1,0 vs POST : 1,4 ± 1,0 ; P < 0,05). La dose cumulative moyenne de diazépam (PRE : 20,0 vs POST : 10,0 mg ; P < 0,05) Objectif : Décrire les changements apportés au retrait du maintien des fonctions vitales (RMFV) dans deux unités de soins intensifs (USI) médicaux et chirurgicaux d'un centre hospitalier universitaire de soins tertiaires au cours de deux périodes distinctes. Méthode : Nous avons utilisé une revue rétrospective des dossiers et réalisé une comparaison du type avant-après. Nous avons évalué les différents aspects des soins aux mourants de l'USI, décédés après le RMFV, avant et après l'introduction d'instruments clarifiant l'ordonnance de ne pas réanimer (PDR) et normalisant le processus de RMFV. Nous avons recueilli les suggestions de la famille sur les soins aux mourants et modifié les ordonnances des médecins sur l'analgésie et la sédation. Résultats : Cent trente-huit patients sont décédés après le RMFV dans les USI entre juillet 1996 et juin 1997 (PRE) et 168 après un RMFV entre mai 1998 et avril 1999 (POST). L'intervalle entre l'admission à l'USI et le RMFV (moyenne ± écart type) a été plus court dans la période POST (191 ± 260 h PRE vs 135 ± 205 h POST, P = 0,05). Moins de patients du groupe POST ont reçu une réanimation cardiopulmonai...

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Incorporating palliative care into critical care education: Principles, challenges, and opportunities

Cited by 156 publications

References 33 publications

Circumstances Surrounding End of Life in a Pediatric Intensive Care Unit

Circumstances Surrounding End of Life in a Pediatric Intensive Care Unit

Brief review: Practice variation in end of life care in the ICU: implications for patients with severe brain injury

Simple changes can improve conduct of end-of-life care in the intensive care unit

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