Life Support Treatment Research Articles

A Psychiatric Perspective of Dialysis Discontinuation

In the 1970s, the suicide rate of patients with end-stage renal disease (ESRD) was calculated by conflating deaths from obvious clinical suicide attempts with deaths caused by lethal noncompliance and deaths preceded by dialysis discontinuation. Three decades later, although society's view about cessation of life-support treatment has markedly changed, relatively little is known about the psychiatric aspects of dialysis discontinuation. This paper reviews the literature and suggests a number of findings that warrant further research investigation.

Sex-and age-based differences in the delivery and outcomes of critical care

Previous studies have suggested that a patient's sex may influence the provision and outcomes of critical care. Our objective was to determine whether sex and age are associated with differences in admission practices, processes of care and clinical outcomes for critically ill patients. We used a retrospective cohort of 466,792 patients, including 24,778 critically ill patients, admitted consecutively to adult hospitals in Ontario between Jan. 1, 2001, and Dec. 31, 2002. We measured associations between sex and age and admission to the intensive care unit (ICU); use of mechanical ventilation, dialysis or pulmonary artery catheterization; length of stay in the ICU and hospital; and death in the ICU, hospital and 1 year after admission. Of the 466,792 patients admitted to hospital, more were women than men (57.0% v. 43.0% for all admissions, p < 0.001; 50.1% v. 49.9% for nonobstetric admissions, p < 0.001). However, fewer women than men were admitted to ICUs (39.9% v. 60.1%, p < 0.001); this difference was most pronounced among older patients (age > or = 50 years). After adjustment for admission diagnoses and comorbidities, older women were less likely than older men to receive care in an ICU setting (odds ratio [OR] 0.68, 95% confidence interval [CI] 0.66-0.71). After adjustment for illness severity, older women were also less likely than older men to receive mechanical ventilation (OR 0.91, 95% CI 0.81-0.97) or pulmonary artery catheterization (OR 0.80, 95% CI 0.73-0.88). Despite older men and women having similar severity of illness on ICU admission, women received ICU care for a slightly shorter duration yet had a longer length of stay in hospital (mean 18.3 v. 16.9 days; p = 0.006). After adjustment for differences in comorbidities, source of admission, ICU admission diagnosis and illness severity, older women had a slightly greater risk of death in the ICU (hazard ratio 1.20, 95% CI 1.10-1.31) and in hospital (hazard ratio 1.08, 95% CI 1.00-1.16) than did older men. Among patients 50 years or older, women appear less likely than men to be admitted to an ICU and to receive selected life-supporting treatments and more likely than men to die after critical illness. Differences in presentation of critical illness, decision-making or unmeasured confounding factors may contribute to these findings.

Dialysis Discontinuation: Quo Vadis?

Approximately 1 in 4 deaths of patients maintained on dialysis in the United States is preceded by a decision to discontinue treatment. Once considered to be a form of suicide, dialysis discontinuation is now increasingly common in most countries that are fortunate enough to offer renal replacement therapies. Given an aging and progressively sicker chronic kidney disease patient population, the rate of terminating dialysis is likely to increase. The literature on dialysis discontinuation includes studies principally from Canada, the United Kingdom, and the United States. The research is reviewed, critiqued, and examined to determine its relevance to practice. Future issues include the need to explore variability in dialysis practice as well as employment of a more patient-centered approach that is consistent with modern palliative medicine.

Síndrome de shock tóxico: experiencia en una UCIP

To review patients with toxic shock syndrome (TSS) in a pediatric intensive care unit. We performed a retrospective study of patients with TSS admitted to the intensive care unit in the previous 15 years. The patients included were those that met the clinical and microbiological criteria for TSS proposed by the Centers for Disease Control and Prevention. There were nine patients (four boys). The mean age was 7 years. The most frequent findings were fever (100 %), hypotension (100 %), erythroderma (100 %), multisystem organ failure [coagulopathy (100 %), lethargy (89 %), hypertransaminasemia (89 %), increased creatine phosphokinase levels (78 %), renal failure (66 %)] and cutaneous desquamation (100 %). Laboratory studies showed changes in the leukocyte count and C-reactive protein value in all patients. The etiology was as follows: Staphylococcus was detected in six patients (S. epidermidis in three and S. aureus in three) and Streptococcus was detected in two patients (S. pyogenes in one and S. pneumoniae in one); no microorganisms were detected in only one patient. The origin of the infection was identified in seven patients (cutaneous in six patients and tonsillar in one). All patients received life support and antibiotic treatment. Six patients received corticosteroid treatment and one received intravenous immunoglobulins. Patients with TSS secondary to Streptococcus showed the greatest severity, exhibiting renal failure and requiring greater respiratory and circulatory support. All patients recovered well from the infection, without serious long-term sequelae. CONCLUSION. TSS should be included in the differential diagnosis of patients with fever, exanthema and shock, since early diagnosis has been shown to improve outcomes. S. pneumoniae should be included among the microorganisms that cause TSS. Treatment is based on life support measures and antibiotic therapy.

Complications associated with the Esophageal-Tracheal Combitube® in the pre-hospital setting

The Esophageal-Tracheal Combitube (Combitube) is widely used for the management of the airway during cardiopulmonary resuscitation in the pre-hospital setting. Although serious complications have been reported with the Combitube, there is a paucity of data relative to the frequency and nature of such complications. The objective of this retrospective study was to determine the incidence and the nature of complications associated to the Combitube in the pre-hospital setting. Since 1993, in the Quebec City Health Region, the basic life support treatment algorithm for emergency medical technicians has included the use of a Combitube as the primary airway device for management of all patients presenting with cardiac or respiratory arrest. The database of the emergency coordination services was searched for the period between 1993 and 2003 (2,981 patients). Only those patients who survived at least 12 hr were included. Medical records of these patients were reviewed to identify complications related to the use of the Combitube. Two-hundred-eighty (280) patients were identified. Fifty-eight (58) patients (20.7%, confidence interval (CI)95%=16.0%-25.4%) presented 69 complications: aspiration pneumonitis (n=31), pulmonary aspiration (n=16), pneumothorax (n=6), upper airway bleeding (n=4), esophageal laceration (n=3), sc emphysema (n=2), esophageal perforation and mediastinitis (n=2), tongue edema (n=2), vocal cord injury (n=1), tracheal injury (n=1), and pneumomediastinum (n=1). Thirteen of these complications (12 patients, 4.3%, CI95%=2.0%-6.3%) were judged as most likely resulting from trauma associated with insertion of the Combitube. The use of the Combitube in the pre-hospital setting is associated with a notable incidence of serious complications.

A Practical Approach to Clinical Lung Transplantation From a Maastricht Category III Donor With Cardiac Death

Although donation after cardiac death (DCD) has the potential to provide a novel source of organs for lung transplantation, even in a controlled DCD situation such as a Maastricht Category III donor (withdrawal of treatment), the limited time frame available after the declaration of death to initiate procurement and preservation remains challenging. Indeed, no publication has detailed the exact time frames and technique applicable for successful Maastricht Category III DCD lung procurement. In this patient report, withdrawal of life-support treatment and death certification was performed in the intensive care unit and the lungs were procured in an operating room 49 minutes after cardiac arrest and successfully transplanted (cold ischemia time <6 hours) into a severely ill recipient with primary pulmonary hypertension.

Female-assigned genetic males with severe hypospadias: Psychosocial changes and psychosexual treatment

<b>Introduction: </b> Disorders such as severe hypospadias presenting as ambiguous genitalia have serious and potentially life-long consequences for affected individuals and, depending on the underlying cause, are likely to entail surgery in childhood and in later life, psychosocial and psychosexual support and possible fertility treatment including assisted conception. <b> Materials and Methods: </b> Genetic males with severe hypospadias who were wrongly brought-up as females formed the study group. They were reassigned as males and underwent surgery for correction of hypospadias. <b> Results: </b> Three children with severe hypospadias were reassigned to male gender. Psychosocial changes were made psychosexual counseling was done. All three have adjusted to their new environment and gender. <b> Conclusions: </b> Management of children with wrongly assigned sex is complex. It is preferable to reassign these children who are genetic males but wrongly assigned as females at birth. Repair of hypospadias, psychosocial changes and psychosexual counseling will help these children to reorient themselves.

C209 スプリッタ付きネーザルCPAP素子の特性

Artificial respiration techniques for patients with respiratory disorder are important as a basic life support treatments for the patients. The nasal CPAP (Continuous Positive Airway Pressure) is a typical clinical treatment for infants keeping self respiration. Some devices for the nasal CPAP have been used in clinical procedure. However, in order to reduce the load for patients in the treatments, the downsizing and improvement of fitting of the devices are required. A new type device of nasal CPAP has been developed by the authors, but its performance in MAP (Mean Airway Pressure) variation did not meet the condition for clinical use. In this report, the performance of a nasal CPAP device improved has been investigated and it has been clarified that the performance was meet to clinical use.

Método de análisis de conflictos éticos en la práctica asistencial

In every clinical relationship decisions must be taken in conditions of uncertainty, which requires reasonableness and prudence. How is this to be done in the best way possible? By deliberating. The two most successful methodological proposals in the application of bioethics have been casuist and principalist, which have similar contents but different bases. In this article these proposals are applied to a practical case in which the withdrawal of life supporting treatment was posed. The analysis is carried out in four steps: the first is to realise, in the absence of malice, a clinical evaluation of the indication or indications for intervening medically. The second step takes us to the principle of justice or the contextual features, procuring an equitable share out of health resources. The third step refers to the principle of autonomy, that of the patients' preferences. This principle is the latest to emerge in health relationships and is probably the one that poses the most problems. Respect for the autonomy of the person affected implies considering three aspects: capacity, information and voluntariness. The fourth and final step deals with the principle of benefit or quality of life. This criterion is necessarily linked to the preferences of the patient himself and, besides, its general content includes attempt by the health practice to promote well-being, to assist and cure diseases, to promote and maintain health, to alleviate pain and suffering, to avoid premature death and to ensure a peaceful death. Deliberation and weighing up each of the contents of the above steps is the methodological proposal that is set forth, with the argument favouring the pre-eminence of one or another of the aspects depending on the data presented by each case.

Dexmedetomidine Facilitates the Withdrawal of Ventilatory Support in Palliative Care

WITHDRAWAL of ventilatory support in the setting of a terminal illness presents the challenge to the physician of maintaining the comfort of the patient and optimizing sedation and analgesia for the time that the patient has remaining to be with his or her family and friends. Opiates and benzodiazepines are most commonly used for terminal palliation, but this combination of medications has the disadvantage of depressing ventilatory drive and airway reflexes to the degree that it may hasten the patient's death. This problem has been discussed in medical and legal literature invoking the medieval theological concept of the rule of double effect to assist physicians who are faced with the need to make the distinction between euthanasia and appropriate symptom relief in the terminally ill. 1,2 Dexmedetomidine (Abbott Laboratories, Abbott Park, IL), with its highly selective α 2 agonism, provides physicians with another pharmacologic treatment option that addresses many of the possible sources of end-of life distress, 3 with less of a problem with the double effect. We report on the care of a patient where provision of palliative care and withdrawal of ventilatory support was optimized by the use of a dexmedetomidine infusion.

Historical Perspectives

In 1984 and 1985, we conducted a prospective randomized trial of extracorporeal life support (ECLS) versus conventional treatment in neonatal respiratory failure that was reported in Pediatrics in 1985. (1) Two decades, later ECLS is standard treatment for neonatal respiratory failure that is unresponsive to other methods of management. The editors of NeoReviews have invited this commentary on the development and clinical implementation of ECLS in neonatal respiratory failure. The heart-lung machine was invented by John Gibbon and initially used clinically in 1954 to replace heart and lung function long enough to allow operations on the heart. The entire field of cardiac surgery resulted from this invention. However, the heart-lung machine itself caused blood damage and multiple organ failure when used for more than 1 hour. The major cause of blood damage was direct exposure of the blood to oxygen gas. In the 1960s, some laboratories and medical device companies developed gas exchange devices in which a silicone rubber membrane was interposed between the blood and the oxygen. This modification (and others) allowed the use of a heart-lung machine for days or weeks. In 1971, prolonged extracorporeal circulation was used successfully to treat a young man who had acute respiratory distress syndrome (ARDS) after trauma. (2) In the next few years, several other cases were reported using prolonged extracorporeal support to treat cardiac failure and respiratory failure from a variety of causes. Because the membrane type of artificial lung was the unique part of the device, the entire technology of prolonged ECLS came to be known as extracorporeal membrane oxygenation (ECMO). Of course, the technology involves much more than oxygenation, but that acronym has remained. In 1975, the National Institutes of Health (NIH) sponsored a prospective, randomized, multicenter trial of ECMO for ARDS in adult patients. (3) Only 10% of …

Evolution of the medical practices and modes of death on pediatric intensive care units in southern Brazil*

To study the possible change on mode of deaths, medical decision practices, and family participation on decisions for limiting life-sustaining treatments (L-LST) over a period of 13 yrs in three pediatric intensive care units (PICUs) located in southern Brazil. A cross-sectional study based on a retrospective chart review (1988 and 1998) and on prospective data collection (from May 1999 to May 2000). Three PICUs in Porto Alegre, southern Brazilian region. Children who died in those PICUs during the years of 1988, 1998, and between May 1999 and May 2000. The 3 PICUs admitted 6,233 children during the study period with a mortality rate of 9.2% (575 deaths), and 509 (88.5%) medical charts were evaluated in this study. Full measures for life support (F-CPR) were recognized in 374 (73.5%) children before dying, brain death (BD) was diagnosed in 43 (8.4%), and 92 (18.1%) underwent some limitation of life support treatment (L-LST) There were 140 (27.5%) deaths within the first 24 hrs of admission and 128 of them (91.4%) received F-CPR, whereas just 11 (7.9%) patients underwent L-LST. The average length of stay for the death group submitted to F-CPR was lower (3 days) than the L-LST group (8.5 days; p < .05). The rate of F-CPR before death decreased significantly between 1988 (89.1%) and 1999/2000 (60.8%), whereas the L-LST rose in this period from 6.2% to 31.3%. These changes were not uniform among the three PICUs, with different rates of L-LST (p < .05). The families were involved in the decision-making process for L-LST in 35.9% of the cases, increasing from 12.5% in 1988 to 48.6% in 1999/2000. The L-LST plans were recorded in the medical charts in 76.1% of the deaths, increasing from 50.0% in 1988 to 95.9% in 1999/2000. We observed that the modes of deaths in southern Brazilian PICUs changed over the last 13 yrs, with an increment in L-LST. However, this change was not uniform among the studied PICUs and did not reach the levels described in countries of the Northern Hemisphere. Family participation in the L-LST decision-making process has increased over time, but it is still far behind what is observed in other parts of the world.

Extubation chez 5 patients en fin de vie en réanimation

Decisions to withhold or withdraw active life support treatment in situations with no hope of improvement remain difficult for critical-care specialists and families; they are not always well understood by the public. This report describes terminal extubation, a particular method of withdrawing ventilator support. This retrospective analysis examines the records of patients who died in our intensive care unit after a decision to withdraw active life support by stopping artificial ventilation. Extubation was proposed for patients with irreversible neurological damage and was always performed only after a standardized collective decision-making process. This process included three stages. In the initial phase, withdrawal of ventilator support was discussed at a department staff meeting. The meeting's conclusions were transcribed into the medical file, and the possibility of extubation was raised with the family during a planned interview. At least a 24-hour period of reflection was necessary before a new interview, and any opposition, hesitation or lack of understanding by the family at this first interview resulted in suspending the decision. The technical procedures for terminal extubation were also standardized. In 5 cases (4 men and one woman, with a mean age of 65 +/- 4 years), terminal extubation was decided in cooperation with the family, following an average of 3 interviews, 16 days after admission. All patients died within 3 days. So-called "terminal" extubation, very common in the United States, but much less so in France, reinforces the transparency of end-of-life decisions in intensive care units and immediately makes tangible the end of the aggressive treatment for which critical-care specialists have been reproached. Since this first series of patients, extubation has been practiced in our department, principally in situations of irreversible neurological damage.

Décisions de non admission et de limitation thérapeutique chez l'insuffisant respiratoire chronique en réanimation

Chronic respiratory failure (CRF) is one of the most common underlying illnesses in ICU patients in whom death is preceded by a decision of withdraw or withhold life support. The number of CRF patients is growing because the prevalence of chronic obstructive pulmonary disease (COPD), a major cause of chronic morbidity and mortality, is increasing. The following medical situations could lead to a decision of not admitting to the ICU: end-stage idiopathic pulmonary fibrosis (IPF) or cystic fibrosis (CF) in patients not included in a lung transplant program, amyotrophic lateral sclerosis (ALS) treated by home noninvasive ventilation in patients who did not want long term ventilation by tracheostomy, any form of CRF associated to another illness with poor short-term prognosis. In ICU, the reasons leading to a decision-making process of life support treatment withholding or withdrawing could be the futility of care (advanced IPF or CF patients receiving prolonged invasive mechanical ventilation without identified reversible cause of respiratory failure) or the future poor quality of life (ventilator-dependent patients with ALS or severe COPD who are not candidate for home ventilation by tracheostomy). The patients must be involved in the decision-making process as they are judged to be competent. In patients with end-stage lung disease, it is important to stimulate discussion about advance care planning before the onset of acute respiratory failure and a possible admission to the ICU.

The Long-Term Impact of Dialysis Discontinuation on Families

Little is known about the long-term psychological impact of stopping life support treatments on surviving loved ones. The authors sought to determine if there was an increase in pathologic grief in family members left behind after deaths that followed dialysis discontinuation. Phone interviews were used to collect data on demographics, attitudes, and families' comfort levels with the decision to withdraw dialysis. The Impact of Event Scale was administered to assess adaptation and stress levels. Avoidance and Intrusiveness subscales were calculated and associations with other survey data were examined using chi2 tests and analysis of variance (ANOVA). The authors contacted families in New England who had previously participated in the Baystate Dialysis Discontinuation Study. Twenty-six family members (66% of the original study sample) were interviewed approximately 55 months after patient deaths. There was a low overall level of distress and the Avoidance subscale had insufficient variability for analysis. Intrusiveness was highest for spouses and primary caregivers. Only one respondent remembered the death as having been "bad," although 62% of patients were recalled as having suffered distressing symptoms in their last days. In ascending order of importance, respondents characterized good deaths as involving mental alertness, occurring at home, taking place while asleep, being peaceful, happening in the company of loved ones, and being painless or largely painfree. Almost all of the families reported becoming more comfortable with the decision to hasten death than originally. After nearly 5 years after dialysis discontinuation, families report low levels of distress. A higher frequency of intrusive thoughts was more likely if respondents were spouses or primary caregivers as compared to adult children, siblings, or other relatives. The findings suggest that families successfully adapt to the impact of dialysis withdrawal deaths.

Predicting whether the ICU can help older patients: score needed

Because the need for intensive care exceeds its availability in several countries, intensivists must admit those patients most likely to benefit. Intensive care unit admissions of elderly patients will increase substantially in the near future. Decreased self sufficiency and quality of life are common after hospitalization in older patients and they may require discharge to a nursing home, although some patients feel that life in a nursing home would be worse than dying. We have much to learn about matching the use of life-supporting treatments to the health-related values of older patients. A specific outcome-prediction score for older patients would help improve quality of care.

A medical revolution in death-hastening decisions

On one level it was a perfectly ordinary wedding—elaborate floral bouquets adorned the room, the family's favorite lemon cake was covered in sugar-frosted curlicues and topped with traditional tiny statuettes of a happy couple, the bride's gown was splendid, and the wedding feast was complete with shrimp cocktail, filet mignon, and champagne. On another level, as the bride's mother, 58-year-old Amy Plasse slowly walked down the aisle, everyone in the hospital chapel knew that they were participating in an extraordinary event. This was the culmination of Amy's life; she had achieved her final goal—to witness the wedding of her only daughter. The way was prepared to stop the life-support treatment of dialysis and to end the prolongation of her suffering.

Pulling the plug

Each year, hundreds of thousands of Americans die following withholding or withdrawal of life-support treatments. This dramatic change in the practice of medicine has quietly taken place and been accompanied by minimal publicity or discussion.

Family involvement in end-of-life hospital care.

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. A retrospective cohort analysis. An urban community hospital. All 370 inpatients who died during a 1-year period. 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. 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. 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.

Depression and suicidal ideation in patients who discontinue the life-support treatment of dialysis.

The objective of this study was to determine the prevalence of major depression and suicidal ideation in patients who stop the life-support treatment of dialysis. The authors prospectively studied 79 subjects who discontinued maintenance dialysis at eight facilities in North America. Structured interviews were conducted with 23 patients and 76 families. The prevalence of major depression in the sample was between 5% and 25%, and only 1 of 22 patients considered himself to have the illness of depression. Approximately 12% of the respondents were unsure or believed that discontinuing dialysis was the equivalent of suicide. This belief did not correlate with measures of depression. In comparison with the general population there seemed to be an increased prevalence of past suicide attempts. Most patients who decide to stop dialysis do not seem to be influenced by major depression or ordinary suicidal ideation. Although the sample size was small, these results highlight the need to further examine the theoretical framework and terminology of depression and suicide in the context of terminal illness.