Meeting physicians' responsibilities in providing end-of-life care.

Despite many clinical examples of exemplary end-of-life care, a number of studies highlight significant shortcomings in the quality of end-of-life care that the majority of patients receive. In part, this stems from inconsistencies in training and supporting clinicians in delivering end-of-life care. This review describes the responsibilities of pulmonary and critical care physicians in providing end-of-life care to patients and their families. While many responsibilities are common to all physicians who care for patients with life-limiting illness, some issues are particularly relevant to pulmonary and critical care physicians. These issues include prognostication and decision making about goals of care, challenges and approaches to communicating with patients and their family, the role of interdisciplinary collaboration, principles and practice of withholding and withdrawing life-sustaining measures, and cultural competency in end-of-life care.     

Accuracy of D-dimer:fibrinogen ratio to diagnose pulmonary thromboembolism in patients admitted to intensive care units

Introduction

Pulmonary thromboembolism (PTE) may increase D-dimer and decrease fibrinogen levels. However, in settings such as intensive care units (ICU) and in long-term hospitalised patients, several factors may influence D-dimer and fibrinogen concentrations and make them unreliable indicators for the diagnosis of PTE. The aim of this study was to evaluate the accuracy of D-dimer:fibrinogen ratio (DDFR) for the diagnosis of PTE in ICU patients.

Methods

ICU patients who were suspected of having a first PTE and had no history of using anti-coagulants and contraceptives were included in the study. Levels of D-dimer and fibrinogen were measured for each patient prior to any intervention. Angiography or CT angiography was done in order to establish a definite diagnosis for each patient. Suitable analytical tests were performed to compare means.

Results

Eighty-one patients were included in the study, of whom 41 had PTE and 40 did not. Mean values of D-dimer and fibrinogen were 3.97 ± 3.22 μg/ml and 560.6 ± 197.3 mg/dl, respectively. Significantly higher levels of D-dimer (4.65 ± 3.46 vs 2.25 ± 2.55 μg/ml, p = 0.006) and DDFR (0.913 ± 0.716 vs 483 ± 0.440 × 10^-3, p = 0.003) were seen in PTE patients than in those without PTE. Receiver operating characteristic (ROC) analysis showed a 70.3% sensitivity and 70.1% specificity with a D-dimer value of 2.43 μg/ml (AUC = 0.714, p = 0.002) as the best cut-off point; and a 70.3% sensitivity and 61.6% specificity with a DDFR value of 0.417 × 10^-3 (AUC = 0.710, p = 0.004) as the best cut-off point. In backward stepwise regression analysis, DDRF (OR = 0.72, p = 0.025), gender (OR = 0.76, p = 0.049) and white blood cell count (OR = 1.11, p = 0.373) were modelled (p = 0.029, R² = 0.577).

Conclusion

For diagnosis of PTE, DDFR can be considered to have almost the same importance as D-dimer level. Moreover, it was possible to rule out PTE with only a D-dimer cut-off value < 0.43 mg/dl, without the use of DDFR. However, these values cannot be used as a replacement for angiography or CT angiography     

Impact of daily bathing with chlorhexidine gluconate on ventilator associated pneumonia in intensive care units: a meta-analysis

Objective

Ventilator associated pneumonia (VAP) is the most important nosocomial infection in intensive care units (ICUs). Our objective was to assess whether daily bathing with chlorhexidine gluconate (CHG) would significantly result in the reduction of VAP.

Materials and methods

Meta-analysis of randomized controlled trials (RCTs) and quasi-experimental studies were conducted. The setting are medical, surgical, trauma, and combined medical-surgical ICUs. The patients are adult. We searched electronic search engine (PubMed), Embase and the Cochrane Central Register database for all published studies related to the application of daily CHG bathing with VAP risk.

Results

In all, six articles reporting a total of 27,638 ventilator-days met the inclusion criteria; 132 patients in the CHG arm developed a VAP (13,349 ventilator-days), compared with 188 patients in the control arm (14,289 ventilator-days). Daily bathing with CHG was significantly associated with decreased incidence risk of VAP [relative risk (RR): 0.73, 95% confidence interval (CI): 0.57-0.92, I²=0%]. In the subgroup analysis, we found that daily bathing with 2% CHG impregnated cloths or wipes would reduce the incidence risk of VAP among before-and-after studies (pooled RR: 0.73, 95% CI: 0.57-0.93).

Conclusions

The application of daily bathing with CHG would decrease incidence risk of VAP, which would be an important complementary intervention to barrier precautions.     

Abdominal compartment syndrome:Often overlooked conditions in medical intensive care units

Intra-abdominal hypertension(IAH)and abdominal compartment syndrome are well recognized entities among surgical patients.Nevertheless,a number of prospective and retrospective observational studies have shown that IAH is prevalent in about half of the critically ill patients in the medical intensive care units(ICU)and has been widely recognized as an independent risk factor for mortality.It is alarming to note that many members of the critical care team in medical ICU are not aware of the consequences of untreated IAH and the delay in making the diagnosis leads to increased morbidity and mortality.Frequently it is underdiagnosed and undertreated in this patient population.Elevated intraabdominal pressure decreases the blood flow to the kidneys and other abdominal viscera and also results in reduced cardiac output and difficulties in ventilating the patient because of increased intrathoracic pressure.When intraabdominal hypertension is not promptly recognized and treated,it leads to abdominal compartment syndrome,multiorgan dysfunction syndrome and death.Large volume fluid resuscitation is very common in medical ICU patients presenting with sepsis,shock and other inflammatory conditions like pancreatitis and it is one of the major risk factors for the development of intra-abdominal hypertension.This article presents an overview of the epidemiology,definitions,risk factors,pathophysiology and management of IAH and abdominal compartment syndrome in critically ill medical ICU patients.     

Family involvement in end-of-life hospital care

OBJECTIVES: To examine whether the end-of-life treatment provided to hospitalized patients differed for those who had a family member present at death and those who did not. DESIGN: A retrospective cohort analysis. SETTING: An urban community hospital. PARTICIPANTS: All 370 inpatients who died during a 1-year period. MEASUREMENTS: Medical records were examined for whether life-support treatments were provided or withdrawn, occurrence and timing of do-not-resuscitate (DNR) orders, and use of comfort measures such as narcotics and sedation. RESULTS: DNR orders were written for 85% of patients. For patients who had a DNR order written, the average time from the DNR order to death was 4.8 days. Only 26% of patients had one or more treatments withdrawn. Sixty-seven percent of patients received narcotics before death, and 22% received sedatives. Patients aged 75 and older and African Americans were less likely to have a family member present at death. After adjusting for age and ethnicity, patients who had a family member present at death were more likely to have DNR orders written, to have treatments withdrawn, and to receive narcotics before death. Patients with a family member present at death also had a shorter time to death after DNR orders were written. CONCLUSION: The presence of a family member at death appears to be an indirect measure of family involvement during patients' hospitalization. Family involvement before death may reduce the use of technology and increase the use of comfort care as patients die.     

Experience with intubated patients does not affect the accidental extubation rate in pediatric intensive care units and intensive care nurseries

Accidental extubation is a potentially serious event for pediatric or neonatal patients with respiratory failure, especially in clinical settings in which personnel capable of performing reintubation may not be readily available. Thus the rate of accidental extubation in small intensive care units that operate without 24-hour in-house physician availability may be an important quality assurance indicator. The objectives of this study were to determine the accidental extubation rate at a single small pediatric intensive care unit (PICU) and compare it with published reports. This study was carried out in a six-bed PICU at Washoe Medical Center in Reno, Nevada, with a relatively low level of patient acuity, as measured by PRISM score and the frequency of intubation, and without 24-hour in-house physician availability. All intubated patients admitted during the 5-year period from January 1, 1989 to December 31, 1993 were included. The primary outcome measure was the occurrence of accidental extubation. We observed only two accidental extubations in 1,749 intubated-patient-days (IPD) (0.114 accidental extubations/100 IPD [95% confidence interval 0.014–0.413 accidental extubations/100 IPD]). This rate of accidental extubation was compared with data in published reports from neonatal intensive care units (NICUs) and PICUs, which ranged from 0.14 accidental extubations/100 IPD to 4.36 accidental extubations/100 IPD. The dependence of the observed accidental extubation rate on unit size and institutional experience with intubated patients, as measured by the average number of intubated patients, was examined. We found no evidence that the accidental extubation rate is higher in smaller units or units with less institutional experience. Low rates can be achieved in small units with low acuity. Pediatr. Pulmonol. 1997; 23:424–428. © 1997 Wiley-Liss, Inc.     

Computerized physician order entry with clinical decision support in long-term care facilities: costs and benefits to stakeholders

Nursing homes are the setting of care for growing numbers of our nation's older people, and adverse drug events are an increasingly recognized safety and quality concern in this population. Health information technology, including computerized physician/provider order entry (CPOE) with clinical decision support (CDS), has been proposed as an important systems-based approach for reducing medication errors and preventable drug-related injuries. This article describes the costs and benefits of CPOE with CDS for the various stakeholders involved in long-term care (LTC), including nurses, physicians, the pharmacy, the laboratory, the payer (e.g., the insurer), nursing home residents, and the LTC facility. Critical barriers to adoption of these systems are discussed, primarily from an economic perspective. The analysis suggests that multiple stakeholders will incur the costs related to implementation of CPOE with CDS in the LTC setting, but the costs incurred by each may not be aligned with the benefits, which may present a major barrier to broad adoption. Physicians and LTC facilities are likely to bear a large burden of the costs, whereas residents and payers will enjoy a large portion of the benefits. Consideration of these costs and benefits suggests that financial incentives to physicians and facilities may be necessary to encourage and accelerate widespread use of these systems in the LTC setting.     

End of life in the intensive care unit: knowledge and practice of clinicians from Karachi, Pakistan

Background:  With improvements in the care of critically ill, physicians are faced with obligations to provide quality end-of-life care. Barriers to this include inadequate understanding of the dying patient and withdrawal or limitation of care. The objectives of this study were to document the comprehensions of physicians and nurses regarding the recognition and practice of end-of-life care for critically ill patients placed on life support in the intensive care unit.
Methods:  This was a cross-sectional study carried out at three hospitals in Karachi. Chi-squared analysis and one-way anova were used to compare differences in response between the groups.
Results:  One hundred and thirty-seven physicians and critical care nurses completed the survey. 'Brain death' was defined as an ' irreversible cessation of brainstem function' by 85% respondents, with 50% relying on specialty consultation. Withdrawal of life support is practised by 83.2%; physicians are more likely (Chi square test P -value < 0.001) to withdraw mechanical ventilation, compared with nurses who would withdraw vasopressors ( P -value 0.006). In a do not resuscitate patient, 72.3% use vasopressors, 83% initiate haemodialysis and 17.5% use non-invasive ventilation; 72.6% consult Hospital Ethics Committees; 16% respondents never withdraw life support; 28.3% considered it their responsibility to 'sustain life at all costs' and only 8% gave religious beliefs as a reason.
Conclusions:  There are confusions in the definition of brain death, end-of-life recognition and indications and processes of withdrawal of life support. There are discrepancies between physicians' and nurses' perceptions and attitudes. Clearly, teaching programmes will need to incorporate cultural and religious differences in their ethics curricula.     

Old patients in intensive care unit (ICU): What decisions to make?

This report is aimed at identifying and suggesting a decision-making approach to handle old patients in ICUs in the light of current epidemiological findings and literature. We reviewed the data provided by the GIVITI network on 107,459 patients admitted to 150 Italian ICUs between 2000 and 2005; patients were divided into age groups (18–65 years: group I; 66–75 years: group II; 76–85 years: group III; ≥85 years: group IV). Comorbidities were recorded on admission in all groups [I (62.2%), II (92.2%), III (94.9%) and IV (94.5%), respectively]. Therapeutic means were virtually applied in the same way to all groups under examination [I (82.1%), II (83.9%), III (85.9%) and IV (83.5%), respectively]. Mortality in ICU was higher in group IV (27.2%), followed by groups III (24.3%), II (19.1%) and I (13.2%). The multivariate logistic regression analysis of GIVITI and some reviewed studies suggest that age is an independent mortality factor; however, current literature is controversial. The choice of admitting and treating old patients in ICUs should result from a balance between clinical and ethical factors.     

Medical specialists prefer to withdraw familiar technologies when discontinuing life support

OBJECTIVE: To assess how members of different specialties vary in their decisions about which form of life support to withdraw. The hypothesis was that each specialty would be more comfortable withdrawing its “own” form of life support relative to other forms and other specialties. DESIGN: Mail survey. SETTING: 24 medical centers. PARTICIPANTS: 225 specialists in six specialties and 225 comparison physicians randomly matched according to percentage of time devoted to clinical practice. MEASUREMENTS: The six specialties were linked with six life-sustaining technologies related to their special expertise: 1) pulmonologists with mechanical ventilation, 2) nephrologists with hemodialysis, 3) gastroenterologists with tube feedings, 4) hematologists with blood products, 5) cardiologists with intravenous vasopressors, and 6) infectious disease specialists with antibiotics. The subjects ranked different forms of life support in the order in which they would prefer to withdraw them. They also expressed their preferences in response to hypothetical clinical vignettes. RESULTS: In five of the six specialties, the specialists had a relative preference for withdrawing their “own” form of life support, compared with the preferences of the comparison physicians. Overall, the physicians tended to prefer withdrawing a form of life support closely linked with their own specialty. CONCLUSIONS: Just as some specialist physicians tend to reach for different technologies first in treating patients, they also tend to reach for different technologies first when ceasing treatment. Specialists’ preferences for different ways to withdraw life support not only may reflect a special understanding of the limits of certain technologies, but also may reveal how ingrained are physicians’ patterns of practice. Supported by the John A. Hartford Foundation, by the Robert Wood Johnson Foundation, and by a Biomedical Research Support Grant from the National Institutes of Health (DAA and NAC). Dr. Christakis was the recipient of a NRSA Fellowship from the Agency for Health Care Policy and Research. Dr. Asch was the recipient of a Health Services Research Career Development Award from the Department of Veterans Affairs. The opinions and conclusions are those of the authors and do not necessarily represent those of the funding agencies. This work was conducted at the University of Pennsylvania.     

Impediments to applying the ‘dignity of risk’ principle in residential aged care services

This discussion paper identifies four core factors currently impeding the application of the dignity of risk principle in residential aged care settings in Victoria, Australia: the fluctuating decision‐making ability of residents; multiple participants in decision‐making; discordance between espoused values and actions; and confusion and fear around legal responsibilities of care providers. Potential solutions identified include a conceptual shift in approach and consensus between key stakeholders, as well as more tangible solutions such as education and point‐of‐care decision support tools.