Increased nonbeneficial care in patients spending their birthday in the ICU

Objective

End-of-life decisions are based on objective and subjective criteria. Previous studies identified substantial subjective biases during end-of-life decision-making. We evaluated whether in-ICU patient’s birthday influenced management decisions.

Design

We used a case–control design in which patients spending their birthday in the ICU (cases) were matched to controls on center, gender, age, severity, type of admission, and length of ICU stay before birthday.

Setting

12 ICUs in French hospitals.

Patients

The cases and controls were patients with ICU admissions >48?h over a 10-year period.

Interventions

None.

Measurements and main results

Compared with the 1,042 controls, the 223 cases were more often trauma patients and received a larger number and longer durations of life-sustaining interventions. This increased intensity of life support occurred after, but not before, the birthday. The cases had longer ICU stay lengths. ICU and hospital mortality were not different between the two groups. End-of-life decisions were made in 22% and 24% of cases and controls, respectively. However, these decisions were made later in the cases than in the controls (18 [5–33] versus 9 [3–19]?days).

Conclusions

Our finding that patients who spent their birthday in the ICU received a higher intensity of life-sustaining care and had longer ICU stays but did not have significantly different mortality rates compared with the controls suggests the use of nonbeneficial interventions. Staff members caring for patients whose birthdays fall during the ICU stay should be aware that this feature can bias end-of-life decisions, leading to an inappropriate level of care.     

beta-arrestin 2 oligomerization controls the Mdm2-dependent inhibition of p53

β-arrestins (β-arrs), two ubiquitous proteins involved in serpentine heptahelical receptor regulation and signaling, form constitutive homo- and heterooligomers stabilized by inositol 1,2,3,4,5,6-hexakisphosphate (IP6). Monomeric β-arrs are believed to interact with receptors after agonist activation, and therefore, β-arr oligomers have been proposed to represent a resting biologically inactive state. In contrast to this, we report here that the interaction with and subsequent titration out of the nucleus of the protooncogene Mdm2 specifically require β-arr2 oligomers together with the previously characterized nucleocytoplasmic shuttling of β-arr2. Mutation of the IP6-binding sites impair oligomerization, reduce interaction with Mdm2, and inhibit p53-dependent antiproliferative effects of β-arr2, whereas the competence for receptor regulation and signaling is maintained. These observations suggest that the intracellular concentration of β-arr2 oligomers might control cell survival and proliferation.