Limitation Of Life-sustaining Therapy Research Articles

Social Determinants of Health and Limitation of Life-Sustaining Therapy in Neurocritical Care: A CHoRUS Pilot Project

Social Determinants of Health and Limitation of Life-Sustaining Therapy in Neurocritical Care: A CHoRUS Pilot Project

Limitation of life-sustaining therapies in critically ill patients with COVID-19: a descriptive epidemiological investigation from the COVID-ICU study

BackgroundLimitations of life-sustaining therapies (LST) practices are frequent and vary among intensive care units (ICUs). However, scarce data were available during the COVID-19 pandemic when ICUs were under intense pressure. We aimed to investigate the prevalence, cumulative incidence, timing, modalities, and factors associated with LST decisions in critically ill COVID-19 patients.MethodsWe did an ancillary analysis of the European multicentre COVID-ICU study, which collected data from 163 ICUs in France, Belgium and Switzerland. ICU load, a parameter reflecting stress on ICU capacities, was calculated at the patient level using daily ICU bed occupancy data from official country epidemiological reports. Mixed effects logistic regression was used to assess the association of variables with LST limitation decisions.ResultsAmong 4671 severe COVID-19 patients admitted from February 25 to May 4, 2020, the prevalence of in-ICU LST limitations was 14.5%, with a nearly six-fold variability between centres. Overall 28-day cumulative incidence of LST limitations was 12.4%, which occurred at a median of 8 days (3–21). Median ICU load at the patient level was 126%. Age, clinical frailty scale score, and respiratory severity were associated with LST limitations, while ICU load was not. In-ICU death occurred in 74% and 95% of patients, respectively, after LST withholding and withdrawal, while median survival time was 3 days (1–11) after LST limitations.ConclusionsIn this study, LST limitations frequently preceded death, with a major impact on time of death. In contrast to ICU load, older age, frailty, and the severity of respiratory failure during the first 24 h were the main factors associated with decisions of LST limitations.

The impact of pre-existing chronic heart failure on the intensive care treatment and outcome of old intensive care patients suffering from COVID-19

Abstract Background Patients suffering from COVID-19 with pre-existing chronic heart failure (CHF) are considered to have a significant risk regarding morbidity and mortality. Similarly, older patients on the intensive care unit (ICU) constitute another vulnerable subgroup. This study investigated the association between pre-existing CHF and clinical practice in critically ill older ICU patients with COVID-19. Methods Patients with severe COVID-19 and who were ≥70 years old were recruited from this prospective multicenter international study. Patients' treatment, follow-up, and pre-existing heart failure data were collected during ICU stay. Univariate and multivariate logistic regression analyses examined the association between pre-existing heart failure and the primary endpoint of 30-day mortality. Results The study included 3,917 patients, with 407 patients (17%) evidencing pre-existing CHF. These patients were older (77±5 versus 76±5, p<0.001) and more frail (Clinical Frailty Scale 4±2 versus 3±2, p<0.0001). The other comorbidities were also significantly more common in CHF patients. Before hospital admission, CHF patients suffered fewer days from symptoms (5 days (3–8) versus 7 days (4–10), p<0.001), but there was no difference in the days in the hospital before ICU admission (2 days (1–5) versus 2 (1–5) days, p=0.21). At ICU admission, disease severity assessed by SOFA scores was significantly higher in CHF patients (7±3 versus 5±3). During ICU-stay, intubation, mechanical ventilation, and tracheostomy occurred significantly more often in patients without CHF (63% versus 69%, p=0.017; and 13% versus 18%, p=0.002, respectively). In contrast, there was no difference regarding non-invasive ventilation (28% versus 27%, p=0.20), and the need for vasoactive drugs (66% versus 64, p=0.30). Regarding the limitation of life-sustaining therapy, therapy was significantly more often withheld (32% versus 25%, p=0.001) but not withdrawn (18% versus 17%, p=0.21) in CHF patients. Length of ICU stay was significantly shorter in CHF patients (166 (72–336) hours versus 260 hours (120–528), p<0.001). CHF patients had significantly higher ICU- (52% versus 46%, p=0.007), 30-day mortality (60% vs. 48%, p<0.001; OR 1.87, 95% CI 1.5–2.3) and 3-month mortality (69% vs. 56%, p<0.001). In the univariate regression analysis, having pre-existing CHF was significantly associated with 30-day mortality (OR 1.89, 95% CI 1.5–2.3; p<0.001), but after adjusting for confounders (SOFA, age, gender, frailty), heart failure was not independently associated any more (aOR 1.2, 95% CI 0.5–1.5; p=0.137). Conclusion In critically ill old COVID-19 patients, pre-existing chronic heart failure is associated with significantly increased short- and long-term mortality, but heart failure is not independently associated with increased 30-day mortality when adjusted for confounders. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): This study was endorsed by the ESICM. Free support for running the electronic database and was granted from the dep. of Epidemiology, University of Aarhus, Denmark. The support of the study in France by a grant from “Fondation Assistance Publique-Hôpitaux de Paris pour la recherche” is greatly appreciated. In Norway, the study was supported by a grant from the Health Region West. In addition, the study was supported by a grant from the European Open Science Cloud (EOSC). EOSCsecretariat.eu has received funding from the European Union's Horizon Programme call H2020-INFRAEOSC-05-2018-2019, grant agreement number 831644. This work was supported by the Forschungskommission of the Medical Faculty of the Heinrich-Heine-University Düsseldorf, No. 2018-32 to GW and No. 2020-21 to RRB for a Clinician Scientist Track.

End-of-life practices in 11German intensive care units : Results from the ETHICUS-2 study.

End-of-life care is common in German intensive care units (ICUs) but little is known about daily practice. To study the practice of end-of-life care. Prospectively planned, secondary analysis comprising the German subset of the worldwide Ethicus‑2 Study (2015-2016) including consecutive ICU patients with limitation of life-sustaining therapy or who died. Among 1092 (13.7%) of 7966 patients from 11multidisciplinary ICUs, 967 (88.6%) had treatment limitations, 92 (8.4%) died with failed CPR, and 33 (3%) with brain death. Among patients with treatment limitations, 22.3% (216/967) patients were discharged alive from the ICU. More patients had treatments withdrawn than withheld (556 [57.5%] vs. 411 [42.5%], p < 0.001). Patients with treatment limitations were older (median 73years [interquartile range (IQR) 61-80] vs. 68years [IQR 54-77]) and more had mental decision-making capacity (12.9vs. 0.8%), advance directives (28.6vs. 11.2%), and information about treatment wishes (82.7 vs 33.3%, all p < 0.001). Physicians reported discussing treatment limitations with patients with mental decision-making capacity and families (91.3and 82.6%, respectively). Patient wishes were unknown in 41.3% of patients. The major reason for decision-making was unresponsiveness to maximal therapy (34.6%). Treatment limitations are common, based on information about patients' wishes and discussion between stakeholders, patients and families. However, our findings suggest that treatment preferences of nearly half the patients remain unknown which affects guidance for treatment decisions.

Global Comparison of Communication of End-of-Life Decisions in the ICU

Prolonging life in the ICU increasingly is possible, so decisions to limit life-sustaining therapies frequently are made and communicated to patients and families or surrogates. Little is known about worldwide communication practices and influencing factors. Are there regional differences in end-of-life communication practices in ICUs worldwide? This analysis of data from a prospective, international study specifically addressed end-of-life communications in consecutive patients who died or had limitation of life-sustaining therapy over 6months in 199 ICUs in 36 countries, grouped regionally. End-of-life decisions were recorded for each patient and ethical practice was assessed retrospectively for each ICU using a 12-point questionnaire developed previously. Of 87,951 patients admitted, 12,850 died or experienced a limitation of therapy (14.6%). Of these, 1,199 patients (9.3%) were known to have an advance directive, and wishes were elicited from 6,456 patients (50.2%). Limitations of life-sustaining therapy were implemented for 10,401 patients (80.9%), 1,970 (19.1%) of whom had mental capacity at the time, and were discussed with 1,507 patients (14.5%) and 8,461 families (81.3%). Where no discussions with patients occurred (n= 8,710), this primarily was because of a lack of mental capacity in 8,114 patients (93.2%), and where none occurred with families (n= 1,622), this primarily was because of unavailability (n= 720 [44.4%]). Regional variation was noted for all end points. In generalized estimating equation (GEE) analyses, the odds for discussions with the patient or family increased by 30%(OR, 1.30; 95%CI, 1.18-1.44; P< .001) for every one-point increase in the Ethical Practice Score and by 92%(OR, 1.92; 95%CI, 1.28-2.89; P= .002) in the presence of an advance directive. End-of-life communication with patients and families or surrogates varies markedly in different global regions. GEE analysis supports the hypothesis that communication may increase with ethical practice and an advance directive. Greater effort is needed to align treatment with patients' wishes.

Changes in communication of end-of-life decisions in European ICUs from 1999 to 2016 (Ethicus-2) - a prospective observational study.

We investigated changes in communication practice about end-of-life decisions in European ICUs over 16years. This prospectively planned secondary analysis of two observational studies in 22 European ICUs in 1999-2000 (Ethicus-1) and 2015-16 (Ethicus-2) included consecutive patients who died or with limitation of life-sustaining therapy. ICUs were grouped into North, Central and South European regions. A total 4592 patients were included in 1999-2000 (n=2807) and 2015-16 (n=1785). Information about patient wishes increased overall (from 25.4% [570] to 51.1% [840]) and in all regions (42% to 61% [North], 22% to 56% [Central] and 20% to 32% [South], all p<0.001). Discussions of treatment limitations with patients or families increased overall (66.0% to 76.1%) and in Northern and Central Europe (87% to 94% and 75% to 82.2%, respectively, all p<0.001) but not in the South. Strongest predictor for discussions was the region (North>Central>South) followed by patient decision-making capacity. End-of-life decisions are increasingly discussed but communication practices vary by region and follow a North-South gradient. Despite increased availability of information, patient preferences still remain unknown in every second patient. This calls for increased efforts to assess patient preference in advance and make them known to ICU clinicians.

Variations in end-of-life practices in intensive care units worldwide (Ethicus-2): a prospective observational study

End-of-life practices vary among intensive care units (ICUs) worldwide. Differences can result in variable use of disproportionate or non-beneficial life-sustaining interventions across diverse world regions. This study investigated global disparities in end-of-life practices. In this prospective, multinational, observational study, consecutive adult ICU patients who died or had a limitation of life-sustaining treatment (withholding or withdrawing life-sustaining therapy and active shortening of the dying process) during a 6-month period between Sept 1, 2015, and Sept 30, 2016, were recruited from 199 ICUs in 36 countries. The primary outcome was the end-of-life practice as defined by the end-of-life categories: withholding or withdrawing life-sustaining therapy, active shortening of the dying process, or failed cardiopulmonary resuscitation (CPR). Patients with brain death were included in a separate predefined end-of-life category. Data collection included patient characteristics, diagnoses, end-of-life decisions and their timing related to admission and discharge, or death, with comparisons across different regions. Patients were studied until death or 2 months from the first limitation decision. Of 87 951 patients admitted to ICU, 12 850 (14·6%) were included in the study population. The number of patients categorised into each of the different end-of-life categories were significantly different for each region (p<0·001). Limitation of life-sustaining treatment occurred in 10 401 patients (11·8% of 87 951 ICU admissions and 80·9% of 12 850 in the study population). The most common limitation was withholding life-sustaining treatment (5661 [44·1%]), followed by withdrawing life-sustaining treatment (4680 [36·4%]). More treatment withdrawing was observed in Northern Europe (1217 [52·8%] of 2305) and Australia/New Zealand (247 [45·7%] of 541) than in Latin America (33 [5·8%] of 571) and Africa (21 [13·0%] of 162). Shortening of the dying process was uncommon across all regions (60 [0·5%]). One in five patients with treatment limitations survived hospitalisation. Death due to failed CPR occurred in 1799 (14%) of the study population, and brain death occurred in 650 (5·1%). Failure of CPR occurred less frequently in Northern Europe (85 [3·7%] of 2305), Australia/New Zealand (23 [4·3%] of 541), and North America (78 [8·5%] of 918) than in Africa (106 [65·4%] of 162), Latin America (160 [28·0%] of 571), and Southern Europe (590 [22·5%] of 2622). Factors associated with treatment limitations were region, age, and diagnoses (acute and chronic), and country end-of-life legislation. Limitation of life-sustaining therapies is common worldwide with regional variability. Withholding treatment is more common than withdrawing treatment. Variations in type, frequency, and timing of end-of-life decisions were observed. Recognising regional differences and the reasons behind these differences might help improve end-of-life care worldwide. None.

Abstract P283: Palliative and End-Of-Life Care After Left Ventricular Assist Device-Associated Intracranial Hemorrhage

Background: Intracranial hemorrhage (ICH) has a high mortality rate (up to 40% in some studies) with most deaths occurring after limitation of life-sustaining therapies. ICH is a feared complication of left ventricular assist device (LVADs) and challenges end-of-life decisions for patients, families, and health-care teams. Palliative care (PC) is considered essential for the management of patients who receive an LVAD, yet little is known about the end-of-life course of patients with LVAD-associated ICH. The goal of this single center study was to better understand the impact of PC involvement in post-ICH care in LVAD patients. Methods: We retrospectively identified all patients within our institutional LVAD database who experienced ICH between 2012 - 2018. Demographic, clinical, and outcome data were collected and analyzed using descriptive statistics. Results: Of the 283 patients who underwent LVAD placement, 32 (11%) experienced 34 ICHs: 16 intraparenchymal (IPH, 47%), 4 subdural (SDH, 12%), and 14 subarachnoid (SAH, 41%), a median of 258 (110-526) days post-LVAD. PC was consulted in 23 (68%) cases (69% of IPHs, 75% of SDHs, and 64% of SAHs). The patients who received PC were younger (50.5 [16.5] vs 54.9 [17.1] years) and more neurologically impaired (mean GCS 12.8 [3.6] vs 13.2 [4.0]). Women were referred more frequently than men (80% vs 63%) and White patients more frequently than non-White (74% vs 63%). All patients were full code at the time of their ICH; following PC consult, code status was changed to DNR in 48%. Ten patients (29%) died during their hospitalization. Though most patients in the cohort were referred for PC, only one died on home hospice; the remaining patients died in the hospital setting, 7 (70%) in the intensive care unit (ICU). Conclusions: In this single-center study, the vast majority of LVAD patients who died from their ICH died in the hospital setting, and most in the ICU, despite high numbers of PC consultation. As prior studies have associated in-hospital death with worse end-of-life-care and more physical and emotional distress for terminal patients, the use of hospice services has been increasing in the stroke population. Further work is needed to provide better end-of-life options for LVAD patients following serious neurologic injuries.

Mortality in severely injured patients: nearly one of five non-survivors have been already discharged alive from ICU

BackgroundMost trauma patients admitted to the hospital alive and die later on, decease during the initial care in the emergency department or the intensive care unit (ICU). However, a number of patients pass away after having been discharged from the ICU during the initial hospital stay. On first sight these cases could be seen as “failure to rescue” of potentially salvageable patients. A low rate of such patients might be a potential indicator of quality for trauma care on ICUs and surgical wards.MethodsRetrospective analysis of the TraumaRegister DGU® with data from 2015 to 2017. Patients that died during the initial ICU stay were compared to those who were discharged from the initial ICU stay for at least 24 h but died later on.ResultsA total of 82,313 trauma patients were included in the TraumaRegister DGU®. In total, 6576 patients (8.0%) died during their hospital stay. Out of those, 5481 were admitted to the ICU alive and 972 patients (17.7%) were discharged from ICU and died later on. Those were older (mean age: 77 vs. 68 years), less severely injured (mean ISS: 23.1 vs. 30.0 points) and had a longer mean ICU length of stay (10 vs. 6 days). A limitation of life-sustaining therapy due to a documented living will was present in 46.1% of all patients who died during their initial ICU stay and in 59.9% of patients who died after discharge from their initial ICU stay.Conclusions17.7% of all non-surviving severely injured trauma patients died within the hospital after discharge from their initial ICU treatment. Their death can partially be explained by a limitation of therapy due to a living will. In conclusion, the rate of such late deaths may partially represent patients that died of potentially avoidable or treatable complications.

Therapeutic Options for Patients with Refractory Status Epilepticus in Palliative Settings or with a Limitation of Life-Sustaining Therapies: A Systematic Review.

BackgroundRefractory status epilepticus (RSE) represents a serious medical condition requiring early and targeted therapy. Given the increasing number of elderly or multimorbid patients with a limitation of life-sustaining therapy (LOT) or within a palliative care setting (PCS), guidelines-oriented therapy escalation options for RSE have to be omitted frequently.ObjectivesThis systematic review sought to summarize the evidence for fourth-line antiseizure drugs (ASDs) and other minimally or non-invasive therapeutic options beyond guideline recommendations in patients with RSE to elaborate on possible treatment options for patients undergoing LOT or in a PCS.MethodsA systematic review of the literature in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, focusing on fourth-line ASDs or other minimally or non-invasive therapeutic options was performed in February and June 2020 using the MEDLINE, EMBASE and Cochrane databases. The search terminology was constructed using the name of the specific ASD or therapy option and the term ‘status epilepticus’ with the use of Boolean operators, e.g. “(brivaracetam) AND (status epilepticus)”. The respective Medical Subject Headings (MeSH) and Emtree terms were used, if available.ResultsThere is currently no level 1, grade A evidence for the use of ASDs in RSE. The best evidence was found for the use of lacosamide and topiramate (level 3, grade C), followed by brivaracetam, perampanel (each level 4, grade D) and stiripentol, oxcarbazepine and zonisamide (each level 5, grade D). Regarding non-medicinal options, there is little evidence for the use of the ketogenic diet (level 4, grade D) and magnesium sulfate (level 5, grade D) in RSE. The broad use of immunomodulatory or immunosuppressive treatment options in the absence of a presumed autoimmune etiology cannot be recommended; however, if an autoimmune etiology is assumed, steroid pulse, intravenous immunoglobulins and plasma exchange/plasmapheresis should be considered (level 4, grade D). Even if several studies suggested that the use of neurosteroids (level 5, grade D) is beneficial in RSE, the current data situation indicates that there is formal evidence against it.ConclusionsRSE in patients undergoing LOT or in a PCS represents a challenge for modern clinicians and epileptologists. The evidence for the use of ASDs in RSE beyond that in current guidelines is low, but several effective and well-tolerated options are available that should be considered in this patient population. More so than in any other population, advance care planning, advance directives, and medical ethical aspects have to be considered carefully before and during therapy.

Outcomes of very elderly trauma ICU patients. Results from the Spanish trauma ICU registry

ObjectiveTo analyze outcomes and factors related to mortality among very elderly trauma patients admitted to intensive care units (ICUs) participating in the Spanish trauma ICU registry. DesignA multicenter nationwide registry. Retrospective analysis. November 2012–May 2017. SettingParticipating ICUs. PatientsTrauma patients aged ≥80 years. InterventionsNone. Main variables of interestThe outcomes and influence of limitation of life sustaining therapy (LLST) were analyzed. Comparisons were established using the Wilcoxon test, Chi-squared test or Fisher's exact test as appropriate. Multiple logistic regression analysis was performed to analyze variables related to mortality. A p-value <0.05 was considered statistically significant. ResultsThe mean patient age was 83.4±3.3 years; 281 males (60.4%). Low-energy falls were the mechanisms of injury in 256 patients (55.1%). The mean ISS was 20.5±11.1, with a mean ICU stay of 7.45±9.9 days. The probability of survival based on the TRISS methodology was 69.8±29.7%. The ICU mortality rate was 15.5%, with an in-hospital mortality rate of 19.2%. The main cause of mortality was intracranial hypertension (42.7%). The ISS, the need for first- and second-tier measures to control intracranial pressure, and being admitted to the ICU for organ donation were independent mortality predictors. LLST was applied in 128 patients (27.9%). Patients who received LLST were older, with more severe trauma, and with more severe brain injury. ConclusionsVery elderly trauma ICU patients presented mortality rates lower than predicted on the basis of the severity of injury.

Changes in End-of-Life Practices in European Intensive Care Units From 1999 to 2016

End-of-life decisions occur daily in intensive care units (ICUs) around the world, and these practices could change over time. To determine the changes in end-of-life practices in European ICUs after 16 years. Ethicus-2 was a prospective observational study of 22 European ICUs previously included in the Ethicus-1 study (1999-2000). During a self-selected continuous 6-month period at each ICU, consecutive patients who died or had any limitation of life-sustaining therapy from September 2015 until October 2016 were included. Patients were followed up until death or until 2 months after the first treatment limitation decision. Comparison between the 1999-2000 cohort vs 2015-2016 cohort. End-of-life outcomes were classified into 5 mutually exclusive categories (withholding of life-prolonging therapy, withdrawing of life-prolonging therapy, active shortening of the dying process, failed cardiopulmonary resuscitation [CPR], brain death). The primary outcome was whether patients received any treatment limitations (withholding or withdrawing of life-prolonging therapy or shortening of the dying process). Outcomes were determined by senior intensivists. Of 13 625 patients admitted to participating ICUs during the 2015-2016 study period, 1785 (13.1%) died or had limitations of life-prolonging therapies and were included in the study. Compared with the patients included in the 1999-2000 cohort (n = 2807), the patients in 2015-2016 cohort were significantly older (median age, 70 years [interquartile range {IQR}, 59-79] vs 67 years [IQR, 54-75]; P < .001) and the proportion of female patients was similar (39.6% vs 38.7%; P = .58). Significantly more treatment limitations occurred in the 2015-2016 cohort compared with the 1999-2000 cohort (1601 [89.7%] vs 1918 [68.3%]; difference, 21.4% [95% CI, 19.2% to 23.6%]; P < .001), with more withholding of life-prolonging therapy (892 [50.0%] vs 1143 [40.7%]; difference, 9.3% [95% CI, 6.4% to 12.3%]; P < .001), more withdrawing of life-prolonging therapy (692 [38.8%] vs 695 [24.8%]; difference, 14.0% [95% CI, 11.2% to 16.8%]; P < .001), less failed CPR (110 [6.2%] vs 628 [22.4%]; difference, -16.2% [95% CI, -18.1% to -14.3%]; P < .001), less brain death (74 [4.1%] vs 261 [9.3%]; difference, -5.2% [95% CI, -6.6% to -3.8%]; P < .001) and less active shortening of the dying process (17 [1.0%] vs 80 [2.9%]; difference, -1.9% [95% CI, -2.7% to -1.1%]; P < .001). Among patients who had treatment limitations or died in 22 European ICUs in 2015-2016, compared with data reported from the same ICUs in 1999-2000, limitations in life-prolonging therapies occurred significantly more frequently and death without limitations in life-prolonging therapies occurred significantly less frequently. These findings suggest a shift in end-of-life practices in European ICUs, but the study is limited in that it excluded patients who survived ICU hospitalization without treatment limitations.

A 2-year multicenter, observational, prospective, cohort study on extracorporeal CO2 removal in a large metropolis area

BackgroundExtracorporeal carbon dioxide removal (ECCO2R) is a promising technique for the management of acute respiratory failure, but with a limited level of evidence to support its use outside clinical trials and/or data collection initiatives. We report a collaborative initiative in a large metropolis.MethodsTo assess on a structural basis the rate of utilization as well as efficacy and safety parameters of 2 ECCO2R devices in 10 intensive care units (ICU) during a 2-year period.ResultsSeventy patients were recruited in 10 voluntary and specifically trained centers. The median utilization rate was 0.19 patient/month/center (min 0.04; max 1.20). ECCO2R was started under invasive mechanical ventilation (IMV) in 59 patients and non-invasive ventilation in 11 patients. The Hemolung Respiratory Assist System (Alung) was used in 53 patients and the iLA Activve iLA kit (Xenios Novalung) in 17 patients. Main indications were ultraprotective ventilation for ARDS patients (n = 24), shortening the duration of IMV in COPD patients (n = 21), preventing intubation in COPD patients (n = 9), and controlling hypercapnia and dynamic hyperinflation in mechanically ventilated patients with severe acute asthma (n = 6). A reduction in median VT was observed in ARDS patients from 5.9 to 4.1 ml/kg (p <0.001). A reduction in PaCO2 values was observed in AE-COPD patients from 67.5 to 51 mmHg (p< 0.001). Median duration of ECCO2R was 5 days (IQR 3–8). Reasons for ECCO2R discontinuation were improvement (n = 33), ECCO2R-related complications (n = 18), limitation of life-sustaining therapies or measures decision (n = 10), and death (n = 9). Main adverse events were hemolysis (n = 21), bleeding (n = 17), and lung membrane clotting (n = 11), with different profiles between the devices. Thirty-five deaths occurred during the ICU stay, 3 of which being ECCO2R-related.ConclusionsBased on a registry, we report a low rate of ECCO2R device utilization, mainly in severe COPD and ARDS patients. Physiological efficacy was confirmed in these two populations. We confirmed safety concerns such as hemolysis, bleeding, and thrombosis, with different profiles between the devices. Such results could help to design future studies aiming to enhance safety, to demonstrate a still-lacking strong clinical benefit of ECCO2R, and to guide the choice between different devices.Trial registrationClinicalTrials.gov: Identifier: NCT02965079 retrospectively registered https://clinicaltrials.gov/ct2/show/NCT02965079

Outcomes of very elderly trauma ICU patients. Results from the Spanish trauma ICU registry.

To analyze outcomes and factors related to mortality among very elderly trauma patients admitted to intensive care units (ICUs) participating in the Spanish trauma ICU registry. A multicenter nationwide registry. Retrospective analysis. November 2012-May 2017. Participating ICUs. Trauma patients aged ≥80 years. None. The outcomes and influence of limitation of life sustaining therapy (LLST) were analyzed. Comparisons were established using the Wilcoxon test, Chi-squared test or Fisher's exact test as appropriate. Multiple logistic regression analysis was performed to analyze variables related to mortality. A p-value <0.05 was considered statistically significant. The mean patient age was 83.4±3.3 years; 281 males (60.4%). Low-energy falls were the mechanisms of injury in 256 patients (55.1%). The mean ISS was 20.5±11.1, with a mean ICU stay of 7.45±9.9 days. The probability of survival based on the TRISS methodology was 69.8±29.7%. The ICU mortality rate was 15.5%, with an in-hospital mortality rate of 19.2%. The main cause of mortality was intracranial hypertension (42.7%). The ISS, the need for first- and second-tier measures to control intracranial pressure, and being admitted to the ICU for organ donation were independent mortality predictors. LLST was applied in 128 patients (27.9%). Patients who received LLST were older, with more severe trauma, and with more severe brain injury. Very elderly trauma ICU patients presented mortality rates lower than predicted on the basis of the severity of injury.

Treatment intensity and outcome of nonagenarians selected for admission in ICUs: a multicenter study of the Outcomerea Research Group.

BackgroundOutcome of very elderly patients admitted in intensive care unit (ICU) was most often reported for octogenarians. ICU admission demands for nonagenarians are increasing. The primary objective was to compare outcome and intensity of treatment of octogenarians and nonagenarians.MethodsWe performed an observational study in 12 ICUs of the Outcomerea™ network which prospectively upload data into the Outcomerea™ database. Patients >90 years old (case patients) were matched with patients 80–90 years old (control patients). Matching criteria were severity of illness at admission, center, and year of admission.ResultsA total of 2419 patients aged 80 or older and admitted from September 1997 to September 2013 were included. Among them, 179 (7.9 %) were >90 years old. Matching was performed for 176 nonagenarian patients. Compared with control patients, case patients were more often hospitalized for unscheduled surgery [54 (30.7 %) vs. 42 (23.9 %), p < 0.01] and had less often arterial monitoring for blood pressure [37 (21 %) vs. 53 (30.1 %), p = 0.04] and renal replacement therapy [5 (2.8 %) vs. 14 (8 %), p = 0.05] than control patients. ICU [44 (25 %) vs. 36 (20.5 %), p = 0.28] or hospital mortality [70 (39.8 %) vs. 64 (36.4 %), p = 0.46] and limitation of life-sustaining therapies were not significantly different in case versus control patients, respectively. Only 16/176 (14 %) of case patients were transferred to a geriatric unit.ConclusionThis multicenter study reported that nonagenarians represented a small fraction of ICU patients. When admitted, these highly selected patients received similar life-sustaining treatments, except RRT, than octogenarians. ICU and hospital mortality were similar between the two groups.Electronic supplementary materialThe online version of this article (doi:10.1186/s13613-016-0133-9) contains supplementary material, which is available to authorized users.

Evaluation of severity in critically ill patients (cips) with limitation of life-sustaining therapy (LLST)

It is considered that the severity of CIPs with LLSt is higher than the overall CIPs requiring ICU admission. The identification of specific clinical variables which determine the severity of the CIPs with LLST perhaps has not been researched enough.

Prevalence and Outcomes of Patients Meeting Palliative Care Consultation Triggers in Neurological Intensive Care Units.

Palliative care needs among patients in the neurological intensive care unit (neuroICU) are poorly characterized. Our aim was to explore the prevalence and type of potential palliative care consultation triggers in neuroICUs. We conducted a retrospective cohort study of neuroICU admissions in Project IMPACT from 2001 to 2008. We assessed the prevalence of neuroICU admissions meeting one or more of five validated palliative care consultation triggers and compared the percentage of admissions meeting these triggers in other ICUs from the same hospitals. Among 1268 admissions to 2 neuroICUs, 200 (15.8%) met one or more triggers for palliative care consultation. Among 13,694 admissions to non-neuroICUs in the same hospitals, 1909 (13.9%) met one or more palliative care triggers (p=0.44). The most common trigger in the neuroICU was intracerebral hemorrhage with mechanical ventilation (n=92; 7.3%). The most common trigger in non-neuroICUs was ICU admission following ≥10-day hospital stay (n=805; 5.9%). Although ICU mortality was not significantly higher in neuroICU vs. non-neuroICU patients meeting triggers (23.4 vs 19.9%, p=0.46), neuroICU patients were significantly more likely to have withdrawal of life-sustaining therapies (19.4 vs 8.0%, p<0.001). Among neuroICU patients, 15.8% met triggers for palliative care consultation. Although prevalence of admissions meeting any trigger was similar amongst all ICUs, neuroICU admissions met different types of triggers and were more likely to have withdrawal of life-sustaining therapy. These data suggest that palliative care needs are common among neuroICU patients and discussions with patients and families regarding limitation of life-sustaining therapy may differ in this setting.

Family meetings and end-of-life decision-making in Thai critically ill patients

Limitation of life-sustaining therapy after critical illnesses in Thailand is uncommon. The barriers may be uncertain prognosis, wrong sense of doctor duty, guilty feeling, conflicts on the goals of care and fear of liability. Therefore we set a formal healthcare team meeting followed by a family meeting to find the balance between curative and palliative intention. The objective was to determine the nature and effects of family meetings in the Thai social context.

Kidney transplantation with grafts from type III Maastricht non-beating-heart donors.

Kidney transplantation (KT) with kidneys from non-beating-heart donors (NBHD) is a growing trend in Spain. The majority of these kidneys come from type II Maastricht patients, although in recent years, organ donations from patients awaiting cardiac arrest following limitation of life-sustaining therapy has already been in practice in certain European and North American countries, involving type III Maastricht patients. We present a series of 6 KT using kidneys from NHBD as a consequence of limitation of life-sustaining therapy in three different hospitals in the sector of Malaga. After agreeing upon a protocol for evaluating the potential of a patient for organ donation after the decision for limiting life-sustaining therapy, the patients’ families were given the option of organ donation. Kidneys were preserved using a Porges double balloon catheter, which was placed prior to cardiac arrest. In two cases, the limitation of life-sustaining therapy took place in the intensive care unit, and in the third case, in the operating room. The interval between limitation of life-sustaining therapy and cardiac arrest ranged between 15 minutes and 40 minutes, with an interval of circulatory arrest prior to perfusion of 5-11 minutes. Perfusion-cooling of the kidneys was initially carried out using saline solution, followed by organ preservation solution (Celsior or Belzer) and extraction of the kidney using a rapid surgical technique. True or functional hot ischaemia times were 60 minutes, 59 minutes, and 50 minutes, respectively, for each of the three donors. Kidneys were evaluated for viability using time intervals for the procedure (including hypotension prior to cardiac arrest), macroscopic appearance, and histopathology of a sample taken from each kidney. The recipients of these 6 kidneys had given their consent to receive organs from expanded-criteria donors. Cold ischaemia lasted between 9 hours and 20 hours (mean: 14.6 hours). One recipient developed haemorrhagic complications during the immediate postoperative period and required a transplantectomy. The other five currently retain functioning grafts. All had delayed graft function, necessitating haemodialysis. The range of estimated glomerular filtration rates at the most recent follow-up evaluation was 23.0-106 ml/min/1.73 m(2). In conclusion, type III Maastricht donors provide valid kidneys for transplantation, although this series showed that supported functional hot ischaemia was very important, the consequence of accumulated ischaemic damage starting in the agonal phase, circulatory arrest, and organ preservation using cold solutions. As such, to improve the quality of results obtained using kidneys from these types of donors would involve a very careful selection of optimal donors and minimisation of total functional ischaemia times.

Attitudes towards ethical problems in critical care medicine: the Chinese perspective

Critical care doctors are frequently faced with clinical problems that have important ethical and moral dimensions. While Western attitudes and practice are well documented, little is known of the attitudes or practice of Chinese critical care doctors. An anonymous, written, structured questionnaire survey was translated from previously reported ethical surveys used in Europe and Hong Kong. A snowball method was used to identify 534 potential participants from 21 regions in China. A total of 315 (59%) valid responses were analysed. Most respondents (66%) reported that admission to an intensive care unit (ICU) was commonly limited by bed availability, but most (63%) would admit patients with a poor prognosis to ICU. Only 19% of respondents gave complete information to patients and family, with most providing individually adjusted information, based on prognosis and the recipient's educational level. Only 28% disclosed all details of an iatrogenic incident, despite 62% stating that they should. The use of do not resuscitate orders or limitation of life-sustaining therapy in terminally ill patients reported as uncommon and according to comparable reports, both are more common practice in Hong Kong or Europe. In contrast to European practices, doctors were more acquiescent to families in decision-making at the end of life. A number of differences in ethical attitudes and related behaviour between Chinese, Hong Kong and European ICU doctors were documented. A likely explanation is differing cultural background, and doctors should be aware of likely expectations when treating patients from a different culture.