Life Support Treatment Research Articles

Characteristics and Prognosis of Patients Who Receive Noninvasive Ventilation and Present Limitation of Life Support Treatment: The LLST-NIVCat Multicenter Cohort Study.

Patients who receive noninvasive ventilation (NIV) in the emergency department (ED) sometimes have a limitation of life support treatment (LLST). The characteristics and prognosis in these patients may be worse, however, few studies have been carried out in this respect. Analyze the differences between patients receiving NIV in the ED with LLST (NIV-LLST) or without LLST (NIV-noLLST) and their impact on in-hospital mortality, as well as investigate in-hospital mortality in the NIV-LLST group. We performed a secondary analysis of data from the NIVCat registry. This was a prospective, multicenter, analytical cohort study with consecutive inclusion of patients receiving NIV from February to March 2015 in 11 hospital EDs in Spain. Data on the baseline characteristics, the acute episode, and final patient destination were collected. The dependent variable was all-cause in-hospital mortality. We analyzed 152 cases receiving NIV, 66 (43.4%) of whom had NIV-LLTS. Age ≥ 75years was associated with NIV-LLST. In-hospital mortality was higher in the NIV-LLST group, with an adjusted hazard ratio of 2.50 (95% confidence interval [CI] 1.03-6.06). Patients with NIV-LLST presenting an exacerbation of chronic obstructive pulmonary disease (COPD) presented the lowest mortality, with an odds ratio of 0.27 (95% confidence interval 0.08-0.93), compared with the remaining patients. In our cohort of patients receiving NIV in the ED, the presence of LLST is frequent and is associated with high hospital mortality. The NIV-LLST patients with a COPD exacerbation have a better prognosis than NIV-LLST patients with other diseases.

Withdrawal of Life-supporting Treatment in Severe Traumatic Brain Injury

There are limited data on which factors affect the critical and complex decision to withdraw life-supporting treatment (LST) in patients with severe traumatic brain injury (sTBI). To determine demographic and clinical factors associated with the decision to withdraw LST in patients with sTBI. This retrospective analysis of inpatient data from more than 825 trauma centers across the US in the American College of Surgeons Trauma Quality Improvement Program database from January 2013 to December 2015 included adult patients with sTBI and documentation of a decision regarding withdrawal of LST (WLST). Data analysis was conducted in September 2019. Factors associated with WLST in sTBI. A total of 37931 patients (9817 women [25.9%]) were included in the multivariable analysis; 7864 (20.7%) had WLST. Black patients (4806 [13.2%]; odds ratio [OR], 0.66; 95% CI, 0.59-0.72; P < .001) and patients of other race (4798 [13.2%]; OR, 0.83; 95% CI, 0.76-0.91; P < .001) were less likely than white patients (26 864 [73.7%]) to have WLST. Patients from hospitals in the Midwest (OR, 1.12; 95% CI, 1.04-1.20; P = .002) or Northeast (OR, 1.23; 95% CI, 1.13-1.34; P < .001) were more likely to have WLST than patients from hospitals in the South. Patients with Medicare (OR, 1.55; 95% CI, 1.43-1.69; P < .001) and self-pay patients (OR, 1.36; 95% CI, 1.25-1.47; P < .001) were more likely to have WLST than patients with private insurance. Older patients and those with lower Glasgow Coma Scale scores, higher Injury Severity Scores, or craniotomy were generally more likely to have WLST. Withdrawal of LST was more likely for patients with functionally dependent health status (OR, 1.30; 95% CI, 1.08-1.58; P = .01), hematoma (OR, 1.19; 95% CI, 1.12-1.27; P < .001), dementia (OR, 1.29; 95% CI, 1.08-1.53; P = .004), and disseminated cancer (OR, 2.82; 95% CI, 2.07-3.82; P < .001) than for patients without these conditions. Withdrawal of LST is common in sTBI and socioeconomic factors are associated with the decision to withdraw LST. These results highlight the many factors that contribute to decision-making in sTBI and demonstrate that in a complex and variable disease process, variation based on race, payment, and region presents as a potential challenge.

Ethical Challenges in Care of Patients on Mechanical Circulatory Support at End-of-Life.

Although the utilization of mechanical circulatory support (MCS) devices is increasing, ethical dilemmas regarding device deactivation and dying process persist, potentially complicating delivery of optimal and compassionate care at end-of-life (EOL). This review aims to study EOL challenges, left ventricular assist devices (LVADs) as a nuanced life support treatment, legal history in the US impacting EOL care, and suggestions to improve EOL care for patients on MCS support. Recent studies have demonstrated challenging aspects of EOL care for patients on LVAD support: low use of advanced directives, high rates of surrogate decision-making due to lack of patient capacity, difficult decision-making involving LVAD deactivation even with cooperating patients, and high rates of death in the hospital and ICU settings. Recent studies also suggest lack of consensus even among clinicians in approaching LVAD deactivation as beliefs equating LVAD deactivation with physician-assisted suicide and/or euthanasia remain. Optimal care at EOL will likely require collaborative efforts among multiple specialties, caregivers, and patients. In light of the complex medical, logistical, and ethical challenges in EOL care for LVAD patients, there is room for improvement by multidisciplinary efforts to reach consensus about LVAD deactivation and best practices for EOL care, development and implementation of LVAD-specific advance planning, and protocols for LVAD deactivation. Programmatic involvement of hospice and palliative care in the continuum of care of LVAD patients has the potential to increase and improve advance care planning, support surrogate decision-making, improve EOL compassionate care, and to support caregivers.

Antithrombin Dosing Guidelines in Children Underestimate Dose Needed for Plasma Level Increase.

Antithrombin is a cofactor in the coagulation cascade with mild anticoagulant activity and facilitates the action of heparin as an anticoagulant. Antithrombin concentrate dosing guidelines vary but most commonly suggest that each unit of antithrombin concentrate per body weight increases the plasma antithrombin level by 1.5% to 2.2% (depending on manufacturer). We aimed to establish a dosing recommendation dependent on age and disease state. A retrospective analysis of all antithrombin concentrate doses over a period of 5 years. We calculated the increase any respective antithrombin concentrate dose achieved, indexed by body weight, and performed a multivariable analysis to establish independent factors associated with the effectiveness of antithrombin concentrate. A PICU at a university-affiliated children's hospital. One hundred fifty-five patients treated in a PICU. None. The effect of 562 doses of antithrombin concentrate on plasma antithrombin levels administered to 155 patients, of which 414 (73.7%) antithrombin concentrate doses administered during extracorporeal life support treatment, were analyzed. For all patients, each unit of antithrombin concentrate/kg increased plasma antithrombin level by 0.86% (SD 0.47%). Plasma antithrombin level increase was influenced by body weight (increase of 0.76% [interquartile range, 0.6-0.92%] for patients < 5 kg; 1.38% [interquartile range, 1.11-2.10%] for > 20 kg), disease state (liver failure having the poorest antithrombin increase) and whether patients were treated with extracorporeal circulatory support (less antithrombin increase on extracorporeal life support). Heparin dose at the time of administration did not influence with amount of change in antithrombin level. Current antithrombin concentrate dosing guidelines overestimate the effect on plasma antithrombin level in critically ill children. Current recommendations result in under-dosing of antithrombin concentrate administration. Age, disease state, and extracorporeal life support should be taken into consideration when administering antithrombin concentrate.

Право пацієнта на припинення життєзабезпечувального лікування як складова права пацієнта на самовизначення компаративний аналіз практики судів Німеччини та Італії

The progress of advanced medical care technologies allowing to sustain and prolong the life of severely morbid, or terminally ill people arose a legal dispute that formed a rather delicate issue: has a patient a right to refute treatment even in spite of an apparent death as a consequence of it? With nearly no legislative or case-law background, a number of American courts came to different conclusions concerning prohibition of blood transfusion on basis of religious beliefs in a series of trials in the 1960s, though the issue of death was not stringently involved in them. As the life-sustaining machinery progressed, the courts faced more difficult lawsuits involving the withdrawal of treatment for terminally ill people being in permanent vegetative state, which featured the trials of Quinlan (1976), Saikewicz (1976) Eichner (1980), Leach (1980) and several subsequent trials, where American courts were the first to sanction an order to withdraw life-supporting treatment mostly upon medical report evidence suggesting no patient’s recovery is expected. The fragility of such trials was apparently distinguished from trials where the courts dealt with withdrawal of life-support appliances for brain-dead people which was clearly determined even by the 1970s medical machinery. In a few decades, the given issue came into the view of German, Italian and English courts. The first two states, belonging to the continental system of law, apparently lacked any legislation on withdrawal of life-supporting treament, which resulted in a number of contraversial judgments by German land courts in the 1990s and 200s, as well as a decade-long trial of Englaro in Italy, and a resonant judgment of Welby, which arose the issue of assisted suicide as well. As the legislatures were seemingly reluctant to elaborate passive euthanasia laws, all the burden of solving the issue was laid on the courts which managed to develop a body of case law on withdrawal of treatment enacting a number of principles so as to determine whether such a order to withdraw treatment is admissible, or it is not, and whether the court posseses subject matter to rule on similar issues. Herein, the advance healthcare directives (or living wills) designating the range of tolerable and intolerable invasive medical procedures and the powers of attorneys, predominantly known in English-speaking counties as “healthcare proxies”, play a substantial role as evidence, albeit their validity in fact may be challenged at trial. The given paper discusses the jurisprudence of German and Italian courts as well as the key principles which they have elaborated by adjudicating trials on withdrawal of treatment with an apparent subsequent death of the patient involved.

Brain Death Islamic Perspective

Western world has well defined criteria for declaring the patient brain dead and discontinuation of life support treatment. However in the Muslim world these methods and practices are seen with skepticism as to their acceptance from Islamic and Sharia point op view, which in fact is incorrect and is due to lack of knowledge and absence of Institutional guidelines on this matter. Islamic law permits the withdrawal of futile treatment, including life support, from brain dead patients allowing death to take its natural course. “Do not resuscitate” is permitted in Islamic law in brain dead patients. Euthenesia is however unacceptable in Islam. Although debate continues about the details of brain death criteria within Islamic scholars, brain death is accepted as true death by the majority of Mulim scholars and there is concensus on discontinuation of life support treatment in brain dead patients.

Coronavirus Disease 2019: Withdrawing Mechanical Ventilation to Reallocate Life Support Under Crisis Standards of Care-Nonequivalence of the Equivalence Thesis.

Coronavirus Disease 2019: Withdrawing Mechanical Ventilation to Reallocate Life Support Under Crisis Standards of Care-Nonequivalence of the Equivalence Thesis.

Esmolol for the treatment of refractory ventricular fibrillation: a systematic review and meta-analysis

&lt;p&gt;&lt;strong&gt;Introduction: &lt;/strong&gt;In light of recent research the efficacy of current advanced life support treatments has been questioned. Ventricular fibrillation refractory to standard therapy is a presentation which may benefit from an updated approach to management, with the b&lt;sub&gt;1&lt;/sub&gt;-adrenoreceptor antagonist esmolol considered a therapy which may confer benefit. This systematic review and meta-analysis aimed to summarise the available evidence for esmolol in refractory ventricular fibrillation and identify if it may have any role in ACLS guidelines.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt; The Cochrane Library, MEDLINE, CINAHL and EMBASE were systematically reviewed, along with trial registries and the grey literature. Studies were included in the review and subsequent meta-analysis if they examined adult patients in cardiopulmonary arrest with ventricular fibrillation refractory to at least three attempts at defibrillation and one dose of adrenaline or anti-arrhythmic therapy, who subsequently received intravenous esmolol.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt; 2,617 results were obtained with 12 full-text articles reviewed for inclusion. Ultimately, two unique results fulfilled the inclusion criteria. A total of 66 patients were included in the meta-analysis, of whom 22 received esmolol. Esmolol appears to improve to survival to hospital admission (RR 2.63, 95% CI 1.37-5.07, p=0.004), temporary (RR 2.34, 95% CI 1.09-5.02, p=0.03) and sustained ROSC (RR 2.63, 95% CI 1.37-5.07, p=0.004) and favourable neurological status at hospital discharge (RR 3.44, 95% CI 1.11-10.67, p=0.03). The use of esmolol also appeared to likely confer a benefit in survival to hospital discharge (RR 2.82, 95% CI 1.01-7.93, p=0.05). However, significant bias was observed across all outcomes and overall these results were considered to be of low to very low certainty.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusion: &lt;/strong&gt;The use of esmolol in refractory ventricular fibrillation appears to improve survival to hospital admission, temporary and sustained ROSC and neurological status at hospital discharge, but not survival to hospital discharge. However, these results should be interpreted with caution in light of the limitations of included studies and the subsequent impact of these limitations on the outcomes included in the meta-analysis. Further high-quality, prospective research is required prior to recommending esmolol for use in refractory ventricular fibrillation.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;

Update and recommendations in decision making referred to limitation of advanced life support treatment

The Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) Bioethics Working Group has developed recommendations on the Limitation of Advanced Life Support Treatment (LLST) decisions, with the aim of reducing variability in clinical practice and of improving end of life care in critically ill patients.The conceptual framework of LLST and futility are explained. Recommendations referred to new forms of LLST encompassing also the adequacy of other treatments and diagnostic methods are developed. In addition, planning of the possible clinical courses following the decision of LLST is commented. The importance of advanced care planning in decision-making is emphasized, and intensive care oriented towards organ donation at end of life in the critically ill patient is described. The integration of palliative care in the critical patient treatment is promoted in end of life stages in the Intensive Care Unit.

Unresponsive wakefulness syndrome: Outcomes from a vicious circle.

Unresponsive wakefulness syndrome: Outcomes from a vicious circle.

Medical assistence to die, and law.

On October 24, 2018 the Italian Constitutional Court held that the absolute ban on assisted suicide provided for by Art. 580 of the Italian criminal code is unconstitutional under certain conditions. On the one hand, this Article «serves the purpose of protecting interests that are worthy of protection by the legal system» (p. 6), such as life and the protection of weak and vulnerable people. On the other hand, in specific situations like the one in the DJ Fabo's case, the assistance to die «may seem to the sick person to be the only way out of being kept alive by artificial methods that are no longer desired, and which he or she has the right to refuse» (p. 8). In particular the Court has set four conditions under which the absolute prohibition of suicide assistance can turn to be unconstitutional, and namely in those cases in which «assisted persons are (a) affected by an illness that is incurable and (b) causes physical or psychological suffering, which they find absolutely intolerable, and who are (c) kept alive by means of life support treatments, but remain (d) capable of making free and informed decisions» (p. 8). In such a situation the absolute ban on suicide assistance obliges the patient to «undergo a slower process, in a scenario that corresponds less well to the patient's vision of a dignified death and which is marked by more pain and suffering for the people close to the patient» (p. 9). Being aware of the impact and scope of its remarks and of the values at stake, the Court decided not to immediately declare the unconstitutionality of art. 580 of the criminal code, but rather to postpone the official discussion of the questions of constitutionality to the hearing on September 24, 2019. In a «"collaborative" and "dialogical"» perspective, the Court thus called upon the Parliament to regulate a subject which is at the «intersection between values of primary importance, the balancing of which presupposes, in a direct and immediate way, choices that the legislator is, first of all, authorized to make» (p. 11). As already known, the Parliament has not passed a law on assisted suicide so far; the Court will therefore decide at the hearing on September 24 how to amend what has already defined as a «unconstitutional regulatory scheme» (p. 11). Against this background and considering the reasoning of the Court in December 2018, the Authors of this Document - legal scholars and professionals with long-standing experience in these topics - decided to open an interdisciplinary discussion on the main legal end-of-life issues. Starting from the Order but without limiting the analysis to it, the Working Group met on a monthly basis at the University of Trento and with the support of the Jean Monnet BioTell Project, addressing and studying in depth the large number of tricky issues raised by the Order of the Constitutional Court and linked to a possible Parliament decision. The results of these discussions have been gathered and developed in the Document together with some operational proposals, offering a "constitutionally oriented" and scientific grounded understanding of end-of-life issues. The Working Group thus aimed to contribute to the public debate suggested by the Court, which must be truly informed and plural due to the impact on institutional choices. On September 25, the Constitutional Court ruled the impunity of those who foster the suicide under the conditions expressed in the Court press release reporting the Court's judgment.

Predict cardiac death after withdrawal of life-supporting treatment in the neurocritical patients: a neurological score

Background: Accurate prediction the time of death after withdrawal of life-supporting treatment (WLST) in the neurocritical patients is important for donation after cardiac death. We aimed to establish a new neurological scoring system to predict the probability of death within 60 minutes after WLST.Methods: We retrospectively reviewed the clinical data from a cohort of 231 neurocritical patients from June 2016 to July 2018. The patients were divided into training and external validation sets. In the training set, we used univariate and multivariable logistic regression analyses to assess associations between death within 60 minutes after WLST and these variables. Points attributed to each variable were summed to create a predictive score for cardiac death. We assessed performance of the score using ROC analysis. Finally, we validated the predictive ability of the score in an external validation set.Results: Multivariable logistic regression analysis showed that absent corneal reflexes, absent cough reflexes, extensor or absent motor response and anisocoric or bilaterally dilated pupil were associated with death within 60 minutes in training set (all p&lt;0.05). The area under curve for the score was 0.839 (95% CI 0.763-0.916) for prediction of death within 60 minutes. A score of 4-6 had a sensitivity of 95.88% and a specificity of 69.05% to predict death within 60 minutes after WSLT. In external validation set, the prevalence of these predictors was similar with training sample.Conclusions: The neurological score may be useful to predict time of death after WLST in neurocritical patients.

Correlates of life-support treatment preferences among low-income home-based cancer management recipients.

To examine the correlates of life-support treatment (LST) preferences from attitudes toward advance directives (ADs), perceived susceptibility, symptom frequency, symptom burden, and global health among low-income community-dwelling cancer management recipients, controlling for age, sex, education, and duration after cancer diagnosis. A cross-sectional, correlational study design was used to assess LST preferences and correlates. Data were collected from low-income cancer survivors during nurses' home visits. Survivors who had mostly solid cancer participated (N = 107, mean age = 67.39 ± 11.57 years, 32.7% males). Hospice care was the most desired (66.4%), while aggressive treatments were less preferred: cardiopulmonary resuscitation (15.9%), ventilation support (15.0%), hemodialysis (18.7%), or chemotherapy (12.1%). Higher symptom frequency was associated with a greater likelihood of preferring all aggressive treatments (odds ratios = 1.44-1.75). In addition, longer cancer duration was associated with a greater likelihood of preferring ventilation support; females had a lesser likelihood of preferring hemodialysis and chemotherapy. Higher education was associated with a lesser likelihood of preferring chemotherapy. More positive attitudes (B = 0.15, p = .001) were associated with a greater likelihood of preferring hospice care, and greater symptom burden of pain (B = -0.03, p = .047) was associated with a lesser likelihood. Results support the feasibility of incorporating ADs into cancer management among community-dwelling cancer survivors, with consideration of AD attitudes and symptom monitoring. An integration of AD discussion into the home visiting service could be a liaison for the quality and continuity of cancer survivorship care that guides and manages patients' survivorship issues.

Elevated ferritin and soluble CD25 in critically ill patients are associated with parameters of (hyper) inflammation and lymphocyte cytotoxicity.

Critically ill patients may develop a potentially fatal hyperinflammatory condition known as secondary (acquired) hemophagocytic lymphohistiocytosis (sHLH), the cause of which is unclear. We evaluated serum ferritin and soluble CD25 (sCD25) in critically ill patients, and their association with other parameters of inflammation and critical illness. Moreover, aiming to better understand the pathogenesis of sHLH, we also evaluated lymphocyte cytotoxicity parameters and correlations with the inflammatory markers ferritin and sCD25. In a prospective observational study, 32 patients with ferritin ≥500 µg/L (24 with sepsis) were studied on admission to an intensive care unit (ICU) with regard to ferritin and corresponding clinical and laboratory features including sCD25, and detailed lymphocyte cytotoxicity and genetic analyses whenever possible. Critically ill patients had elevated, positively correlated levels of serum ferritin and sCD25 (rs=0.465, P=0.008); both associated with other risk factors of poor outcome in critically ill, such as thrombocytopenia (rs=-0.534, P=0.002 and rs=-0.421, P=0.018, respectively), and sCD25 with hypoalbuminemia (rs=-0.678, P<0.001) and life support treatments (rs=0.479, P=0.006). Interestingly, ferritin levels were inversely associated with natural killer (NK)-cell cytotoxicity (rs=-0.462, P=0.047) and degranulation (rs=-0.504, P=0.030). Moreover, of four patients with abnormally low cytotoxicity, three (75%) had <5% circulating NK-cells. Our study suggests that hyperferritinemia and sCD25 correlate with other laboratory parameters indicative of severe hyperinflammation and organ dysfunction in critically ill ICU-patients, indicating their value in identifying hyperinflammatory critically ill patients for early intervention. Furthermore, it suggests that hyperferritinemia and hyperinflammation may partly be associated with a low percentage circulating NK-cells, and hence, the associated low lymphocyte cytotoxicity.

Update and recommendations in decision making referred to limitation of advanced life support treatment.

The Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) Bioethics Working Group has developed recommendations on the Limitation of Advanced Life Support Treatment (LLST) decisions, with the aim of reducing variability in clinical practice and of improving end of life care in critically ill patients. The conceptual framework of LLST and futility are explained. Recommendations referred to new forms of LLST encompassing also the adequacy of other treatments and diagnostic methods are developed. In addition, planning of the possible clinical courses following the decision of LLST is commented. The importance of advanced care planning in decision-making is emphasized, and intensive care oriented towards organ donation at end of life in the critically ill patient is described. The integration of palliative care in the critical patient treatment is promoted in end of life stages in the Intensive Care Unit.

The appropriateness of low-acuity cases referred for emergency ambulance dispatch following ambulance service secondary telephone triage: A retrospective cohort study.

ObjectiveAmbulance-based secondary telephone triage systems have been established in ambulance services to divert low-acuity cases away from emergency ambulance dispatch. However, some low-acuity cases still receive an emergency ambulance dispatch following secondary triage. To date, no evidence exists identifying whether these cases required an emergency ambulance. The aim of this study was to investigate whether cases were appropriately referred for emergency ambulance dispatch following secondary telephone triage.MethodsA retrospective cohort analysis was conducted of cases referred for emergency ambulance dispatch in Melbourne, Australia following secondary telephone triage between September 2009 and June 2012. Appropriateness was measured by assessing the frequency of advanced life support (ALS) treatment by paramedics, and paramedic transport to hospital.ResultsThere were 23,696 cases included in this study. Overall, 54% of cases received paramedic treatment, which was similar to the state-wide rate for emergency ambulance cases (55.5%). All secondary telephone triage cases referred for emergency ambulance dispatch had transportation rates higher than all metropolitan emergency ambulance cases (82.2% versus 71.1%). Two-thirds of the cases that were transported were also treated by paramedics (66.5%), and 17.7% of cases were not transported to hospital by ambulance following paramedic assessment.ConclusionsOverall, the cases returned for emergency ambulance dispatch following secondary telephone triage were appropriate. Nevertheless, the paramedic treatment rates in particular indicate a considerable rate of overtriage requiring further investigation to optimize the efficacy of secondary telephone triage.

Physician workload associated with do-not-resuscitate decision-making in intensive care units: an observational study using Cox proportional hazards analysis

BackgroundPhysicians play a substantial role in facilitating communication regarding life-supporting treatment decision-making including do-not-resuscitate (DNR) in the intensive care units (ICU). Physician-related factors including gender, personal preferences to life-supporting treatment, and specialty have been found to affect the timing and selection of life-supporting treatment decision-making. This study aimed to examine the influence of physician workload on signing a DNR order in the ICUs.MethodsThis is retrospective observational study. The medical records of patients, admitted to the surgical ICUs for the first time between June 1, 2011 and December 31, 2013, were reviewed. We used a multivariate Cox proportional hazards model to examine the influence of the physician’s workload on his/her writing a DNR order by adjusting for multiple factors. We then used Kaplan–Meier survival curves with log-rank test to compare the time from ICU admission to DNR orders written for patients for two groups of physicians based on the average number of patients each physician cared for per day during data collection period.ResultsThe hazard of writing a DNR order by the attending physicians who cared for more than one patient per day significantly decreased by 41% as compared to the hazard of writing a DNR order by those caring for fewer than one patient (hazard ratio = 0.59, 95% CI 0.39—0.89, P = .01). In addition, the factors associated with writing a DNR order as determined by the Cox model were non-operative, cardiac failure/insufficiency diagnosis (hazard ratio = 1.71, 95% CI 1.00—2.91, P = .05) and the Therapeutic Intervention Scoring System score (hazard ratio = 1.02, 95% CI 1.00—1.03, P = .03). Physicians who cared for more than one patient per day were less likely to write a DNR order for their patients than those who cared for in average fewer than one patient per day (log-rank chi-square = 5.72, P = .02).ConclusionsOur findings highlight the need to take multidisciplinary actions for physicians with heavy workloads. Changes in the work environmental factors along with stress management programs to improve physicians’ psychological well-being as well as the quality.

The Role of Palliative Care in the Cardiac Intensive Care Unit.

In the last few years, important changes have occurred in the clinical and epidemiological characteristics of patients that were admitted to cardiac intensive care units (CICU). Care has shifted from acute coronary syndrome patients towards elderly patients, with a high prevalence of non-ischemic cardiovascular diseases and a high burden of non-cardiovascular comorbid conditions: both increase the susceptibility of patients to developing life-threatening critical conditions. These conditions are associated with a significant symptom burden and mortality rate and an increased length of stay. In this context, palliative care programs, including withholding/withdrawing life support treatments or the deactivation of implanted cardiac devices, are frequently needed, according to the specific guidelines of scientific societies. However, the implementation of these recommendations in clinical practice is still inconsistent. In this review, we analyze the reasons for this gap and the main cultural changes that are required to improve the care of patients with advanced illness.

After the Italian Constitutional Court's ruling on the absence of criminal liability for assisted suicide: the role of ethics committees and clinical ethics. Editorial.

The Constitutional Court handed down a judgment on 25 September 2019 following on from that Court’s Order No 207 of 24 October 2018. The issue of constitutionality of Article 580 of the Criminal Code, in the part about the punishment of the aid to suicide, was raised by the Court of Milan. According to the Court “under certain conditions, a person who facilitates the execution of the suicide intention, autonomously and freely formed, of a patient kept alive by life support treatments and affected by a irreversible pathology, source of physical or psychological suffering that he considers intolerable but fully capable of making free and conscious decisions”. According to the Court, a local ethics committee must provide an opinion in all cases involving a request for medically-assisted suicide.

Uncontrolled DCD donation—tilting at windmills or pushing against an open door?

Wider use of donation after circulatory death donors may increase transplant numbers substantially. Most countries that have adopted donation after circulatory death donation have focused on controlled donation after circulatory death donors, whereby life-supporting treatment is withdrawn in a coordinated manner. In this issue, del Río and colleagues report the Spanish experience for kidneys transplanted from uncontrolled donation after circulatory death donors (typically individuals with sudden cardiorespiratory arrest in the community). In the largest series to date, they confirm that remarkably good transplant outcomes are achievable.