Obstacles to organ donation in Swedish intensive care units

OBJECTIVE: To identify obstacles to organ donation in Swedish intensive care units. DESIGN: A survey exploring attitudes and experiences of organ donation activities was sent to half of all anaesthetists and all neurosurgeons in Sweden (n=644). Total response rate was 67%; 69% from the anaesthetists and 54% from the neurosurgeons. RESULTS: Neurosurgeons had more experiences of caring for potential donors and requesting donation than anaesthetists. Twenty-seven percent of the anaesthetists were not confident with clinical neurological criteria for brain incarceration. Nine per cent found donation activities solely burdensome, and 14% wanted an external team to take over the donation request. A quarter regarded the request definitely as an extra load on the family, and more than half of the respondents had refrained from asking in emotionally strained situations. Forty-nine per cent had a neutral approach to relatives when requesting donation while 38% had a pro-donation approach. Thirty-six per cent terminated ventilator treatment for a potential donor without waiting for total brain infarction. Lack of resources in the ICUs resulted in not identifying a possible donor according to 29% of respondents. Knowing the prior wish of the deceased was regarded as the single most important factor that facilitated the work with organ donation for the intensivists. CONCLUSIONS: The identified obstacles (neutral approach of donation request, ethical problems concerning the potential donor and the relatives, varying competence in diagnosing total brain infarction, and lack of intensive care bed resources) require tailored efforts in order to increase organ donation. Checking these factors can be used as a quality control when analysing donation activities at hospitals.     

End-of-life care in intensive care units: family routines and environmental factors

The purpose of this study was to describe family care routines and to explore environmental factors when patients die in Swedish intensive care units (ICUs). The main research questions were: what are the physical environmental circumstances and facilities when caring for patients in end‐of‐life and are there any routines or guidelines when caring for dying patients and their families? A questionnaire was sent to 79 eligible Swedish ICUs in December 2003, addressed to the unit managers. The response rate was 94% (n = 74 units). The findings show that, despite recommendations highlighting the importance of privacy for dying ICU patients and their families, only 11% of the respondents stated that patients never died in shared rooms in their ICU. If a patient dies in a shared room, nurses strive to ensure a dignified good‐bye by moving the body to an empty room or to one specially designated for this purpose. The majority (76%) of the units had waiting rooms within the ICU. The study also revealed that there is a need for improvements in the follow‐up routines for bereaved families. Many units reported (51%) that they often or almost always offer a follow‐up visit, although in most cases the bereaved family had to initiate the follow‐up by contacting the ICU. Guidelines in the area of end‐of‐life care were used by 25% of the ICUs. Further research is necessary to acquire a deeper knowledge of the circumstances under which patients die in ICUs and what impact the ICU environment has on bereaved families.     

End-of-life care in the intensive care unit: a research agenda

BACKGROUND: The intensive care unit (ICU) represents a unique clinical setting in which mortality is relatively high and the professional culture tends to be one of "rescue therapy" using technological and invasive interventions. For these reasons, the ICU is an important environment for understanding and improving end-of-life care. Although there have been consensus statements and review articles on end-of-life care in the ICU, there is limited evidence on which to base an assessment of best practices for providing high-quality end-of-life care in this setting. OBJECTIVE: To convene a Working Group of experts in critical care, palliative medicine, medical ethics, and medical law to address the question "What research needs to be done to improve end-of-life care to patients in the ICU?" METHODS: Participants were identified for membership in the Working Group by purposive sampling within the fields of critical care medicine and nursing, palliative medicine, and medical ethics; others were chosen to represent social work and hospital chaplains. Through a process of breakout and plenary sessions, the group identified important questions that need to be addressed in the areas of defining the problem, identifying solutions, evaluating solutions, and overcoming barriers. CONCLUSIONS: Outlining unanswered questions on end-of-life care in the ICU is a first step to providing the answers that will allow us to improve care to patients dying in the ICU. These questions also serve to focus clinicians and educators on the important areas for improving quality of care.     

Clinical review: Moral assumptions and the process of organ donation in the intensive care unit

The objective of the present article is to review moral assumptions underlying organ donation in the intensive care unit. Data sources used include personal experience, and a Medline search and a non-Medline search of relevant English-language literature. The study selection included articles concerning organ donation. All data were extracted and analysed by the author. In terms of data synthesis, a rational, utilitarian moral perspective dominates, and has captured and circumscribed, the language and discourse of organ donation. Examples include "the problem is organ shortage", "moral or social duty or responsibility to donate", "moral responsibility to advocate for donation", "requesting organs" or "asking for organs", "trained requesters", "pro-donation support persons", "persuasion" and defining "maximising donor numbers" as the objective while impugning the moral validity of nonrational family objections to organ donation. Organ donation has recently been described by intensivists in a morally neutral way as an "option" that they should "offer", as "part of good end-of-life care", to families of appropriate patients. In conclusion, the review shows that a rational utilitarian framework does not adequately encompass interpersonal interactions during organ donation. A morally neutral position frees intensivists to ensure that clinical and interpersonal processes in organ donation are performed to exemplary standards, and should more robustly reflect societal acceptability of organ donation (although it may or may not "produce more donors").     

End-of-life care in the pediatric intensive care unit: research review and recommendations

Improving the quality of end-of-life care has become a national health care priority. A necessary step in this process in the pediatric intensive care unit (ICU) is examining the knowledge, attitudes,and behaviors of pediatric critical care practitioners in this area. In addition, the perspectives of bereaved parents must be uncovered as well. In this article, the empirical data in the literature on end-of-life care in the pediatric ICU are reviewed, common ethical controversies in this environment are discussed, and promising interventions for the future are presented.     

End-of-life decision making in the intensive care unit

Physicians are increasingly involved in how their critically ill patients die [72]. The more this happens, the more physicians will have to understand not only how their own backgrounds and biases influence their medical management, but also the cultural and religious backgrounds of the patient and surrogate [72, 73]. The medical profession must realise that, despite tremendous advances in medical knowledge and technology, not everyone can be saved all the time, even in the area of intensive care. Physicians must understand that "doing everything" that is best for the patient may not mean starting epinephrine or performing CPR, but rather may imply moving from a process of curing to caring with palliative care [10]. This process should be initiated by discussions with the patient or surrogate, and should include knowledge of the patients' wishes as demonstrated by advance directives and durable power of attorney. The patient's code status and the intention of forgoing life-sustaining treatment should be discussed with other members of staff together with the patient and/or family in a compassionate and humane manner. The wishes of the patient and family should be taken into consideration and the physician must try to make an impartial decision by doing what is medically and ethically correct and best for this specific patient. Hopefully, in this way, a more ethical and compassionate approach to end-of-life decisions in the ICU will be obtained.     

End-of-life decisions in an Indian intensive care unit

Background

There is a paucity of data on end-of-life decisions (EOLD) for patients in Indian intensive care units (ICUs).

Objective

To document the end-of-life and full-support (FS) decisions among patients dying in an ICU, to compare the respective patient characteristics and to describe the process of decision-making.

Design

Retrospective, observational.

Patients

Consecutive patients admitted to a 12-bed closed medical-surgical ICU.

Exclusions

Patients with EOLD discharged home or transferred to another hospital.

Measurements and results

Demographic profile, APACHE IV at 24 h, ICU outcome, type of limitation, disease category, pre-admission functional status, reasons for EOLD, interventions and therapies within 3 days of death, time to EOLD, time to death after EOLD and ICU length of stay. Out of 88 deaths among 830 admissions, 49% were preceded by EOLD. Of these 58% had withholding of treatment, 35% had do-not-resuscitate orders (DNR) and 7% had a withdrawal decision. Mean age and APACHE IV scores were similar between EOLD and FS groups. Functional dependence before hospitalization favored EOLD. Patients receiving EOLD as opposed to FS had longer stays. Fifty-three percent of limitations were decided during the first week of ICU stay well before the time of death. Escalation of therapy within 3 days of death was less frequent in the EOLD group.

Conclusions

Despite societal and legal barriers, half the patients dying in the ICU received a decision to limit therapy mostly as withholding or DNR orders. These decisions evolved early in the course of stay and resulted in significant reduction of therapeutic burdens.     

End-of-life care in the intensive care unit: a challenge for nurses.

Results from several research studies combined with increasing public tensions surrounding physician-assisted suicide have fueled a growing awareness of the inadequacies of end-of-life care. Investigators also suggest that intensive care unit nurses have a limited role in end-of-life decision making and care planning. This article explores cultural issues influencing end-of-life care in intensive care units, explores factors surrounding the limited involvement of critical care nurses in end-of-life decision making and care planning, and offers recommendations for changing nursing practice. Because improving end-of-life care will require cultural changes, an understanding of the cultural issues involved is needed. Recommendations for changing nursing practice include a model of end-of-life care that incorporates the goals of both cure and comfort care, as well as a shared decision-making process. Nurses are essential to improving end-of-life care in today's intensive care units.     

Eligibility for organ donation following end-of-life decisions: a study performed in 43 French intensive care units

Purpose

A persistant shortage of available organs for transplantation has driven French medical authorities to focus on organ retrieval from patients who die following the withdrawal of life-sustaining therapy. This study was designed to assess the theoretical eligibility of patients who have died in French intensive care units (ICUs) after a decision to withhold or withdraw life-sustaining therapy to organ donation.

Methods

This was an observational multi-center study in which data were collected on all consecutive patients admitted to any of the 43 participating ICUs during the study period who qualified for a withholding/withdrawal procedure according to French law. The theoretical organ donor eligibility of the patients once deceased was determined a posteriori according to current medical criteria for graft selection, as well as according to the withholding/withdrawal measures implemented and their impact on the time of death.

Results

A total of 5,589 patients were admitted to the ICU during the study period, of whom 777 (14 %) underwent withholding/withdrawal measures. Of the 557 patients who died following a foreseeable circulatory arrest, 278 (50 %) presented a contraindication ruling out organ retrieval. Of the 279 patients who would have been eligible as organ donors regardless of measures implemented, cardiopulmonary support was withdrawn in only 154 of these patients, 70 of whom died within 120 min of the withdrawal of life-sustaining treatment. Brain-injured patients accounted for 29 % of all patients who qualified for the withholding/withdrawal of treatment, and 57 % of those died within 120 min of the withdrawal/withholding of treatment.

Conclusion

A significant number of patients who died during the study period in French ICUs under withholding/withdrawal conditions would have been eligible for organ donation. Brain-injured patients were more likely to die in circumstances which would have been compatible with such practice.     

End-of-life care for the critically ill: A national intensive care unit survey

OBJECTIVE: One in five Americans dies following treatment in an intensive care unit (ICU), and evidence indicates the need to improve end-of-life care for ICU patients. We conducted this study to elicit the views and experiences of ICU directors regarding barriers to optimal end-of-life care and to identify the type, availability, and perceived benefit of specific strategies that may improve this care. DESIGN: Self-administered mail survey. SETTING: Six hundred intensive care units. PARTICIPANTS: A random, nationally representative sample of nursing and physician directors of 600 adult ICUs in the United States. INTERVENTIONS: Mail survey. MEASUREMENTS AND MAIN RESULTS: We asked participants about barriers to end-of-life care (1 = huge to 5 = not at all a barrier), perceived benefit of strategies to improve end-of-life care, and availability of these strategies. From 468 ICUs (78.0% of sample), 590 ICU directors participated (406 nurses [65.1% response] and 184 physicians [31.7% response]). Respondents had a mean of 16.6 yrs (sd 7.6 yrs) of ICU experience. Important barriers to better end-of-life care included patient/family factors, including unrealistic patient/family expectations 2.5 (1.0), inability of patients to participate in discussions 2.7 (0.9), and lack of advance directives 2.9 (1.0); clinician factors, which included insufficient physician training in communication 2.9 (1.1) and competing demands on physicians' time 3.0 (1.1); and institution/ICU factors, such as suboptimal space for family meetings 3.5 (1.2) and lack of a palliative care service 3.4 (1.2). More than 80% of respondents rated 14 of 14 strategies as likely to improve end-of-life care, including trainee role modeling by experienced clinicians, clinician training in communication and symptom management, regular meetings of senior clinicians with families, bereavement programs, and end-of-life care quality monitoring. However, few of these strategies were widely available. CONCLUSIONS: Intensive care unit directors perceive important barriers to optimal end-of-life care but also universally endorse many practical strategies for quality improvement.