Recommendations for end-of-life care in the intensive care unit: A consensus statement by the American College of Critical Care Medicine

Truog, Robert D.; Campbell, Margaret L.; Curtis, J. Randall; Haas, Curtis E.; Luce, John M.; Rubenfeld, Gordon D.; Rushton, Cynda Hylton; Kaufman, David

doi:10.1097/ccm.0b013e3181659096

Cited by 934 publications

(689 citation statements)

References 124 publications

Supporting

Mentioning

644

Contrasting

Unclassified

Order By: Relevance

“…In North America, our current practice favours a model of shared decisionmaking 35 in which physicians are expected to make recommendations based on patient/family values. Although many patients and family members prefer this model 2 , some find these recommendations burdensome 36 .…”

Section: Discussionmentioning

confidence: 99%

Why Do Patients Agree to a “Do Not Resuscitate” or “Full Code” Order? Perspectives of Medical Inpatients

et al. 2011

View full text Add to dashboard Cite

BACKGROUND:The majority of patients who die in hospital have a "Do Not Resuscitate" (DNR) order in place at the time of their death, yet we know very little about why some patients request or agree to a DNR order, why others don't, and how they view discussions of resuscitation status. METHODS:We conducted semi-structured interviews of English-speaking medical inpatients who had clearly requested a DNR or full code (FC) order after a discussion with their admitting team, and analyzed the transcripts using a modified grounded-theory approach. RESULTS:We achieved conceptual saturation after conducting 44 interviews (27 DNR, 17 FC) over a 4-month period. Patients in the DNR group were much older than those in the FC group, but they had broadly similar admission diagnoses and comorbidities. DNR patients reported much greater familiarity with the subject and described a more positive experience than FC patients with their resuscitation discussions. Participants typically requested FC or DNR orders based on personal, relational or philosophical considerations, but these considerations manifested differently depending on the participant's preference for resuscitation. Most FC patients stated that would not want a prolonged period of life support, and they would not want resuscitation in the event of a poor quality of life. FC and DNR patients understood resuscitation and DNR orders differently. DNR patients described resuscitation in graphic, concrete terms that emphasized suffering and futility, and DNR orders in terms of comfort or natural processes. FC patients understood resuscitation in an abstract sense as something that restores life, while DNR orders were associated with substandard care or even euthanasia.CONCLUSION: Our study identified important differences and commonalities between the perspectives of DNR and FC patients. We hope that this information can be used to help physicians better understand the needs of their patients when discussing resuscitation.

show abstract

Section: Discussionmentioning

confidence: 99%

Why Do Patients Agree to a “Do Not Resuscitate” or “Full Code” Order? Perspectives of Medical Inpatients

et al. 2011

View full text Add to dashboard Cite

show abstract

“…This hypothesis is supported by evidence that ICU deaths are commonly preceded by decisions to withdraw life support [3], and evidence that both ICU processes of care [4,5] and behaviors of ICU clinicians [1,6] near the end of life can influence family members' post-ICU psychological outcomes. Thus, uncertainty regarding which approaches to withdrawing mechanical ventilation are least distressing for patients and families [7,8] represents an important area for rigorous investigation.In this context, Reignier and colleagues performed a prospective observational cohort study to compare psychological symptoms in over 400 family members of patients who died after withdrawal of mechanical ventilation by immediate extubation vs. terminal weaning in 43 French ICUs [9]. Impressively, the authors were able to assess the primary endpoint of PTSD symptoms 3 months after death among over 95% of enrolled family members.…”

mentioning

confidence: 99%

mentioning

confidence: 99%

Life after death in the ICU: detecting family-centered outcomes remains difficult

2017

View full text Add to dashboard Cite

Family members of patients who die in the ICU experience significant and lasting psychological burdens, such as post-traumatic stress disorder (PTSD), anxiety, depression, and prolonged grief [1,2]. Among the many potential contributors to these adverse bereavement outcomes are the circumstances surrounding and processes of limiting life support. This hypothesis is supported by evidence that ICU deaths are commonly preceded by decisions to withdraw life support [3], and evidence that both ICU processes of care [4,5] and behaviors of ICU clinicians [1,6] near the end of life can influence family members' post-ICU psychological outcomes. Thus, uncertainty regarding which approaches to withdrawing mechanical ventilation are least distressing for patients and families [7,8] represents an important area for rigorous investigation.In this context, Reignier and colleagues performed a prospective observational cohort study to compare psychological symptoms in over 400 family members of patients who died after withdrawal of mechanical ventilation by immediate extubation vs. terminal weaning in 43 French ICUs [9]. Impressively, the authors were able to assess the primary endpoint of PTSD symptoms 3 months after death among over 95% of enrolled family members. Secondary endpoints included symptoms of anxiety, depression, and complicated grief among family members, symptom burdens of patients during the dying process, and strains on ICU staff.The authors found no differences between groups in any of the psychological outcomes reported by family members at 3 months. This was a durable finding when adjusted for patient characteristics and center effects, and at 6-and 12-month follow-up assessments. ICU staff experienced similar levels of job strain regardless of the withdrawal method chosen, with the exception of nursing assistants who reported less strain with immediate extubation. Patients in the immediate extubation group experienced more gasping and airway obstruction and received significantly lower doses, on average, of sedatives and analgesics compared to those undergoing terminal weaning. Given these results, the authors conclude that the choice between these two approaches to withdrawal of mechanical ventilation does not impact psychological symptoms among family members. They also suggest, and we agree, that standardized approaches to medication administration near the end of life may reduce patient suffering.This study is innovative in empirically evaluating the impact of how mechanical ventilation is withdrawn on family-centered outcomes. It is also strengthened by the diverse sample of ICUs, and the outstanding follow-up rate. However, the ability to draw conclusions is tempered by the non-randomized design. Although the authors appropriately note that randomly assigning ICUs to an unfamiliar withdrawal method might engender low adherence to the assigned interventions, the observational design amounts to a comparison of withdrawal methods on family members who chose (or whose clinicians chose for them) a particul...

show abstract

“…Bioethicists have long argued against making a distinction between the ethical acceptability of withholding versus withdrawing treatment [1]. The modern secular consensus was expressed concisely in a landmark 1983 report: ''neither law nor public policy should mark a difference in moral seriousness between stopping and not starting treatment'' [2].…”

mentioning

confidence: 99%

Recommendations for end-of-life care in the intensive care unit: A consensus statement by the American College of Critical Care Medicine

Cited by 934 publications

References 124 publications

Why Do Patients Agree to a “Do Not Resuscitate” or “Full Code” Order? Perspectives of Medical Inpatients

Why Do Patients Agree to a “Do Not Resuscitate” or “Full Code” Order? Perspectives of Medical Inpatients

Life after death in the ICU: detecting family-centered outcomes remains difficult

“No escalation of treatment” as a routine strategy for decision-making in the ICU: con

Contact Info

Product

Resources

About