Futile Treatment Research Articles

Survival penalty in patients undergoing transcatheter versus surgical aortic valve replacement: is it just a question of frailty? Insights from a large cohort with demographic matching

Abstract Background Transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) are the reference treatments for aortic stenosis. Conflicting data exist on late survival results of these two techniques. While randomised controlled trials (with highly selected patients) assert the non-inferiority of TAVR, real-world data from large registries (with potential uncorrected confounders) suggest the opposite. Comparing the survival rates of SAVR and TAVR with those of a matched reference population could help circumvent potential biases of direct procedural comparisons and quantify the impact of frailty on post-operative survival. Purpose Our study aims to compare the 5-year overall survival rates of SAVR, non-frail TAVR, and frail TAVR patients with the survival of their demographically matched reference population. Methods This study included all consecutive patients undergoing either SAVR or TAVR at a tertiary hospital between January 2010 and December 2021. Each patient underwent a comprehensive geriatric assessment by an experienced geriatric team, from which a Clinical Frailty Scale (CFS) was derived using a validated classification tree. Frailty was defined as a CFS ≥ 6, in accordance with ESC guidelines. The patients were stratified into 3 subgroups: SAVR, non-frail TAVR, and frail TAVR patients. For each subgroup, a corresponding reference population was generated using national actuarial tables to ensure individual-level matching based on age, gender, and year of observation. Survival of each subgroup was then compared to its corresponding reference population over a 5-year period using standardized mortality ratios (SMR) and one-sample logrank tests. Results Our cohort included 1183 SAVR, 254 non-frail TAVR, and 151 frail TAVR patients, with mean ages of 74.1, 85.4, and 85.7 years, and median EuroSCORE II of 2.0%, 4.2%, and 5.4%, respectively. Survival of SAVR patients was equivalent to the reference population (80.1 vs 80.9% survival; SMR = 1.06 [0.89 – 1.25]; p = 0.454; Figure 1A). Similarly, non-frail TAVR patients also achieved survival rates comparable to those of the reference population (50.9 vs 54.0% survival; SMR = 0.94 [0.76 – 1.18]; p = 0.549; Figure 1B). However, frail TAVR patients faced a significantly reduced survival rate (41.7% vs 54.0% survival; SMR = 1.48 [1.15 – 1.90]; p < 0.001; Figure 1C). The frailty of this subgroup could therefore explain a 48% increase in mortality risk compared with their reference population after 5 years. Conclusions Treating non-frail patients with aortic stenosis through TAVR or SAVR restores life expectancy to levels comparable with their reference population, challenging results from other real-world registries. In contrast, TAVR in frail patients is associated with worse survival, raising the question of treatment futility in this specific subgroup. Refining the selection of frail patients who may benefit from TAVR remains an important clinical challenge.

Fertility treatment when the prognosis is very poor or futile: an Ethics Committee opinion

The Ethics Committee recommends that invitro fertilization centers develop patient-centered policies regarding requests for futile treatment. In most cases, clear communication can avoid a direct confiict, but clinicians ethically may refuse to provide treatment believed to be futile or to carry a very poor prognosis. In certain instances, clinicians may provide limited treatment, which they judge likely to be futile, but must be vigilant in their presentation of risks, benefits, and alternatives. This version replaces the previously published draft of this name last published in 2019.

Treatment Escalation Plans: A Snapshot Review on Acute Medical Wards

Abstract Background In medical care, Do Not Attempt Cardiopulmonary Resuscitation (DNA CPR) orders serve as vital tools in determining whether CPR should be administered to patients, particularly those with progressive life-limiting illnesses or approaching the end of life. Failure to make timely and appropriate CPR-related decisions and treatment escalation plans can lead to the risk of administering futile or inappropriate treatments. Methods Admission booklets in our centre prompt clinicians to indicate whether a patient was for CPR or not as part of the admission process, with further instructions to fill out a DNA CPR form if applicable. We conducted a chart review on acute medical wards to assess the frequency and adequacy of DNA CPR decision-making and communication. Data was collected by three investigators on a structured proforma and anonymised. Data analysis was conducted using Excel. Results Data was collected on 67 patients, with a mean age of 76.6. Of those 67, only six had CPR status indicated on admission, with five specified for resuscitation and one not for resuscitation. A total of 14 patients went on to have DNA CPR forms filled out during admission, but in only five cases were these decisions discussed with the patients themselves. The main reasons for lack of patient involvement in the discussions included confusion and cognitive impairment. Documentation regarding discussions with next of kin was present in eight cases. Conclusion Our snapshot review underscores the importance of early discussions regarding treatment escalation plans and DNA CPR decisions. Our findings reveal that these discussions are not occurring as frequently as advised, and when decisions are made, they are not adequately communicated with patients or those close to them. There is an urgent need for further training on the legal aspects and ethical considerations surrounding DNA CPR decisions to ensure better patient-centered care and decision-making.

Futile therapeutic nursing interventions in adult intensive care: A descriptive study.

Background: Despite the progress made in recent decades on the phenomenon of futility in adult intensive care, recognizing it during clinical care practice remains a complex and sensitive process, during which questions are often raised for which concrete answers are difficult to find. Aims: To analyze the frequency with which futile nursing interventions are implemented in critically ill patients admitted to adult intensive care in specific situations and how often futile autonomous and interdependent nursing interventions are implemented in the same population, as perceived by adult intensive care nurses. Research design: Cross-sectional, quantitative, and descriptive study, which employed a questionnaire constructed specifically for this research to assess the perception of therapeutic futility in nursing in adult intensive care. Following an evaluation of the psychometric properties, the questionnaire was made available in an electronic format on the EUSurvey platform between August and October 2024. The data was analyzed between November 2023 and March 2024 using the statistical software packages SPSS and R. Participants and research context: A simple random sample of nurses working in level II and level III intensive care units in Portugal. Ethical considerations: Research ethical approvals were obtained, and the participants provided informed consent. Findings/results: Four hundred and fourteen valid questionnaires were obtained. The results allow the identification of thirty-three statistically significant associations, the inference of intervals for the mean and median for the perception of futility of nursing interventions with a 95% confidence interval, and enable the hierarchization of nursing interventions implemented in critically ill patients admitted to adult intensive care units according to the nurses' perception of their futility. Conclusion: There is a balance in nurses' perception of the futility of their interventions in the specific situations analyzed. There is statistically significant evidence that interdependent nursing interventions are, in general, more frequently perceived as futile when compared to autonomous nursing interventions.

Intensive care unit cardiac arrest among very elderly critically ill patients – is cardiopulmonary resuscitation justified?

IntroductionThe proportion of very elderly patients in the intensive care unit (ICU) is expected to rise. Furthermore, patients are likely more prone to suffer a cardiac arrest (CA) event within the ICU. The occurrence of intensive care unit cardiac arrest (ICU-CA) is associated with high mortality. To date, the incidence of ICU-CA and its clinical impact on outcome in the very old (≥ 90 years) patients treated is unknown.MethodsRetrospective analysis of all consecutive critically ill patients ≥ 90 years admitted to the ICU of a tertiary care university hospital in Hamburg (Germany). All patients suffering ICU-CA were included and CA characteristics and functional outcome was assessed. Clinical course and outcome were assessed and compared between the subgroups of patients with and without ICU-CA.Results1,108 critically ill patients aged ≥ 90 years were admitted during the study period. The median age was 92.3 (91.0–94.2) years and 67% (n = 747) were female. 2% (n = 25) of this cohort suffered ICU-CA after a median duration 0.5 (0.2–3.2) days of ICU admission. The presumed cause of ICU-CA was cardiac in 64% (n = 16). The median resuscitation time was 10 (2–15) minutes and the initial rhythm was shockable in 20% (n = 5). Return of spontaneous circulation (ROSC) could be achieved in 68% (n = 17). The cause of ICU admission was primarily medical in the total cohort (ICU-CA: 48% vs. No ICU-CA: 34%, p = 0.13), surgical - planned (ICU-CA: 32% vs. No ICU-CA: 37%, p = 0.61) and surgical - unplanned/emergency (ICU-CA: 43% vs. No ICU-CA: 28%, p = 0.34). The median Charlson Comorbidity Index (CCI) was 2 (1–3) points for patients with ICU-CA and 1 (0–2) for patients without ICU-CA (p = 0.54). Patients with ICU-CA had a higher disease severity according to SAPS II (ICU-CA: 54 vs. No ICU-CA: 36 points, p < 0.001). Patients with ICU-CA had a higher rate of mechanically ventilation (ICU-CA: 64% vs. No ICU-CA: 34%, p < 0.01) and required vasopressor therapy more often (ICU-CA: 88% vs. No ICU-CA: 41%, p < 0.001). The ICU and in-hospital mortality was 88% (n = 22) and 100% (n = 25) in patients with ICU-CA compared to 17% (n = 179) and 28% (n = 306) in patients without ICU-CA. The mortality rate for patients with ICU-CA was observed to be 88% (n = 22) in the ICU and 100% (n = 25) in-hospital. In contrast, patients without ICU-CA had an in-ICU mortality rate of 17% (n = 179) and an in-hospital mortality rate of 28% (n = 306) (both p < 0.001).ConclusionThe occurrence of ICU-CA in very elderly patients is rare but associated with high mortality. Providing CPR in this cohort did not lead to long-term survival at our centre. Very elderly patients admitted to the ICU likely benefit from supportive care only and should probably not be resuscitated due to poor chance of survival and ethical considerations. Providing personalized assurances that care will remain appropriate and in accordance with the patient’s and family’s wishes can optimise compassionate care while avoiding futile life-sustaining interventions.

Withdrawal/Withholding of Life-Sustaining Therapies: Limitation of Therapeutic Effort in the Intensive Care Unit.

Background/Objectives: The change in critically ill patients makes limitation of therapeutic effort (LTE) a widespread practice when therapeutic goals cannot be achieved. We aimed to describe the application of LTE in a post-surgical Intensive Care Unit (ICU), analyze the measures used, the characteristics of the patients, and their evolution. Methods: Retrospective observational study, including all patients to whom LTE was applied in a postsurgical ICU between January 2021 and December 2022. The LTE defined were brain death, withdrawal of measures, and withholding. Withholding limitations included orders for no cardiopulmonary resuscitation, no orotracheal intubation, no reintubation, no tracheostomy, no renal replacement therapies, and no vasoactive support. Patient and ICU admission data were related to the applied LTE. Results: Of the 2056 admitted, LTE protocols were applied to 106 patients. The prevalence of LTE in the ICU was 5.1%. Data were analyzed in 80 patients. A total of 91.2% of patients had been admitted in an emergency situation, and 56.2% had been admitted after surgery. The most widespread limitation was treatment withholding (83.8%) compared to withdrawal (13.8%). No differences were found regarding who made the decision and the type of limitation employed. However, patients with the limitation of no intubation had a longer stay (p = 0.025). Additionally, the order of not starting or increasing vasopressor support resulted in a longer hospital stay (p = 0.007) and a significantly longer stay until death (p = 0.044). Conclusions: LTE is a frequent measure in critically ill patient management and is less common in the postoperative setting. The most widespread measure was withholding, with the do-not-resuscitate order being the most common. The decision was made mainly by the medical team and the family, respecting the wishes of the patients. A joint patient-centered approach should be made in these decisions to avoid futile treatment and ensure end-of-life comfort.

Racial disparities in end-of-life suffering within surgical intensive care units

BackgroundEnd-of-life (EOL) care is associated with high resource utilization. Recognizing and effectively communicating that EOL is near promotes more patient-centered care, while decreasing futile interventions. We hypothesize that provider assessment...

Navigating Improper Care Settings: Nurses' Experiences Assisting Oncological Patients at the End of Life in Surgical Departments.

Despite the growing preference for end-of-life care at home, numerous oncological patients continue to spend their final moments in surgical wards. This incongruity in settings may contribute to "dysthanasia," unnecessarily prolonging futile treatments and resulting in undue suffering. As frontline caregivers, nurses frequently bear the brunt of these challenging situations for patients and their families. To investigate the experiences of nurses providing care to terminally ill oncological patients inappropriately admitted to surgical departments. We adopted a phenomenological descriptive study. Nurses purposefully selected from 7 distinct surgical units at a University Hospital in Northeast Italy were recruited. Data collection took place through open-ended semistructured interviews. The interview content was analyzed using Colaizzi's framework. The study with 26 participants revealed emotional challenges, especially for less-experienced nurses. Diverse perspectives among nurses emphasized the need for better palliative care knowledge. Despite the commitment to quality care, collaboration challenges and discordant goals with physicians impacted comprehensive care delivery. Dysthanasia relates to participants' challenges in caring for oncological patients in inappropriate settings, hindering transparent communication and exacerbating discordance with doctors. Communication and collaboration among healthcare professionals, particularly nurses, and surgeons are crucial. Ongoing education in end-of-life care, coupled with advance care planning, empowers patients, aligns treatment choices, and prevents dysthanasia across diverse healthcare settings.

End of Life Care Practices at a Tertiary Cancer Centre in India: An Observational Study.

To assess the End of life care (EOLC ) practices and the magnitude of futile care in a tertiary cancer center. To find out the barriers in provision of good EOLC in cancer patients. An observational study was done on 129 patients. Patients were enrolled using the palliative prognostic index (PPI) in the end of life stages. Socio-demographic and clinical details were recorded. Detailed counselling done by the palliative physician or the oncologist was recorded. The barriers in provision of care were recorded. In this study initial experience of 129 patients were analyzed. PPI score was >6 (survival shorter than 3 weeks) in 85 (65.89%) ; 34 (26.36%) had PPI score between >4 to 6 (survival between 3 to 6 weeks); and 10 (7.75%) patients had PPI score less than equal to 4( survival more than 6 weeks).77 (59.69%) patients preferred home as their place for EOLC while 41(31.78%) preferred hospital, 7 (5.43%) preferred hospice while 4 (3.10%) opted ICU for their EOLC . The most common barrier associated was caregiver related in 34 case, followed by physician related in 14 cases and patients related in 3 cases, because of hope of being cured in hospital, social stigma, fear of worsening of symptoms at home, denial. EOLC is the least studied part of patient care with various barriers. With proper communication and a good palliative care support, futile treatment can be avoided. With healthy communication we can empower family members and patients for a good EOLC.

Recognizing and acknowledging end-of-life for patients with cancer - a balancing act. A qualitative study of doctors' and nurses' experiences

PurposeDoctors and nurses are central in the challenging task of end-of-life (EOL) care, and this study aims to explore and describe doctors' and nurses' experiences of recognition and acknowledgment of the end of life for patients with cancer. MethodsA qualitative, explorative research design with individual interviews was carried out based on a semi-open interview guide. A total of 6 doctors and 6 nurses working in medical or surgical departments at a Norwegian University hospital were interviewed. The interviews were analyzed using qualitative content analysis. ResultsThe study’s findings highlight that recognizing and acknowledging patients with cancer as being at end-of-life is a challenging process. Three subthemes emerged from the analysis; the significance of being experienced, the significance of organizational structures, and the significance of having a common understanding. A main theme was analyzed further and abstracted from the subthemes; Being safe to manage the balancing act of recognizing and acknowledging the end of life. ConclusionsMuch is at stake in the EOL setting, and healthcare professionals (HCP) must balance several aspects regarding EOL decisions. Striking the right balance in these situations is challenging. HCPs need a safety net through collaboration with, and support from, colleagues, supporting organizational structures and experience. Strengthening the safety net will have a clear impact on improving clinical practice to reduce futile treatment and provide high-quality EOL care for all dying patients in hospitals.

When Life-Supporting Interventions Lead to Moral Distress.

Moral distress can impact nurses and the care team significantly. A profession dedicated to the principles of caring and compassion is often subjected to patients receiving futile treatment. With the proliferation of extreme life-prolonging measures come the difficulties in the withdrawal of those medical modalities. If a prognosis is poor and care is perceived as curative rather than palliative, providers may often feel conflicted and distressed by their interventions. The American Association of Colleges of Nursing has expressed growing concern about an increase in the use of inappropriate life-support treatments related to futile care. The compelling case of a severely beaten 69-year-old homeless man who had cardiac-arrested and was resuscitated after an unknown amount of down-time, provides the contextual framework for this report. Ethical conflicts can become very challenging, which inevitably increases the suffering of the patient and their caregivers. Research findings suggest that health care organizations can benefit from enacting processes that make ethical considerations an early and routine part of everyday clinical practice. A proactive approach to ethical conflicts may improve patient care outcomes and decrease moral distress.

HER2/neu in head and neck cancers: A worthy target or not?

e18022 Background: Head and neck cancers (HNC) account for a major public health problem across the globe, more so in India where it ranks as the second most common cancer. Most cases involve oral cavity due to use of chewable tobacco products and more than 65% present in locally advanced stage. It thus becomes imperative to continuously look for newer, more advanced targets and treatment modalities. One such target we sought to evaluate was HER2/neu, which has been successfully used for treatment in different tumors showing HER2/neu amplification from breast cancers to Gastric cancers and others, significantly improving survival outcomes. Further, with the development of Trastuzumab Deruxtecan now being evaluated as a tumor agnostic antibody for cancers showing even low levels of HER2/neu expression, we attempted to assess the incidence of HER2/neu expression (including HER2 low) in 50 cases of HNC using Immunohistochemistry (IHC) and Fluorescence In Situ Hybridization (FISH) with an aim to evaluate the utility vs futility, of treatment with Anti-HER2 antibody. Methods: Retrospective analysis was done in 50 recent cases of HNC diagnosed at Global Reference Laboratory, Agilus Diagnostics and they were evaluated for HER2/neu expression by IHC using the FDA approved Ventana clone. The study design was akin in most aspects to HER2/neu analysis in breast cancer, in which, on IHC, Score 3+ was considered positive and Score 0 was considered negative, both of which not warranting subsequent FISH analysis. Score 2+ on IHC was considered equivocal and thus subjected to FISH for confirmation. Positive cases in this category would be considered positive while negative cases would be considered negative but analyzed for appropriate group and kept in a separate category of HER2/neu low for analysis and future reference. Score 1+ though considered negative was also subjected to FISH to analyze copy numbers and HER2/CEP17 ratio and these cases were also clubbed separately in HER2/neu low group for analysis and future reference. Results: In 50 cases analyzed, none tested positive (Score 3+) for HER2/neu on IHC. Two cases showed equivocal staining while six cases showed Score 1+. Both equivocal cases tested negative on FISH and fell in Group 5 as per the latest 2023 guideline update. Of the six cases which showed Score 1+ on IHC, four cases fell in Group 5 while two showed Group 4 pattern. Thus, none of the cases were positive for HER2/neu as per the recent guidelines, while 8 cases fell under the category of HER2/neu low expression by definition. Conclusions: This study is in concordance with extremely low HER2 expression documented in HNC implying the futility of treatment with current Anti- HER2 antibodies. However, 16% cases showing HER2/neu low expression definitely make it prudent to do clinical studies assessing the utility of Trastuzumab Deruxtecan and similar antibody drug conjugates in this setting just like other tumor types where numerous studies are already undergoing at the moment.

#2045 Epigenetic data can predict initial treatment response in nephrotic syndrome

Abstract Background and Aims The majority of children with idiopathic nephrotic syndrome (INS) and adults with Focal Segmental Glomerulosclerosis (FSGS) and Minimal Change Disease (MCD) receive glucocorticoid treatment at diagnosis. Only those with a high likelihood of having monogenic disease or a contraindication to steroids might avoid this treatment. About 10% overall will not respond to steroids and we have no reliable way of prospectively identifying these patients. Therefore, some patients will receive a futile treatment which is accompanied by significant side effects. DNA methylation (DNAm) is an epigenetic mechanism meaning that it can induce stable but reversible changes in gene expression without any change in underlying DNA sequence. DNAm has shown great potential as a treatment stratification tool, for example, DNAm data is used in oncology to identify which patients are likely to benefit from alkylating chemotherapy. We investigated whether DNAm can predict initial response to steroids in children and young adults with nephrotic syndrome. Method Three hundred and seventeen patients with INS were selected from the NephroS and NURTuRE cohorts. All patients were diagnosed with INS ≤ 30 years of age and those who underwent a renal biopsy had a histological diagnosis of either FSGS or MCD. Peripheral blood DNAm measurements were generated using the Illumina MethylationEPIC Beadchip (&amp;gt;850, 000 CpG sites). Clinical data was used to label patients by their initial response to steroids (sensitive, n = 156, or resistant, n = 161). Machine learning models were created to predict steroid response from the DNAm data. Models were generated using elastic net following feature filtering, and model hyperparameters were tuned and performance measured within the context of cross validation. To exclude whether cumulative steroid exposure prior to sample collection had impacted our results, the CpG sites in the final model were compared to those identified in a published study examining steroid exposure and DNAm (4). Results The 317 INS patients had a median age at diagnosis of 5 years (IQR 2-10) and a median time between diagnosis and DNAm sample collection of 4 years (IQR 1-10). The steroid resistant group were made up of patients with known monogenic disease (n = 75, 24%) and those without pathogenic variants (n = 86, 27%). Initial response to steroid treatment could be predicted with 65% accuracy and an area under the curve (AUC) of 0.75, (sensitivity 0.65, specificity of 0.66, see Fig. 1) using DNAm levels at 14 CpG sites. There was no overlap between the 14 CpG sites in our prediction model and those that are known to alter with steroid treatment. Conclusion We have demonstrated that peripheral blood cell DNAm profiles are a promising predictor of steroid response in INS. Further work to incorporate genetic data into the prediction models is underway and external validation of the results in a separate cohort of patients is required.

#1563 Family feedback survey on quality of dialysis withdrawal and end-of-life care on hemodialysis patients in an ICU – a single-center study from India

Abstract Background and Aims End-of-life care in hemodialysis is emerging, with limited implementation in developing countries. There is a sparsity of data on dialysis withdrawal and the quality of end-of-life care in these regions. Developing countries differ in their cultural, social, and spiritual practice compared to the Western world and family plays a major role in decision-making. No survey has been done on family's perception of dialysis withdrawal and end-of-life care in our settings. So, we studied feedback from families regarding the quality of dialysis withdrawal and end-of-life care provided to maintenance hemodialysis (MHD) patients admitted to our intensive care unit (ICU). Method This study was conducted at Kasturba Medical College, Manipal, MAHE, Manipal, India between January 2020 to October 2022 involving the data from end-stage kidney disease (ESKD) patients on MHD admitted in the ICU, who had withdrawn from dialysis before death and received end-of-life care as per the hospital policy (Blue Maple) from Renal supportive and Palliative care team. The baseline data was collected for all patients and indications for withdrawal of dialysis and ICU treatment and end-of-life care provided were collected. The next of kin were interviewed by telephone by a single interviewer using a modified Quality of Death and Dying questionnaire. The data was analyzed using SPSS 20 Results Among 98 ESKD patients on maintenance hemodialysis who died in our ICU, 23 were referred to Palliative care, counselled, had withdrawal of dialysis at least 48 hours before death and received end-of-life care. Table 1 outlines baseline characteristics. The mean age was 57 ± 12.09 years, with a male predominance (82.6%). Common comorbidities included hypertension (100%), type 2 diabetes (69.5%), and ischemic heart disease (65.2%). The primary cause for ICU admission was infectious disease (47.8%). The majority of reasons for dialysis withdrawal and end-of-life care were worsening hemodynamic status (82.6%) and illness deterioration (69.5%). After consent and establishment of futility, dialysis withdrawal was done for all patients (100%), No CPR for 100%, withdrawal of inotropes in 50%, and withdrawal of ventilator was done in 80% of the patients. A successful telephonic interview/survey was conducted with 21 out of the 23 subjects, with the majority of next of kin being the spouse (47.6%) followed by children (33.3%) and siblings (14.3%). The questionnaire and response are given in Table 2. All expressed a need for palliative care involvement. 82% accepted the decision of dialysis withdrawal and end-of-life care put forth by the doctor's team without difficulty;74% of families were present with the patient in their final hours and were grateful for the same 20% had their spiritual leader to visit during the end-of-life event. None of the family members (100%) interviewed had a guilty feeling and all had a positive rating on the involvement of the palliative care team and the need to ease patients' distress and suffering during their final hours (100%). Unfortunately, none of the patients had prior discussions of advance care planning (ACP) with their doctors regarding end-of-life care before the specific event Conclusion Our study highlights that families agree with the withdrawal of artificial life support measures, such as MHD, CPR, withdrawal of inotropes, and/withdrawal of ventilator in ICU settings when these interventions are considered futile for end-of-life care in ESKD patients. It also emphasizes the need for ACP, and early integration of palliative care for discussions about dialysis withdrawal, and withholding futile interventions at end-of-life care in ESKD patients, especially in resource-constrained settings like ours, for high-quality end-of-life care. This will also lead to better end-of-life care outcomes and improved patient and family satisfaction with care.

Futility, communicating bad news and burnout in doctors and other health practitioners

Futile medical interventions have virtually no chance of success. Doctors might perform such procedures because of pressure from families or patients. The doctor might also have an ulterior motive of gain or prefer to do it rather than take time to communicate with the patient about a poor prognosis. Established ways to communicate bad news to patients are not always used by managing physicians with time constraints. The SPIKES protocol method is outlined to assist in sensitive communication where further intervention is futile. This review primarily explores various aspects of medical futility. It also explores strategies for effectively communicating with patients and their families regarding futility interventions. A side-effect of futile interventions is burnout in doctors and other health practitioners (HPs). The complex relationship between futility and burnout is described.

Overall Survival after Radiotherapy for Brain Metastases According to ECOG Status-A Prospective Study of 294 NSCLC Patients.

Up to 40% of non-smallcell lung cancer (NSCLC) patients develop brain metastases (BMs). The potential benefits of radiotherapy (RT) in patients with poor performance status (PS) are questionable, with considerable risk for futile treatment. We analyzed overall survival after initial radiotherapy in NSCLC patients with BMs, focusing on the relationship between PS and survival after RT. This study reports a prospective observational study including consecutive 294 NSCLC patients with first-time BMs. Overall survival (OS) was calculated from the start of RT to death or last follow-up (1 June 2023). Overall, in the 294 included patients (median age 69 years), the median OS was 4.6 months; 2.5 months after WBRT (n = 141), and 7.5 months after SRT (n = 153). After WBRT, mOS was equally poor for patients with ECOG 2 (1.9 months) and ECOG 3-4 (1.2 months). After SRT, mOS for patients with ECOG 2 was 4.1 months; for ECOG 3 patients, mOS was 4 1.6 months. For NSCLC patients with ECOG 2 diagnosed with BMs who are not candidates for surgery or SRT, WBRT should be questioned due to short survival.

Goals of Care Among Patients With Advanced Cancer and Their Family Caregivers in the Last Years of Life

Understanding goals of care for terminally ill patients at the end of life is crucial to ensure that patients receive care consistent with their preferences. To investigate the patterns of goals of care among patient-caregiver dyads over the last years of the patient's life and the associations of the goals of care with patient-caregiver characteristics. This prospective cohort study of 210 patient-caregiver dyads involved surveys every 3 months from July 8, 2016, until the patient's death or February 28, 2022. Data from the last 2 years of the patients' lives were analyzed. Dyads, which comprised patients with stage IV solid cancer and their caregivers, were recruited from outpatient clinics at 2 major cancer centers in Singapore. Goals of care were examined via the tradeoffs between life extension and symptom management and between life extension and cost containment. The actor-partner interdependence framework was implemented using mixed-effects linear regressions. This study included 210 dyads (patients: mean [SD] age, 62.6 [10.5] years; 108 men [51.4%]; caregivers: mean [SD] age, 49.4 [14.6] years; 132 women [62.9%]). On average, 34% of patients (264 of 780 observations; range, 23%-42%) and 29% of caregivers (225 of 780 observations; range, 20%-43%) prioritized symptom management over life extension, whereas 24% of patients (190 of 780 observations; range, 18%-32%) and 19% of caregivers (148 of 780 observations; range, 8%-26%) prioritized life extension. Between cost containment and life extension, on average, 28% of patients (220 of 777 observations; range, 22%-38%) and 17% of caregivers (137 of 780 observations; range, 10%-25%) prioritized cost containment, whereas 26% of patients (199 of 777 observations; range, 18%-34%) and 35% of caregivers (271 of 780 observations; range, 25%-45%) prioritized life extension. Goals of care did not change as patients approached death. Patients prioritized symptom management if they experienced higher symptom burden (average marginal effect [SE], 0.04 [0.01]), worse spiritual well-being (average marginal effect [SE], -0.04 [0.01]), and accurate (vs inaccurate) prognostic awareness (average marginal effect [SE], 0.40 [0.18]) and if their caregivers reported accurate prognostic awareness (average marginal effect [SE], 0.53 [0.18]), lower impact of caregiving on finances (average marginal effect [SE], -0.28 [0.08]), and poorer caregiving self-esteem (average marginal effect [SE], -0.48 [0.16]). Compared with patients, caregivers expressed lower preferences for cost containment (average marginal effect [SE], -0.63 [0.09]). Patients prioritized cost containment if they were older (average marginal effect [SE], 0.03 [0.01]), had higher symptom burden (average marginal effect [SE], 0.04 [0.01]), had poorer spiritual well-being (average marginal effect [SE], -0.04 [0.01]), and their caregivers reported poorer caregiving self-esteem (average marginal effect [SE], -0.51 [0.16]) and more family support (average marginal effect [SE], -0.30 [0.14]). In this cohort study of patient-caregiver dyads, findings suggested the importance of interventions aimed at reducing discordance in goals of care between patients and caregivers and helping them develop realistic expectations to avoid costly, futile treatments.

Implementation and evaluation of the Supportive and Palliative Care Indicators Tool (SPICT™) in acute care.

The Supportive and Palliative Care Indicators Tool (SPICT™) has been used to identify patients at risk of deteriorating and dying within 1 year. Early identification and integration of advance care planning (ACP) provides the opportunity for a better quality of life for patients. The aims of this study were to identify the number of patients who were SPICT™ positive; their mortality rates at 6 and 12 months of the SPICT™ assessment; and level of adherence to ACP documentation. A retrospective audit of the Supportive and Palliative Care database was conducted at an acute aged care precinct in a major metropolitan tertiary referral hospital in New South Wales, Australia. Data comprising demographics, clinical conditions, SPICT™ positivity and compliance with ACP documentation were collected. SPICT™-positive patients and mortality were tracked at 6 and 12 months, respectively. Data from 153 patients were collected. The mean age of the patients was 84.1 (±7.8) years, and the length of hospital stay was 10 (±24.7) (range 1-269) days. Approximately 37% were from residential care, and 80% had family deciding on their care. About 15% died during hospitalisation, and 48% were discharged to a care facility. The ACP documentation showed various levels of completion. Mortality rates at 6 and 12 months were 36% and 39%, respectively. Most patients (99%) were SPICT™-positive, with indicators correlating with higher mortality rates at both follow-ups. The study emphasises the critical need for addressing ACP and palliative care among older patients with life-limiting conditions. It underscores the importance of timely discussions, documentation, and cessation of futile interventions.

Topical imiquimod treatment of residual or recurrent cervical intraepithelial neoplasia lesions (TOPIC-2): A randomised controlled trial.

To investigate the efficacy of imiquimod in women with residual or recurrent cervical intraepithelial neoplasia (rrCIN), compared with large loop excision of the transformation zone (LLETZ). Randomised controlled non-inferiority trial. One academic and one regional hospital in the Netherlands. Thirty-five women with rrCIN were included in the study between May 2016 and May 2021. Women were randomised to receive treatment with 5% imiquimod cream (12.5 mg) intravaginally (three times a week for a duration of 16 weeks) or a LLETZ procedure (standard treatment). The primary outcome was reduction to normal cytology at 6 months after starting treatment. Secondary outcomes were clearance of high-risk human papilloma virus (hr-HPV) in both groups and reduction to ≤CIN1 in the imiquimod group. Side effects were monitored. Treatment success was 33% (6/18) in the imiquimod group versus 100% (16/16) in the LLETZ group (P < 0.001), whereas HPV clearance was 22% (4/18) in the imiquimod group versus 88% (14/16) in the LLETZ group (P < 0.001). After the randomisation of 35 women, the futility of treatment with imiquimod was proven and the trial was prematurely finished. In the follow-up period, three patients remained without additional treatment, whereas all other patients underwent LLETZ, conisation or hysterectomy. In the LLETZ group none of the patients received additional treatment during 2 years of follow-up. This is the first randomised controlled trial to show that topical imiquimod has a significantly lower success rate in terms of reduction to normal cytology and hr-HPV clearance, compared with LLETZ, in women with rrCIN. Additionally, imiquimod has numerous side effects and after using imiquimod most women with rrCIN still required additional surgical treatment.

Acute kidney injury requiring dialysis in children: a multicentric, emerging country perspective.

Acute kidney injury (AKI) is a life-threatening condition, especially in extreme age groups and when kidney replacement therapy (KRT) is necessary. Studies worldwide report mortality rates of 10-63% in pediatric patients undergoing KRT. Over 13years, this multicenter study analyzed data from 693 patients with AKI, all receiving KRT, across 74 hospitals and medical facilities in Rio de Janeiro, Brazil. The majority were male (59.5%), under one year old (55.6%), and treated in private hospitals (76.5%). Sixty-six percent had comorbidities. Pneumonia and congenital heart disease were the most common admission diagnoses (21.5% and 20.2%, respectively). The mortality rate was 65.2%, with lower rates in patients over 12years (50%). Older age was protective (HR: 2.35, IQR [1.52-3.62] for neonates), and primary kidney disease had a three-fold lower mortality rate. ICU team experience (HR: 0.74, IQR [0.60-0.91]) correlated with lower mortality, particularly in hospitals treating 20 or more patients. Among the deceased, 40% died within 48h of KRT initiation, suggesting possible late referral or treatment futility. This study confirms the high mortality in pediatric dialytic AKI in middle-income countries, underlining early mortality and offering critical insights for improving outcomes.