Withdrawal Of Life-sustaining Treatment Research Articles

MP31-11 DURATION OF THE AGONAL PHASE DOES NOT IMPACT DELAYED GRAFT FUNCTION NOR ONE-YEAR RENAL FUNCTION IN DONATION AFTER CIRCULATORY DEATH KIDNEY TRANSPLANTATION

You have accessJournal of UrologyCME1 Apr 2023MP31-11 DURATION OF THE AGONAL PHASE DOES NOT IMPACT DELAYED GRAFT FUNCTION NOR ONE-YEAR RENAL FUNCTION IN DONATION AFTER CIRCULATORY DEATH KIDNEY TRANSPLANTATION Yanbo Guo, Jirong Lu, Juliano Offerni, Danny Matti, Grant Luke, Edem Afenu, Alp Sener, and Patrick Luke Yanbo GuoYanbo Guo More articles by this author , Jirong LuJirong Lu More articles by this author , Juliano OfferniJuliano Offerni More articles by this author , Danny MattiDanny Matti More articles by this author , Grant LukeGrant Luke More articles by this author , Edem AfenuEdem Afenu More articles by this author , Alp SenerAlp Sener More articles by this author , and Patrick LukePatrick Luke More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003264.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Donation after circulatory death (DCD) has significantly expanded the limited pool of available kidney allografts. The agonal phase is measured between the withdrawal of life-sustaining treatment and the time of circulatory arrest. Due to concerns about ischemic kidney injury during the agonal phase, many transplant programs use a cut-off time of 1 hour before abandoning the kidney retrieval. Our centre may use kidneys with an agonal phase for up to 3 hours. We evaluated how the length of the agonal phase influences graft outcomes. METHODS: We analysed a single-centre database of DCD renal transplant recipients between 2006-2020. Pediatric and donation after euthanasia donors were excluded. Data collected included recipient and donor demographics, surgery information, and outcomes up to one-year post transplant. SPSS was used for statistical analysis. RESULTS: Of the 182 DCD kidney donations that were identified, 27 (14.8%) arrested after 1 hour, and 10 (5.5%) arrested after 1.5 hours. The mean agonal time was 25 minutes. The longest interquartile range was between 37 and 130 minutes. Binary logistic regression showed no significant association between time to arrest and delayed graft function (DGF) (p=0.79) or primary nonfunction (PNF) (p=0.50). The Chi-square test also showed no significant association between DGF or PNF and donors who arrested in the longest quartile (X2=0.17, p=0.67), after 1 hour (X2=0.611, p=0.44), or after 1.5 hours (X2=0.161, p=0.69). Pearson correlation did show a weak association between time to arrest and a higher creatinine at three months (0.245, p=0.002) and six months (0.177, p=0.043), but this association was no longer present at one year (-0.032, p=0.77). CONCLUSIONS: We found no association between the length of the agonal phase and DGF or one-year renal function after transplantation. This supports the use of kidneys from DCD donors with agonal phases of one hour and beyond. Source of Funding: No disclosures © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e433 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Yanbo Guo More articles by this author Jirong Lu More articles by this author Juliano Offerni More articles by this author Danny Matti More articles by this author Grant Luke More articles by this author Edem Afenu More articles by this author Alp Sener More articles by this author Patrick Luke More articles by this author Expand All Advertisement PDF downloadLoading ...

Identification of predictors for neurological outcome after cardiac arrest in peripheral blood mononuclear cells through integrated bioinformatics analysis and machine learning

Neurological prognostication after cardiac arrest (CA) is important to avoid pursuing futile treatments for poor outcome and inappropriate withdrawal of life-sustaining treatment for good outcome. To predict neurological outcome after CA through biomarkers in peripheral blood mononuclear cells, four datasets were downloaded from the Gene Expression Omnibus database. GSE29546 and GSE74198 were used as training datasets, while GSE92696 and GSE34643 were used as verification datasets. The intersection of differentially expressed genes and hub genes from multiscale embedded gene co-expression network analysis (MEGENA) was utilized in the machine learning screening. Key genes were identified using support vector machine recursive feature elimination (SVM-RFE), least absolute shrinkage and selection operator (LASSO) logistic regression, and random forests (RF). The results were validated using receiver operating characteristic curve analysis. An mRNA-miRNA network was constructed. The distribution of immune cells was evaluated using cell-type identification by estimating relative subsets of RNA transcripts (CIBERSORT). Five biomarkers were identified as predictors for neurological outcome after CA, with an area under the curve (AUC) greater than 0.7: CASP8 and FADD-like apoptosis regulator (CFLAR), human protein kinase X (PRKX), miR-483-5p, let-7a-5p, and let-7c-5p. Interestingly, the combination of CFLAR minus PRKX showed an even higher AUC of 0.814. The mRNA-miRNA network consisted of 30 nodes and 76 edges. Statistical differences were found in immune cell distribution, including neutrophils, NK cells active, NK cells resting, T cells CD4 memory activated, T cells CD4 memory resting, T cells CD8, B cells memory, and mast cells resting between individuals with good and poor neurological outcome after CA. In conclusion, our study identified novel predictors for neurological outcome after CA. Further clinical and laboratory studies are needed to validate our findings.

Intraventricular Hemorrhage in Very Preterm Children: Mortality and Neurodevelopment at Age 5.

The objectives were to describe mortality and causes of death in children with intraventricular hemorrhage (IVH) and to study neurodevelopmental outcomes. The study was a secondary analysis of the French national prospective and population-based cohort EPIPAGE-2. Children were recruited in 2011. A standardized assessment was conducted at age 5. Children born before 32 weeks' gestation and admitted to a NICU were eligible. Exposure was IVH defined by the Papile classification. Main outcomes were mortality, causes of death, and neurodevelopmental outcomes at age 5. Among the 3468 children included, 578 (16.7%) had grade 1 IVH, 424 (12.2%) grade 2 IVH, and 114 (3.3%) grade 3 IVH; 144 (4.1%) had intraparenchymal hemorrhage (IPH). Mortality was 29.7% (36 of 114) for children with grade 3 IVH and 74.4% (109 of 144) for those with IPH; 67.6% (21 of 31) and 88.7% (86 of 97) of deaths, respectively, were because of withholding and withdrawing of life-sustaining treatment. As compared with no IVH, low-grade IVH was not associated with measured neurodevelopmental disabilities at age 5. High-grade IVH was associated with moderate and severe neurodevelopmental disabilities, reduced full-scale IQ, and cerebral palsy. Rates of neurodevelopmental disabilities at age 5 did not differ between children without IVH and those with low-grade IVH. For high-grade IVH, mortality rate was high, mostly because of withholding and withdrawal of life-sustaining treatment, and we found a strong association with overall neurodevelopmental disabilities in survivors.

The final decision among the injured elderly, to stop or to continue? Predictors of withdrawal of life supporting treatment.

There is a paucity of data on factors that influence the decision regarding withdrawal of life supporting treatment (WLST) in geriatric trauma patients. We aimed to identify predictors of WLST in geriatric trauma patients. This retrospective analysis of the American College of Surgeons- Trauma Quality Improvement Program (2017-2019) included all severely injured (Injury Severity Score >15) geriatric trauma patients (≥65 years). Multivariable logistic regression was performed to identify independent predictors of WLST. There were 155,583 patients included. Mean age was 77 ± 7 years, 55% were male, 97% sustained blunt injury, and the median Injury Severity Score was 17 [16-25]. Overall WLST rate was 10.8%. On MLR analysis, increasing age (adjusted odds ratio [aOR], 1.35; 95% confidence interval [CI], 1.33-1.37; p < 0.001), male sex (aOR, 1.14; 95% CI, 1.09-1.18; p < 0.001), White race (aOR, 1.44; 95% CI, 1.36-1.52; p < 0.001), frailty (aOR, 1.42; 95% CI, 1.34-1.50; p < 0.001), government insurance (aOR, 1.27; 95% CI, 1.20-1.33; p < 0.001), presence of advance directive limiting care (aOR, 2.55; 95% CI, 2.40-2.70; p < 0.001), severe traumatic brain injury (aOR, 1.80; 95% CI, 1.66-1.95; p < 0.001), ventilator requirement (aOR, 12.73; 95% CI, 12.09-13.39; p < 0.001), and treatment at higher level trauma centers (Level I aOR, 1.49; 95% CI, 1.42-1.57; p < 0.001; Level II aOR, 1.43; 95% CI, 1.35-1.51; p < 0.001) were independently associated with higher odds of WLST. Our results suggest that nearly one in 10 severely injured geriatric trauma patients undergo WLST. Multiple patient and hospital related factors contribute to decision making and directed efforts are necessary to create a more standardized process. Prognostic and Epidemiological; Level III.

COVID-19 pandemic experiences, ethical conflict and decision-making process in critical care professionals (Quali-Ethics-COVID-19 research part 1): An international qualitative study.

The aim of this study was to explore the sources of ethical conflict and the decision-making processes of ICU nurses and physicians during the first and subsequent waves of the COVID-19 pandemic. Depside several studies exploring ethical conflicts during COVID-19 pandemic, few studies have explored in depth the perceptions and experiences of critical care professionals regarding these conflicts, the decision-making process or which have analysed the complexity of actually implementing the recommendations of scientific societies and professional/healthcare institutions in interdisciplinary samples. A descriptive phenomenological study. Thirty-eight in-depth interviews were conducted with critical care nurses and physicians from five hospitals in Spain and Italy between December 2020 and May 2021. A thematic content analysis of the interview transcripts was conducted by two researchers. Consolidated criteria for reporting qualitative research (COREQ) were employed to ensure the quality and transparency of this study. Two main themes emerged as sources of ethical conflict: the approach to end of life in exceptional circumstances and the lack of humanisation and care resources. The former comprised two subthemes: end-of-life care and withholding and withdrawal of life-sustaining treatment; the latter comprised three subthemes: the impossibility of guaranteeing the same opportunities to all, fear of contagion as a barrier to taking decisions and the need to humanise care. Professionals sought to take their decisions in line with professional ethics and bioethical principles, but, nevertheless, they experienced moral dilemmas and moral distress when not being able to care for, or to treat, their patients as they believed fit. Further education and training are recommended on the provision of end-of-life and post-mortem care, effective communication techniques via video calls, disclosure of bad news and bioethical models for decision-making in highly demanding situations of uncertainty, such as those experienced during the COVID-19 pandemic.

End of Life Care of People with Long Term Neurological Conditions: Interface between Neurology, Neurorehabilitation and Palliative Care

Neurologists address diagnosis, modification of disease course and management of symptoms of people with long-term neurological conditions such as Parkinson’s disease, multiple sclerosis, motor neuron disease and sequelae of stroke. Neurorehabilitation specialists focus on management of symptoms and alleviation of activity limitations. Palliative care specialists are involved in end-of-life care of these patients. Guidance and protocols of palliative care services have been directed towards the care of patients with cancer. While it may be possible to extrapolate some of these to people with long-term neurological conditions, there are obvious differences between the two groups. The time course of progressive neurological conditions varies widely between and within the disorders which make timing of initiation of these discussions challenging. Common issues during end-of-life care are when to start discussions about end-of-life care, advanced care planning, management of common symptoms, withdrawal of life-sustaining treatments, support for family and caregivers and when to involve specialist palliative care team. The unique social, economic and cultural aspects of India influence these decisions. End-of-life care cannot be seen in isolation and as such close collaboration between neurology, neurorehabilitation and specialist palliative care is imperative. In this article, we will discuss the end-of-life care of people with long-term neurological condition in India.

Timing and causes of death after endovascular thrombectomy in patients with acute ischemic stroke.

Endovascular thrombectomy (EVT) increases the chance of good functional outcome after ischemic stroke caused by a large vessel occlusion, but the risk of death in the first 90 days is still considerable. We assessed the causes, timing and risk factors of death after EVT to aid future studies aiming to reduce mortality. We used data from the MR CLEAN Registry, a prospective, multicenter, observational cohort study of patients treated with EVT in the Netherlands between March 2014, and November 2017. We assessed causes and timing of death and risk factors for death in the first 90 days after treatment. Causes and timing of death were determined by reviewing serious adverse event forms, discharge letters, or other written clinical information. Risk factors for death were determined with multivariable logistic regression. Of 3180 patients treated with EVT, 863 (27.1%) died in the first 90 days. The most common causes of death were pneumonia (215 patients, 26.2%), intracranial hemorrhage (142 patients, 17.3%), withdrawal of life-sustaining treatment because of the initial stroke (110 patients, 13.4%) and space-occupying edema (101 patients, 12.3%). In total, 448 patients (52% of all deaths) died in the first week, with intracranial hemorrhage as most frequent cause. The strongest risk factors for death were hyperglycemia and functional dependency before the stroke and severe neurological deficit at 24-48 h after treatment. When EVT fails to decrease the initial neurological deficit, strategies to prevent complications like pneumonia and intracranial hemorrhage after EVT could improve survival, as these are often the cause of death.

End-of-life care over four decades in a quaternary neonatal intensive care unit.

Death in the neonatal intensive care unit (NICU) commonly follows a decision to withdraw or limit life-sustaining treatment. Advances in medicine have changed the nature of life-sustaining interventions available and the potential prognosis for many newborn conditions. We aimed to assess changes in causes of death and end-of-life care over nearly four decades. A retrospective review of infants dying in the NICU was performed (2017-2020) and compared with previous audits performed in the same centre (1985-1987 and 1999-2001). Diagnoses at death were recorded for each infant as well as their apparent prognosis and any withdrawal or limitations of medical treatment. In the recent epoch, there were 88 deaths out of 2084 admissions (4.2%), a reduction from the previous epochs (132/1362 (9.7%) and 111/1776 (6.2%), respectively, for epochs 1 and 2). More than 90% of infants died after withdrawal of life-sustaining treatment, an increase from the previous two epochs (75%). There was a reduction in deaths from chromosomal abnormalities, complications related to prematurity and severe birth asphyxia. There continue to be changes in both the diagnoses leading to death and approaches to withdrawal of treatment in the NICU. These may reflect ongoing changes in both prenatal and post-natal diagnostics as well as changing attitudes towards palliative care within the medical and wider community.

자기결정권 존중을 위해 선행해야 하는 것들: 의사조력자살과 연명의료 유보나 중단과 관련하여*

In this article I review Koh YS’s recent article concerning the legalization of physician-assisted suicide and provide additional support for the arguments he advances. Koh argues against the legalization of physican-assisted suicide and for an extension of the period in which the withholding or withdrawal of life-sustaining treatment is carried out following a patient’s request. I claim that the very arguments Koh presents against the legalization of physician-assisted suicide may be arguments against the extension. In particular, the extension presupposes a new social consensus just as the current performance period for withholding or withdrawing life-sustaining treatment was based on the social consensus that existed at the time that legislation was passed. Additionally, I argue that certain safeguards must be established or implemented to respect the right to self-determination in our society. For example, the monitoring and service of end-of-life care must be enhanced in order to prevent any coercion or abuse in individual decisions on life-sustaining treatment.

Grey area nursing: high-dependency nurses' experiences of caring for patients approaching the transition from curative to palliative care.

Background: Nurses in high-dependency units frequently facilitate the withdrawal of life-sustaining treatments and provide end-of-life care. Providing this care has been shown to cause distress, burnout and cumulative grief. There remains a lack of understanding of high dependency nurses' experiences of caring for patients approaching withdrawal of life-sustaining treatments. Aim: To explore experiences of high dependency nurses caring for patients approaching withdrawal of life-sustaining treatment and highlight any support or needs they may have. Methods: Interviews were conducted and analysed using qualitative thematic analysis. Findings: Nurses experienced conflict in decision making, which was reported to prolong patient distress and cause nurses moral anguish. Nurses need time to talk and further education to support them to provide withdrawal of life-sustaining treatment. Conclusion: High-dependency nurses need time to talk following caring for this patient group and more extensive education to support them to provide quality end-of-life care.

Organ Donation and End-of-Life Discussions: A Scripting Template for Supportive Palliative Care.

This article describes the importance of introducing donation after circulatory death during discussions about the withdrawal of life-sustaining treatment and provides a scripting template to facilitate these discussions, developed by a multidisciplinary team of stakeholders.

End-of-life care for patients with prolonged disorders of consciousness following withdrawal of life-sustaining treatment: Experience and lessons from an 8-year cohort

National guidelines provide advice for end-of-life care in patients with prolonged disorders of consciousness (PDOC). Following a Supreme Court judgment in July 2018, updated guidelines set out requirements to ensure that decisions to withdraw clinically assisted nutrition and hydration (CANH) are made responsibly in the absence of a mandatory application to the court.This retrospective 8-year cohort analysis of prospectively collected clinical data examines the experience and lessons learned from implementing the guidelines in the 80 PDOC patients who have died in one tertiary centre since 2014. It also reports performance against the standards for elective withdrawal of CANH outside of court since July 2018.CANH was withdrawn in 39/80 (49%) of the patients, over half of whom were already imminently dying. Even in a centre where patients are referred for this purpose, elective CANH withdrawal is comparatively rare (just 14 patients since 2018). The requirements were met in all cases.

Hospital to Hospital Transfers of Cerebral Hemorrhage: Characteristics of Early Withdrawal of Life-Sustaining Treatment.

Large intracerebral hemorrhages (ICHs) are associated with significant morbidity and mortality. Patient transfer to higher level centers is common, but care in these centers rarely demonstrably improves morbidity or reduces mortality. Patients may rapidly progress to brain death, but a large number die shortly after transferring because of withdrawal of life-sustaining treatment (WOLST). This outcome may result in poor resource use and unnecessary cost to patients, families, and institutions. We sought to determine clinical and radiographic predictors of early death or WOLST that may alter potential transfer. We performed a retrospective review of patients admitted from outside medical centers to the neurosciences intensive care unit at Saint Marys Mayo Clinic Hospital in Rochester, MN, from January 2014 to December 2019. Patients ≥ 18years old with a spontaneous ICH were included. Exclusion criteria included trauma, subarachnoid hemorrhage, and subdural hematoma. We identified patients who died or underwent WOLST within 24h of transfer. Descriptive characteristics of patients and ICH were collected. Data were analyzed with univariable, multivariable, and logistic regression. Predictive modeling was performed. An additional case-matched study was completed to evaluate for characteristics further. A total of 317 consecutive patients were identified. Forty-two patients were found with early death or WOLST within 24h of transfer. Do not resuscitate/do not intubate (DNR/DNI) code status (odds ratio [OR] 5.23, confidence interval [CI] 3.31-8.28), anticoagulation use (OR 2.11, CI 1.09-4.09), and lower level of consciousness at presentation based on Glasgow Coma Score (OR 1.41, CI 1.29-1.54) and Full Outline of Unresponsiveness (FOUR) score (OR 1.34, CI 1.26-1.46) were associated with WOLST. Associated characteristics on the computed tomography scan included midline shift (OR 4.64, CI 2.32-9.29), hydrocephalus (OR 9.30, CI 4.56-18.96), and intraventricular extension (OR 5.27, CI 2.60-10.68). Case matching restricted to midline shift demonstrated similarity between patients with aggressive care and WOLST. DNR/DNI code status, warfarin use, ICH score, and composite FOUR score were the best predictive characteristics (area under the curve 0.942). Early death or WOLST after ICH within 24h of presentation was most associated with DNR/DNI code status, warfarin use, ICH score, and lower level of consciousness at presentation. These characteristics may be used by clinicians to guide conversations prior to transfer to tertiary care centers.

Longitudinal Trends in Severe Traumatic Brain Injury Inpatient Rehabilitation.

The goal of this study is to describe national trends in inpatient rehabilitation facility (IRF) discharges for the most severely disabled cohort of patients with traumatic brain injury (TBI). Data from the Uniform Data System for Medical Rehabilitation for patients discharged from an IRF between January 1, 2002, and December 31, 2017, with a diagnosis of TBI and an admission Functional Independence Measure of 18, the lowest possible score, were obtained and analyzed. Of the 252 112 patients with TBI discharged during the study period, 10 098 met the study criteria. From 2002 to 2017, the number of patients with an IRF admission Functional Independence Measure of 18 following TBI discharged from IRFs annually decreased from 649 to 488, modeled by a negative regression (coefficient = -2.97; P = .001), and the mean age (SD) increased from 43.0 (21.0) to 53.7 (21.3) years (coefficient = 0.70; P < .001). During the study period, the number of patients with the most severe disability on admission to IRF who were discharged annually as a proportion of total patients with TBI decreased from 5.5% to 2.5% (odds ratio = 0.95; P < .001) and their mean length of stay decreased from 41.5 (36.2) to 29.3 (24.9) days (coefficient = -0.83; P < .001]. The number and proportion of patients with the most severe disability on IRF admission following TBI who are discharged from IRFs is decreasing over time. This may represent a combination of primary prevention, early mortality due to withdrawal of life-sustaining treatment, alternative discharge dispositions, or changes in admitting and reimbursement practices. Furthermore, there has been a decrease in the duration of IRF level care for these individuals, which could ultimately lead to poorer functional outcomes, particularly given the importance of specialized rehabilitative care in this population.

ARE BEST PRACTICE GUIDELINES INFORMING WITHDRAWAL OF LIFE SUSTAINING THERAPY FOLLOWED AFTER CARDIAC ARREST?

Out-of-Hospital Cardiac Arrest (OHCA) is a leading cause of mortality worldwide. Amongst patients who achieve return of spontaneous circulation and are admitted to hospital, most will die from the effects of brain injury. Withdrawal of Life Sustaining Treatments (WLST) is the most common means of death, and current guidelines recommend WLST only after formal neuroprognostication, and after 72 hours. We aimed to determine the incidence and characteristics associated with WLST compared with no WLST in comatose patients following OHCA.

EFFECTIVENESS OF NURSING EDUCATION IN TIMELY ORGAN REFERRAL: A SMALL INTERVENTION, AN IMPRESSIVE OUTCOME

EFFECTIVENESS OF NURSING EDUCATION IN TIMELY ORGAN REFERRAL: A SMALL INTERVENTION, AN IMPRESSIVE OUTCOME

Predicting mortality in moderate-severe TBI patients without early withdrawal of life-sustaining treatments including ICU complications: The MYSTIC-score

PurposeTo develop and internally validate the MortalitY in Moderate-Severe TBI plus ICU Complications (MYSTIC)-Score to predict in-hospital mortality of msTBI patients without early (<24 h) withdrawal-of-life-sustaining treatments. MethodsWe analyzed data from a Neuro-Trauma Intensive Care Unit prospectively collected between 11/2009–5/2019. Consecutive adult msTBI patients were included if Glasgow Coma Scale≤12, and neither died nor had withdrawal-of-life-sustaining treatments within 24 h of admission (n = 485). Using univariate and multivariable logistic regression in a random-split cohort approach (2/3 derivation;1/3 validation), we identified independent predictors of in-hospital mortality while adjusting for validated predictors of mortality (IMPACT-variables). We constructed the MYSTIC-Score and examined discrimination and calibration. ResultsThe MYSTIC-Score included the ICU complications brain edema, herniation, systemic inflammatory response syndrome, sepsis, acute kidney injury, cardiac arrest, and urinary tract infection. In the derivation cohort(n = 324), discrimination and calibration were excellent (area-under-the-receiver-operating-curve [AUC-ROC] = 0.95;Hosmer-Lemeshow p-value = 0.09, with p > 0.05 indicating good calibration). Internal validation revealed an AUC-ROC = 0.93 and Hosmer-Lemeshow-p-value = 0.76 (n = 161). ConclusionsCertain ICU complications are independent predictors of in-hospital mortality and strengthen outcome prediction in msTBI when combined with validated admission predictors of mortality. However, external validation is needed to determine robustness and practical applicability of our model given the high potential for residual confounders.

The theoretical and practical arguments against the unilateral withdrawal of life-sustaining treatment during crisis standards of care: Does the Knobe effect apply to unilateral withdrawal?

Some argue that it is ethically justifiable to unilaterally withdraw life-sustaining treatment during crisis standards of care without the patient's consent in order to reallocate it to another patient with a better chance of survival. This justification has been supported by two lines of argument: the equivalence thesis and the rule of the double effect. We argue that there are theoretical issues with the first and practical ones with the second, as supported by an experiment aimed at exploring whether the Knobe effect, which affects the folk concept of intention, applies to situations of unilateral withdrawal. Fifty-two critical care physicians from one university were asked to ascribe intention in two hypothetical scenarios A and B in which outcomes differ-the patient from whom life-sustaining treatment is withdrawn dies in scenario A but survives in scenario B-but the intention, to save the other patient regardless of the outcome of the other, is the same. The survey was administered via a web-based survey and all answers were anonymous. A paired proportion test was used to compare responses to both questions. All 52 surveyed individuals responded in scenario A and 30 (57.7%) ascribed intention when outcomes were unfavorable, whereas 50 responded in scenario B and 8 (16%) ascribed intention when outcomes were favorable, a difference that was statistically significant (p < 0.001). There are theoretical and practical issues with the arguments proposed to justify the unilateral withdrawal of life-sustaining treatment based on the equivalence thesis and the rule of double effect.

Predicting Time to Death After Withdrawal of Life-Sustaining Treatment in Children.

OBJECTIVES:Accurately predicting time to death after withdrawal of life-sustaining treatment is valuable for family counseling and for identifying candidates for organ donation after cardiac death. This topic has been well studied in adults, but literature is scant in pediatrics. The purpose of this report is to assess the performance and clinical utility of the available tools for predicting time to death after treatment withdrawal in children.DATA SOURCES:Terms related to predicting time to death after treatment withdrawal were searched in PubMed and Embase from 1993 to November 2021.STUDY SELECTION:Studies endeavoring to predict time to death or describe factors related to time to death were included. Articles focusing on perceptions or practices of treatment withdrawal were excluded.DATA EXTRACTION:Titles, abstracts, and full text of articles were screened to determine eligibility. Data extraction was performed manually. Two-by-two tables were reconstructed with available data from each article to compare performance metrics head to head.DATA SYNTHESIS:Three hundred eighteen citations were identified from the initial search, resulting in 22 studies that were retained for full-text review. Among the pediatric studies, predictive models were developed using multiple logistic regression, Cox proportional hazards, and an advanced machine learning algorithm. In each of the original model derivation studies, the models demonstrated a classification accuracy ranging from 75% to 91% and positive predictive value ranging from 0.76 to 0.93.CONCLUSIONS:There are few tools to predict time to death after withdrawal of life-sustaining treatment in children. They are limited by small numbers and incomplete validation. Future work includes utilization of advanced machine learning models.

"A Delicate balance"-Perceptions and Experiences of ICU Physicians and Nurses Regarding Controlled Donation After Circulatory Death. A Qualitative Study.

Controlled donation after circulatory death (cDCD) is considered by many as a potential response to the scarcity of donor organs. However, healthcare professionals may feel uncomfortable as end-of-life care and organ donation overlap in cDCD, creating a potential barrier to its development. The aim of this qualitative study was to gain insight on the perceptions and experiences of intensive care units (ICU) physicians and nurses regarding cDCD. We used thematic analysis of in-depth semi-structured interviews and 6-month field observation in a large teaching hospital. 17 staff members (8 physicians and 9 nurses) participated in the study. Analysis showed a gap between ethical principles and routine clinical practice, with a delicate balance between end-of-life care and organ donation. This tension arises at three critical moments: during the decision-making process leading to the withdrawal of life-sustaining treatments (LST), during the period between the decision to withdraw LST and its actual implementation, and during the dying and death process. Our findings shed light on the strategies developed by healthcare professionals to solve these ethical tensions and to cope with the emotional ambiguities. cDCD implementation in routine practice requires a shared understanding of the tradeoff between end-of-life care and organ donation within ICU.