Life-sustaining Treatment Research Articles

A Scoping Review of End-of-Life Discussions and Palliative Care: Implications for Neurological Intensive Care in Latin America and the Caribbean.

Background: Palliative care (PC) is essential to improve quality of life for individuals with life-limiting acute neurological conditions, particularly in resource-limited settings. In Latin America and the Caribbean (LAC), there is limited health care professional training and education on PC. Objective: We reviewed the peer-reviewed literature discussing end-of-life care, withdrawal of life-sustaining treatments (WOLST), and PC in the acute inpatient setting. Methods: We searched 10 databases, including peer-reviewed published conference abstracts and articles published until May 22, 2024, and included literature describing goals-of-care discussions or availability of PC services in an inpatient setting in LAC countries. Results: We identified 34 articles that highlighted end-of-life discussions, WOLST, and PC utilization in inpatient settings in LAC. We identified several themes across literature as follows: limitations to PC referrals, hospice/end-of-life care, and the role of advanced directives in LAC. Our review found that several articles highlight the limitations of PC usage in LAC and inadequate access to treatments, including gastrostomy and tracheostomy tube placement. Conclusions: Our review demonstrates a need to improve PC knowledge and access to end-of-life care resources. Regional educational efforts are needed to improve PC knowledge among health care providers who care for patients with acute neurological conditions in LAC.

Global longitudinal strain correlates poorly with mortality in people with diabetes mellitus and receiving haemodialysis.

Haemodialysis (HD) is a life-sustaining treatment for individuals with end-stage kidney disease (ESKD). However, the risk of mortality remains significantly higher compared to the general population, even when matched for age and sex. Global longitudinal strain (GLS), derived from speckle tracking echocardiography, has shown promise as a predictor of mortality in HD patients. However, its prognostic utility in patients with multiple cardiovascular risk factors such as diabetes mellitus (DM) and receiving HD, remains unclear. This study aimed to evaluate the prognostic value of GLS in HD patients, with and without DM. This prospective study was a long term follow up extension study of an earlier published study that investigated a cohort of haemodialysis patients from a single centre with a comprehensive cardiovascular imaging protocol. All patients had an echocardiography with the use of speckle-tracking software to determine GLS. Patients were divided into Group A (with DM) and Group B (without DM). Patients were followed up until death, major adverse cardiovascular events (MACE), transplantation or the censoring date (29 February 2024). Statistical analyses were performed using univariate Cox proportional hazards models. A total of 184 patients receiving HD were included in the analysis. Patients with DM (Group A) had significantly higher all-cause mortality (ACM) (47.1% vs. 20.7%, P<0.001) and a lower chance of receiving a kidney transplant (13.2% vs. 43.1%, P<0.001). In Group A, GLS did not predict ACM, whereas in Group B, a GLS cutoff of -15.76% correlated with higher 5-year ACM (P=0.036). Left ventricular ejection fraction (LVEF) was a significant predictor of ACM in Group A (HR 0.98; P=0.036). GLS is a poor predictor of adverse outcomes in HD patients with DM, likely due to their high cardiovascular risk. In contrast, GLS was a significant predictor of mortality in non-diabetic HD patients. LVEF may be a more reliable prognostic indicator in high-risk diabetic patients.

Experiences and Emotions of Critical Care Nurses Toward Dealing with Patients and Their Families in Process of Withdrawal of Life-Sustaining Treatments

Experiences and Emotions of Critical Care Nurses Toward Dealing with Patients and Their Families in Process of Withdrawal of Life-Sustaining Treatments

Professional ethical challenges and suggested strategies in nursing: a qualitative study

Professional ethics are essential for supporting nurses in making ethical decisions and responding to current challenges. This study aimed to explore professional ethical challenges and the strategies nurses use to address them in Iran. An exploratory descriptive qualitative approach was employed, with data collected through two focus groups involving 16 nurses and semi-structured individual interviews with six nursing faculty members. Data were analyzed using thematic analysis following Braun and Clarke’s method. Participants shared their experiences and perceptions of professional ethical challenges and proposed strategies to address them. Nine categories and 51 subcategories were identified, including: 1) Deficiencies in patient-centered care; 2) Communicating bad news to patients and families; 3) Decisions on withholding or withdrawing life-sustaining treatments; 4) Lack of cultural consideration in nursing care; 5) Challenges of incorporating new technology; 6) Ethical concerns in managing and using large patient datasets; 7) Upholding ethical principles in disaster or crisis nursing; 8) Gaps in providing palliative care; and 9) Fear of causing moral distress. The findings underscore the ethical challenges faced by nurses in clinical practice and suggest strategies for addressing each challenge in Iran.

Exploring end-of-life decision-making in China for disorders of consciousness

Objectives We aim to investigate the ethical attitudes of the Chinese population toward withdrawal of life-sustaining treatment (WLST) in disorders of consciousness (DoC) patients. Methods A self-administered questionnaire concerning WLST was distributed to Chinese medical professionals and non-medical participants between February and July 2022. Statistical analysis included chi-square tests and logistic regressions. Results A total of 1223 Chinese participants responded to the questionnaire (39% of whom were medical professionals). Less than one third of participants reported positive attitudes towards withdrawing artificial nutrition and hydration (ANH), antibiotics, and do-not-resuscitation (DNR) orders in patients with unresponsive wakefulness syndrome (UWS) (30%, 24%, 24%) and minimally conscious state (MCS) (23%, 19%, 15%). More respondents agreed with WLST in UWS compared to MCS (p < 0.05). Positive attitudes toward DNR orders were associated with participants’ older age, religion, monthly income > 5000 RMB and medical profession (p < 0.05). Most participants deemed patient’s will (78%), families’ wishes (67%), and financial burden (63%) to be crucial factors when considering WLST. Conclusions Chinese respondents exhibit a relatively low propensity to accept WLST in DoC. Ethical attitudes toward WLST resulted to be affected by individual characteristics of responders. These results call for developing better regulations for identifying qualified surrogate decision-makers and reducing legal ambiguities.

Understanding the Best Nutritional Management for Creutzfeldt-Jakob Disease Patients: A Comparison Between East Asian and Western Experiences.

(1) Background: Creutzfeldt-Jakob disease (CJD) is a rare and fatal neurodegenerative disorder caused by the accumulation of an altered prion protein, which usually leads to death within one year after clinical onset. CJD patients usually present with rapid cognitive impairment associated with declines in cerebellar, motor, visual, behavioral, and swallowing functions. Moreover, CJD patients lose their ability to eat and take medications orally very early on in treatment; nevertheless, there are no specific nutritional guidelines for this disease shared worldwide. (2) Methods: This review aims to describe the nutritional outcomes of CJD patients in Western countries to compare them with those described in East Asian countries and then aims to explore the most recent trends in the nutritional management of CJD patients, including some dietary compounds that present neuroprotective effects. (3) Results: In Japan's, Taiwan's, and China's healthcare systems, CJD patients receive intensive life-sustaining treatment that prolongs their survival (i.e., artificial feeding); conversely, in Western countries, intensive life-sustaining treatments like tube feeding are not commonly provided to CJD patients. (4) Conclusions: It is difficult to pinpoint the reasons for these discrepancies around CJD palliative care supply, but it is clear that specific nutritional guidelines may directly improve the nutritional management of CJD patients and thus allow their families and caregivers to ensure the best end-of-life care for these patients.

Navigating shared decision-making after the Life-Sustaining Treatment Decision Act: a qualitative study of in-depth interviews with terminal cancer patients, families, and healthcare professionals

PurposeEnd-of-life decision-making, particularly relating to withholding life-sustaining treatment (LST), is a complex and emotionally charged process involving healthcare professionals, patients, and caregivers.MethodsThis qualitative study explored the decision-making process in South Korea, where cultural norms and ethical considerations influence the dynamics of shared decision-making (SDM). In-depth interviews were conducted with healthcare professionals, patients, and caregivers using a grounded theory approach to elucidate the themes and processes underlying SDM for LST. This study used the “6C” framework, which could reflect the intricacies of the SDM process.ResultsThe results suggest that healthcare professionals face emotional challenges and an ethical dilemma in disclosing prognoses and discussing LST withholding, often deferring such discussions until the condition of patients worsens. Cultural factors, such as collectivist values and societal taboos surrounding death, influence decision-making dynamics, highlighting the need for tailored interventions and cultural competence in healthcare settings.ConclusionThe proposed “6C” framework provides insights into addressing current challenges in SDM and emphasizes the importance of cultural norms and ethical obligations in end-of-life decision-making. Further research is warranted to examine the SDM process in diverse cultural contexts and develop interventions to enhance patient and family involvement in the decision-making process for LST.

Quality of Life as a Non-mortality Patient-centred Outcome in the Critically Ill: A Retrospective Analysis.

Mortality is a common gauged endpoint in critically ill patients. Reduced quality of life is an aligned repercussion of protracted critical illness. Baseline status, severity of illness and its trajectory influence the outcomes. Patient-oriented outcomes are those that matter the most to a patient. However, quite often, family approves of trade-offs with survivorship in the Indian context. We looked at non-mortality outcomes in patients on high-intensity life-sustaining interventions admitted to the intensive care unit (ICU) despite poor prognosis and died on full support or survived to be completely dependent. In this retrospective chart review study, we studied patients (1) who spent more than 1 month in the hospital enduring a myriad of distressing physical and psychological vicissitudes, (2) whose primary illness was fairly advanced (3) and either succumbed or survived to be impeded in their response to cognitive assessment and with severe functional impairment. Patient demographics, comorbidities, pre-morbid functional status, burden of critical illness, use of life-sustaining therapies, functional dependence in the last week of ICU stay, best neurological status in the last week pre-death or discharge, dying trajectories and economic analysis were noted. Trends of clinical progress of 23 patients were deliberated. The mean age of males was 65 years and 61 years for females. Five patients had a Barthel index score of 10-20, indicating total dependency and two patients had a score of 21-60, indicating severe dependency. Two patients were cognitively impaired at baseline. The worst neurological status in the week before death or discharge was eye1, motor1, and verbaltracheostomised. Thirteen patients succumbed during ongoing treatment. Daily discussions on the dynamics of illness progression need to take place with family on a regular basis for patients managed in ICU. Realistic perceptions and grounded expectations from the families and caregivers are necessary for patient-centred outcomes.

Donor Time to Death and Kidney Transplant Outcomes in the Setting of a 3-Hour Minimum Wait Policy

Lengthening waiting lists for organ transplant mandates the development of strategies to expand the deceased donor pool. Due to concerns regarding organ viability, most organ donation organizations internationally wait no longer than 1 to 2 hours for potential donation after circulatory death (DCD), possibly underutilizing an important organ source; UK policy mandates a minimum 3-hour wait time. To assess whether time to death (TTD) from withdrawal of life-sustaining treatment (WLST) is associated with kidney transplant outcomes. This population-based cohort study used data from the prospectively maintained UK Transplant Registry from all 23 UK kidney transplant centers from January 1, 2013, to December 31, 2021; follow-up was until the date of data extraction (October 2023). Participants comprised 7183 adult recipients of DCD kidney-alone transplants. Duration of TTD, defined as time from WLST to donor mechanical asystole. Primary outcome was 12-month estimated glomerular filtration rate (eGFR; for the main eGFR model, variables with significant right skew [histogram visual assessment] were analyzed on the log2 scale), with secondary outcomes of delayed graft function and graft survival (censored at death or 5 years). This study included 7183 kidney transplant recipients (median age, 56 years [IQR, 47-64 years]; 4666 men [65.0%]). Median donor age was 55 years (IQR, 44-63 years). Median TTD was 15 minutes (range, 0-407 minutes), with 885 kidneys transplanted from donors with TTD over 1 hour and 303 kidneys transplanted from donors with TTD over 2 hours. Donor TTD was not associated with recipient 12-month eGFR on adjusted linear regression (change per doubling of TTD, -0.25; 95% CI, -0.68 to 0.19; P = .27), nor with delayed graft function (adjusted odds ratio, 1.01; 95% CI, 0.97-1.06; P = .65) or graft survival (adjusted hazard ratio, 1.00; 95% CI, 0.95-1.07; P = .92). These findings were confirmed with restricted cubic spline models (assessing nonlinear associations) and tests of interaction (including normothermic regional perfusion). In contrast, donor asystolic time, cold ischemic time, and reperfusion time were independently associated with outcomes. Compared with a theoretical 1-hour maximum wait time, the UK policy (minimum 3-hour wait time) has been associated with 885 extra DCD transplants compared with 6298 transplants (14.1% increase). In this cohort study of DCD kidney recipients, donor TTD was not associated with posttransplant outcomes, in contrast to subsequent ischemic times. Altering international transplant practice to mandate minimum 3-hour donor wait times could substantially increase numbers of kidney transplants performed without prejudicing outcomes.

The impact of early surgery on mortality and functional recovery in older adults with traumatic intracranial lesions: a propensity score-based analysis.

There is skepticism about the benefit of surgery in elderly patients affected by traumatic brain injury (TBI) due to the negative effect of age on the outcome and surgical complications. However, there are few studies that have investigated differences in patient's outcome between surgically and conservatively managed patients after adjusting for the imbalance in preinjury characteristics and clinical and radiological features. The primary aim of this study was to evaluate the effect of early surgery on mortality and functional recovery in a cohort of older adults with acute traumatic intracranial lesions after adjustment by Propensity Score (PS) matching. MATERIALS AND METHODS: We conducted a retrospective cohort study on older adult patients (≥ 65 years) admitted for TBI between 2013 and 2023 to a single level 1 trauma center. Patients were categorized based on whether they underwent early surgery (< 48h after TBI) for a space-occupying lesion evacuation. PS model was constructed based on age, frailty, comorbidities (Charlson comorbity index and American Society of Anaesthesiologists score), anticoagulants, hypoxia, shock, pupillary abnormalities and GCS motor response upon admission, midline shift, basal cistern effacement, volume of subdural and intracerebral hematomas, and limitation of life-sustaining treatment decisions.The effect of early surgery on 30-day mortality and unfavorable functional outcomes (GOSE 1-3) at 6 and 12 months were investigated after matching by paired test. We identified and reviewed 301 patients who met all inclusion criteria and contained no exclusions. After matching, 62 patients (31 pairs of conservative and surgical patients) remained as the matched datasets. Our key finding was that older adult TBI patients who underwent early surgery had a statistically significant reduction in the risk of 30-day mortality (OR 0.313, 95% CI 0.114-0.853, p = 0.023) and unfaourable outcome at 12 months after TBI (OR 0.286, 95% CI 0.094-0.868, p = 0.027). Early surgery was associated with decreased 30-day mortality and better functional outcome at 12 months after TBI in older adults with few comorbidities and good functionality when clinically affected by acute traumatic intracranial lesions with mass effect.

What ethical conflicts do internists in Spain, México and Argentina encounter? An international cross-sectional observational study based on a self-administrated survey

BackgroundThe differences in clinical bioethics between the Mediterranean and Latin American cultures have not been analyzed. The objective of the study is to compare the ethical conflicts that internists in Spain, Mexico and Argentina have.MethodsCross-sectional observational study through a survey directed at internists from Spain, Argentina and Mexico. The survey was administered to affiliated members of the National Societies of Internal Medicine across three countries via an online platform.Results762 internists participated, 261 from Spain, 154 from Argentina and 347 from Mexico. The main ethical conflicts that internists in Spain, Argentina and Mexico have are related (in order) to the end of life, to the clinical relationship and to the patient’s autonomy. Withholding and withdrawing life-sustaining treatment is the most frequent conflict in Spain and Argentina and the second in Mexico.ConclusionsInternists from Spain and Argentina identify very similar ethical conflicts. Furthermore, they consider them more frequent and difficult than in Mexico. In Argentina they are less satisfied with the way they are resolved. To explain these differences, socio-cultural factors are postulated, among others: paternalism, individualism, masculinity, organization of the health system, formal training in bioethics and assessment of death.

Advance care planning towards the end of life.

New national clinical guidelines are now available on advance care planning (ACP). Confidence in communication is important for implementation of the guidelines. This study aims to identify healthcare personnel's self-perceived confidence in communication about future medical care and patients' wishes at the end of life. Healthcare personnel in twelve geriatric units in South-Eastern Norway Regional Health Authority responded to an online questionnaire survey in autumn 2022. The four response alternatives for self-reported confidence - 'unconfident', 'fairly confident', 'very confident' and 'extremely confident'- are combined into two categories: 'limited confidence' ('unconfident' and 'fairly confident') and 'high confidence' ('very confident' and 'extremely confident'). We received responses from 289 of the 470 (61.5%) invited, with an average age of 37.8 ± 11.3 years, of whom 217 out of 289 (75%) had more than five years of professional experience. Of the doctors, 15 out of 67 (22%) reported limited confidence in communication about 'future deterioration of the patient's health condition', 20 out of 67 (30%) about 'life-sustaining treatment' and 13 out of 67 (19%) about 'preferences towards the end of life'. For other healthcare personnel, the corresponding responses were 119 out of 222 (54%), 140 out of 222 (63%) and 109 out of 222 (49%). Self-assessed confidence in communication about future deterioration, future medical care and the patient's own wishes at the end of life varies, and such confidence is limited among many health personnel in geriatric units. Measures appear to be needed to increase confidence in the communication and implementation of ACP in the Norwegian health service.

Large language models to identify advance care planning in patients with advanced cancer

ContextEfficiently tracking Advance Care Planning (ACP) documentation in electronic heath records (EHRs) is essential for quality improvement and research efforts. The use of large language models (LLMs) offers a novel approach to this task. ObjectivesTo evaluate the ability of LLMs to identify ACP in EHRs for patients with advanced cancer and compare performance to gold-standard manual chart review and natural language processing (NLP). MethodsEHRs from patients with advanced cancer followed at seven Dana Farber Cancer Center (DFCI) clinics in June 2024. We utilized GPT-4o-2024-05-13 within DFCI's HIPAA-secure digital infrastructure. We designed LLM prompts to identify ACP domains: goals of care (GOC), limitation of life-sustaining treatment, hospice, and palliative care. We developed a novel hallucination index to measure production of factually-incorrect evidence by the LLM. Performance was compared to gold-standard manual chart review and NLP. Results60 unique patients associated with 528 notes were used to construct the gold-standard data set. LLM prompts had sensitivity ranging from 0.85-1.0, specificity ranging from 0.80-0.91, and accuracy ranging from 0.81-0.91 across domains. The LLM had better sensitivity than NLP for identifying complex topics such as GOC. Average hallucination index for notes identified by LLM was less than 0.5, indicating a low probability of hallucination. Despite lower precision compared to NLP, false positive documentation identified by LLMs was clinically-relevant and useful for guiding management. ConclusionLLMs can capture ACP domains from EHRs, with sensitivity exceeding NLP methods for complex domains such as GOC. Future studies should explore approaches for scaling this methodology.

Medical Decision-Making and Bereavement Experiences After Cardiac Arrest: Qualitative Insights From Surrogates.

Surrogates of incapacitated patients in the intensive care unit (ICU) face decisions related to life-sustaining treatments. Decisional conflict is understudied. To compare experiences of ICU surrogates by reported level of decisional conflict related to treatment decisions after a patient's cardiac arrest preceding death. Convergent mixed methods were used. Bereaved surrogates recruited from a single northeastern US academic medical center completed surveys including the low-literacy Decisional Conflict Scale (moderate-to-high cut point >25) and individual interviews about 1 month after the patient's death. Interview data were analyzed by directed and conventional content analysis. Surrogates were stratified by median total survey score, and interview findings were compared by decisional conflict level. Of 16 surrogates, 7 reported some decisional conflict (median survey score, 0; range, 0-25). About two-thirds decided to withdraw treatments. Three themes emerged from interviews: 2 reflecting decision-making experiences ("the ultimate act"; "the legacy of clinician communication") and 1 reflecting bereavement experiences ("I wish there was a handbook"). Surrogates reporting decisional conflict included those who first pursued but later withdrew treatments after a patient's in-hospital cardiac arrest. Surrogates with decisional conflict described suboptimal support, poor medical understanding, and lack of clarity about patients' treatment preferences. These findings provide insight into bereaved ICU surrogates' experiences. The low overall survey scores may reflect retrospective measurement. Surrogates who pursued treatment were underrepresented. Novel approaches to support bereaved surrogates are warranted.

PP302 Topic: AS05–End of Life: Palliative Care/Organ Donation/Ethics/Spirituality &amp; Wellness/Other: PARENTAL PERCEPTIONS ON WITHHOLDING AND WITHDRAWING LIFE-SUSTAINING TREATMENT FOR THEIR CHILDREN IN THE PAEDIATRIC INTENSIVE CARE UNIT: A QUALITATIVE INTERVIEW STUDY

PP302 Topic: AS05–End of Life: Palliative Care/Organ Donation/Ethics/Spirituality &amp; Wellness/Other: PARENTAL PERCEPTIONS ON WITHHOLDING AND WITHDRAWING LIFE-SUSTAINING TREATMENT FOR THEIR CHILDREN IN THE PAEDIATRIC INTENSIVE CARE UNIT: A QUALITATIVE INTERVIEW STUDY

Using Human-Centered Design to Improve Serious Illness Care for Older Adults with Advanced Dementia

ContextOlder adults with advanced dementia increasingly receive potentially non-beneficial, high-intensity life-sustaining treatments and goal-discordant care in the United States. Interventions to address this issue have shown limited success. ObjectivesTo use human-centered design (HCD) with clinicians caring for older adults with advanced dementia to develop intervention ideas to reduce high-intensity, goal-discordant treatments near the end of life. MethodsWe used the first two steps of HCD, inspiration, and ideation, to understand clinicians’ perspectives regarding challenges in providing goal-concordant care for older adults with advanced dementia and to generate intervention ideas. In inspiration, we conducted in-depth interviews with clinicians caring for older adults with advanced dementia. We analyzed interviews using thematic analysis to identify themes and insights, which we synthesized into design opportunities using HCD. In ideation, we completed structured brainstorming sessions with study investigators, physicians, and designers to generate ideas for interventions at different healthcare system levels. ResultsDuring inspiration, we developed seven themes about clinicians’ experiences providing serious illness care for older adults with advanced dementia. We identified six instances where two or more themes were in tension. We synthesized these tensions into five insight statements capturing clinicians’ key challenges, which we reframed as three design opportunities. Brainstorming sessions conducted as part of ideation generated 132 solution ideas for these three opportunities, with participants selecting nine for testing. ConclusionThe HCD process generated ideas at multiple healthcare system levels to address an enduring challenge in serious illness care by involving clinicians, researchers, and designers in intervention design.

Changes in Pediatric End-of-Life Process After the Enforcement of the Act on Life-Sustaining Treatment Decisions-The Experience of a Single Children's Hospital.

Background: The Act on Life-Sustaining Treatment (LST) for patients at the end of life (the Korean LST Decision Act), implemented in the Republic of Korea in February 2018, has led to changes in the end-of-life decision-making (EOLDM) process in children. This study aimed to investigate changes in pediatric EOLDM process and LST practices since the Korean LST Decision Act. Methods: This retrospective cohort study included 107 patients who died at Kyungpook National University Children's Hospital from January 2015 to December 2020. Patients were divided into two groups: pre-law (January 2015-January 2018, n = 55) and post-law (February 2018-December 2020, n = 52). We analyzed medical records for EOLDM process, patient characteristics, intensive care unit (ICU) admission, documentation types, and LST withholding or withdrawal decisions. Results: After the Korean LST Decision Act, the median total hospitalization duration decreased significantly (14 days [IQR, 3-80] vs. 6 days [IQR, 2-18], p = 0.020), as did the median ICU length of stay (3 days [IQR 1-33] vs. 2.5 days [IQR 1-10.3], p = 0.002). The time from admission to end-of-life decision documentation was significantly shorter in group 2 (6 days [IQR 1-31] vs. 4 days [IQR 1-9], p = 0.027). The use of physician orders for life-sustaining treatment (POLST) documents increased (0% to 33.3%), while do-not-resuscitate (DNR) orders decreased (85.3% to 16.7%). Notably, LST withdrawal decisions increased from 0% to 27.8% (p = 0.001) in the post-legislation period. Conclusions: The Korean LST Decisions Act has led to significant changes in the EOLDM process for terminally ill children, including earlier decision-making, increased use of POLST documents, more frequent LST withdrawal decisions, and shorter hospital and ICU stays. These findings suggest a shift towards more structured and timely end-of-life care discussions in pediatric settings.

End-of-Life Decision Making in Patients with Advanced Dementia: The Perspectives of the Korean General Population and Clinicians.

Korea's transition into a super-aged society brings to the forefront the escalating dementia prevalence and the consequent rise in mortality, highlighting the need for effective end-of-life (EOL) care strategies. Despite legislative advancements, gaps remain in addressing the medical and ethical challenges of EOL care for patients with advanced dementia, particularly in evaluating treatment options like nasogastric tube (NGT) use and mechanical ventilation (MV). This study investigates the attitudes of the general population (GP) and clinicians in Korea towards EOL treatment decisions. A cross-sectional, web-based survey was conducted among 500 members of the GP and 200 clinicians from a university hospital. Case vignettes were used to assess attitudes towards EOL treatment decisions, specifically focusing on NGT and MV use, and to explore the influencing factors. There was a notable difference in favorable attitudes toward NGT withdrawal between the GP (62.2%) and clinicians (39.0%). Otherwise, both groups showed higher acceptance of MV withholding (82.2% [GPs] and 82.5% [clinicians]) when informed of the patient's verbal intention regarding life-sustaining treatment (LST), and attitudes were more positive with written advance directives. Also, it was decreased when patient intentions were unclear. The results suggested the need to consider NGT as a medical intervention requiring a risk-benefit analysis. Although LST decision-making in patients with advanced dementia is still limited in Korea, this study showed the shared recognition among the GP and clinicians of the importance of EOL treatment decisions that consider patient wishes and quality of life for patients with advanced dementia.

A multicenter observational study to establish practice for circulatory death declaration for organ donation in South Korea

Background This study aimed to determine the proportion of organ donors suitable for donation after circulatory death and investigate the current process followed by critical care physicians for declaring circulatory death to establish organ donation. Methods This observational study involved potential organ donors who had recently died after discontinuation of life support. We conducted an online survey of intensivists to determine how these deaths were confirmed. Results Among the 177 patients who died after withdrawal of life-sustaining treatment across 19 intensive care units in 11 institutions, 49 (27.7%) were considered potential donors. According to general medical criteria for organ donation, 20 (11.3%) patients were identified as medically suitable donors. Notably, 116 (73.9%) patients exhibited a flat electrocardiogram within 5 min after the loss of pulse. In the survey, 90 physicians (59.2%) agreed to implement the concept of the 5-min no-touch period for the declaration of circulatory death. Conclusions This study found that 11.3% of the patients who died following the withdrawal of life-sustaining treatment in the intensive care units were identified as suitable donors after circulatory death. Most of critical care physicians agree with the concept of a 5-min no-touch period for the declaration of circulatory death.

Decisions about the limitations of life-sustaining treatment for acutely admitted older patients: a retrospective study of a Danish patient cohort.

Life-sustaining therapy, including heart and lung resuscitation and transfer to the intensive care department, is demanding for patients and relatives and utilizes large amounts of healthcare resources. For older patients acutely admitted to the hospital, very sparse data exist on decision making about life-sustaining therapy. Retrospective data were extracted from patients ≥ 70 years old who were acutely admitted to the hospital. Age, sex, clinical frailty scale score and Charlson comorbidity index were manually extracted from patients' files. Furthermore, data about life-sustaining treatment decisions were extracted. This was further divided into decisions documented within 24h from admission or during the hospital stay. Data were extracted for 200 patients with a median age of 80 years. Patients had a Charlson Comorbidity Index of 6 (5-8 IQR) and a Clinical Frailty Scale (CFS) score of 5 (3-6 IQR). During the first 24h, 61 patients (30.5%) had a written decision about heart and cardiopulmonary resuscitation (CPR), and 52 patients (26%) had written information about intensive care therapy. A total of 93 patients (46.5%) had a written decision about cardiopulmonary resuscitation (CPR), intensive care therapy or both during their hospital stay. With increasing Charlson Comorbidity Index and Clinical Frailty Scale scores, more patients had decisions about limitations in therapy documented in their files. Within the first 24h, 30.5% of the patients had a written decision about cardiopulmonary resuscitation (CPR), and 26% had written information about intensive care therapy. These numbers increased to 46.5% of patients who had a decision made during their hospital stay whether they were candidates for either cardiopulmonary resuscitation (CPR), intensive care therapy or both. These data suggest that further work should be done to determine the limitations of therapy early on the admission for all older frail acutely admitted patients.