Withdrawal Of Care Research Articles

AA amyloidosis associated with cancers.

Systemic AA amyloidosis is associated with systemic inflammatory processes such as autoimmune disorders or chronic infections. In addition, AA amyloidosis can develop in a localized or systemic form in patients with malignant neoplastic disorders, and usually involves kidneys impacting renal function. Among solid tumors, renal cell carcinoma (RCC) appears to be responsible for one-quarter to half of all cancers associated with amyloidosis. Among other solid cancers, various clinical presentations and pathological types of lung cancer and basal cell carcinoma skin were reported with AA amyloidosis more often than isolated case reports on other cancers with AA amyloidosis. Symptoms from kidney involvement rather than from the tumor per se were the presenting manifestations in cases of RCC associated with AA amyloidosis. Among hematological malignancies, clonal B cell/plasma cell dyscrasias such as monoclonal gammopathy and lymphoma were noted to be associated with AA amyloidosis. In addition, AA amyloidosis was reported in a substantial number of cases treated with immune checkpoint inhibitors such as pembrolizumab and nivolumab. The mechanism of association of cancer and AA amyloidosis seems to be mediated by the immune response exacerbated from the tumor and its microenvironment or immune therapy. The mainstay of treatment consists of therapy directed against the underlying malignancy or careful withdrawal of the offending agent. This review will discuss this rare but highly morbid clinical condition.

Decisions for Treatment of Neonates With Poor Prognosis: A Qualitative Study

Advances in medicine and medical technology have presented new moral challenges in terms of the management of extremely preterm infants and newborns with severe anomalies and advanced asphyxia. The aim of the present study was to examine the attitudes of health care providers and parents regarding decisions about the treatment of these neonates. The attitude of the Shia clerics is assessed in this study as well. In this qualitative content analysis research, data were collected through semi-structured interviews and focus group discussions (FGDs) with 98 participants, including physicians, nurse practitioners, medical ethicists, Shia clerics, and parents. Purposive sampling was employed by selecting those members of the community whom we thought would provide us with the best information and were also eager to participate. Data collection continued until data saturation was reached. Data analysis was carried out using conventional content analysis. Analysis of the data resulted in the extraction of 332 codes along with the following four categories: the necessity for preparation of a national guideline for the management of neonates with poor prognosis, the establishment of hospital neonatal-management committees, decision-making regarding the limits of viability, and parental support. This study affirms that the responsibility in terms of decision-making for neonates with poor prognosis lies upon hospital neonatal-management committees based on approved national guidelines such that decisions are made according to the aforementioned guidelines, Islamic moral codes, and scope of services available in medical units. This study dismisses individual decision-making and underlines the responsibility of a hospital neonatal-management committee in making decisions based on approved guidelines that conform to the regulations of national law and Islamic moral codes that determine the continuation or withdrawal of medical care and treatment of infants with a poor prognosis while bearing in mind that regulations, hospital facilities, resources, and other conditions differ in various hospitals within the country and with developed countries.

Movement disorders in COVID-19 times: impact on care in movement disorders and Parkinson disease.

The purpose of this review is to outline the impact of the COVID-19 pandemic on movement disorder holistic care, particularly in the care of people with Parkinson disease (PWP). As the pandemic unfolds, a flurry of literature was published regarding the impact of COVID-19 on people with Parkinson disease including the direct impact of infection, availability of ambulatory care, loss of community-based team care, and acceptability of telemedicine. COVID-19 has impacted the care of PWP in numerous ways. Recognizing infection in PWP poses challenges. Specific long-term complications, including emerging reports of long COVID syndrome is a growing concern. Caregivers and PWP have also been impacted by COVID-19 social isolation restrictions, with radical changes to the structure of social networks and support systems globally. In a matter of weeks, the global community saw an incredible uptake in telemedicine, which brought benefits and pitfalls. As PWP adapted to virtual platforms and the changing architecture of care delivery, the pandemic amplified many preexisting inequities amongst populations and countries, exposing a new 'digital divide'.

The role of temporary mechanical circulatory support as a bridge to advanced heart failure therapies or recovery.

Temporary mechanical circulatory support (tMCS) has become central in the treatment of refractory cardiogenic shock and can be used to bridge patients to durable MCS, heart transplant or recovery. This review will discuss contemporary data regarding bridging strategies utilizing tMCS. There has been significant growth in tMCS use recently, driven by increased familiarity with tMCS devices, and increased experience with both implantation and management. Identifying goals of therapy at the time of therapy initiation can facilitate better outcomes. The three primary goals are bridge to recovery, bridge to heart transplantation or bridge to durable left ventricular assist device. Bridging to recovery requires adequate treatment of underlying conditions and optimization of haemodynamics. Bridging to heart transplantation has become more frequent following changes to the heart allocation policy. Despite early concerns, patients bridge with tMCS, including ventricular-arterial extracorporeal membrane oxygenation, do not appear to have worse posttransplant outcomes. When bridging to durable mechanical circulatory support, tMCS can be used to enhance end-organ dysfunction and improve perioperative outcomes. In situations in which none of these goals are attainable, palliative care plays a critical role to identify patient wishes and assist with withdrawal of care when necessary. The use of tMCS, as a bridge to recovery or heart replacement therapy in patients with refractory cardiogenic shock has grown significantly over the past decade. Multiple device choices are available and must be chosen appropriately to address the specific situation and the goals of therapy.

Palliative and Critical Care: Their Convergence in the Pediatric Intensive Care Unit.

Palliative care (PC) is an integral component of optimal critical care (CC) practice for pediatric patients facing life-threatening illness. PC acts as an additional resource for patients and families as they navigate through critical illness. Although PC encompasses end of life care, it is most effective when integrated early alongside disease-directed and curative therapies. PC primarily focuses on improving quality of life for patients and families by anticipating, preventing and treating suffering throughout the continuum of illness. This includes addressing symptom distress and facilitating communication. Effective communication is vital to elicit value-based goals of care, and to guide parents through patient-focused and potentially difficult decision-making process which includes advanced care planning. A multidisciplinary approach is most favorable when providing support to both patient and family, whether it is from the psychosocial, practical, emotional, spiritual or cultural aspects. PC also ensures coordination and continuity of care across different care settings. Support for family carries on after death with grief and bereavement support. This narrative review aims to appraise the current evidence of integration of PC into pediatric CC and its impact on patient- and family-centered outcomes. We will also summarize the impact of integration of good PC into pediatric CC, including effective communication with families, advanced care planning, withholding or withdrawal of life sustaining measures and bereavement support. Finally, we will provide a framework on how best to integrate PC in PICU. These findings will provide insights on how PC can improve the quality of care of a critically ill child.

Uncovering Consciousness and Revealing the Preservation of Mental Life in Unresponsive Brain-Injured Patients.

In the last few years, functional neuroimaging and electroencephalography-based techniques have been used to address one of the most complex and challenging questions in clinical medicine, that of detecting covert awareness in behaviorally unresponsive patients who have survived severe brain injuries. This is a very diverse population with a wide range of etiologies and comorbidities, as well as variable cognitive and behavioral abilities, which render accurate diagnosis extremely challenging. These studies have shown that some chronic behaviorally unresponsive patients harbor not only covert consciousness but also highly preserved levels of mental life. Building on this work, although in its infancy, the investigation of covert consciousness in acutely brain-injured patients could have profound implications for patient prognosis, treatment, and decisions regarding withdrawal of care. The body of evidence on covert awareness presents a moral imperative to redouble our efforts for improving the quality of life and standard of care for all brain-injured patients with disorders of consciousness.

Hypomagnesemia In Patients OF Critical Care And Alcohol Withdrawal Syndrome: A Review

IntroductionMagnesium is one of the crucial electrolytes that plays a significant role in maintaining various cellular and metabolic processes. Studies demonstrate that Hypomagnesemia is evident in patients of critical care unit and alcohol withdrawal syndrome. Low Magnesium level is associated several dreadful complications as such higher mortality, cardiac arrythmias, septic shock, prolonged ICU stay, increased need for intubations and delayed weaning from ventilation etc. Prescribing Magnesium with cautious supervision might prevent these alarming sequels. Value to determine Hypomagnesemia regarding critical patients is extremely significant to determine timing for possible interventions.ObjectivesTo review the impact and significance of low serum Magnesium level on prognosis of patients with critical care unit and alcohol withdrawal syndrome.MethodsTo evaluate our reseach topic, we search through “Pubmed” and “Google Scholar” database using key words “Hypomagnesemia”, “Critical care” and “Alcohol withdrawal syndrome”, articles popped up. We select 5 articles on the basis of internal and external validity.ResultsLevel of Magnesium determination is extremely crucial to steer proper management in ICU, CDU, and critically ill patients. Studies reflecting most of the patients in critical care and alcohol withdrawal syndrome suffer from Hypomagnesemia. Most recent studies demonstrate that a level below 0.75 mmol/L is considered Hypomagnesemia for total Mg and level below 0.42 mmol/L for ionized Mg.ConclusionsHypomagnesemia is associated with dire consequences and fatal outcomes for critical patients in terms of mortality,prolonged ICU stay,septic shock as well as need for mechanical ventilation.Supplementing Mg with careful monitoring could prevent lethal aftermath while treating patients of AWS and critical care.DisclosureNo significant relationships.

Perimortem dynamics of blood potassium concentration in patients dying in intensive care unit: A prospective nested cohort study.

To enable diagnosis of hyperkalemia from the perimortem blood sample, we aim to describe the natural dynamics of blood potassium [K+ ] in patients dying after withdrawal of care while in an intensive care unit. In a nested sub-study of international Death Prediction and Physiology after Removal of Therapy (DePPaRT) project, we obtained serial whole-blood samples and analyzed ions and acid-base parameters in 23 patients just before life-sustaining treatment withdrawal, at the time of death, and after 5 and 30 min after death. Of the 631 patients in the DePPaRT study, we obtained consent and enrolled 23 subjects in the [K+ ] sub-study (12 M, 11F, aged 73 ± 14 years), mostly dying from irreversible brain damage or multi-organ failure. Blood [K+ ] rose from the median 4.3 (IQR 3.9; 4.8) mEq/L at treatment withdrawal to 5.2 (IQR 5.0; 6.8) mEq/L at death and then to 5.85 (IQR 5.2; 6.8) mEq/L after 30 min (mean rise of +0.64 mEq.L-1 .h-1 ). These changes were associated with progressive lactic and hypercapnic acidemia. After correcting the measured [K+] for pH by subtracting 0.6mEq/L from [K+] for every 0.1 pH decrease from 7.40, the calculated [K+] remained normal or decreased from that measured at treatment withdrawal. In contrast to the late autolysis phase, the early changes of blood [K+ ] after death are slow and can be fully explained by progressive acidemia. Our data suggest that the diagnosis of hyperkalemia at death from a blood sample obtained within 30 min after death can be made by adjusting the [K+] concentration to a pH7.40.

Jail Health Care in the Southeastern United States From Entry to Release.

Millions of people are incarcerated in US jails annually. These individuals commonly have ongoing medical needs, and most are released back to their communities within days or weeks. Jails are required to provide health care but have substantial discretion in how they provide care, and a thorough overview of jail health care is lacking. In response, we sought to generate a comprehensive description of jails' health care structures, resources, and delivery across the entire incarceration experience from jail entry to release. We conducted in-depth interviews with jail personnel in five southeastern states from August 2018 to February 2019. We purposefully targeted recruitment from 34 jails reflecting a diversity of sizes, rurality, and locations, and we interviewed personnel most knowledgeable about health care delivery within each facility. We coded transcripts for salient themes and summarized content by and across participants. Domains included staffing, prebooking clearance, intake screening and care initiation, withdrawal management, history and physicals, sick calls, urgent care, external health care resources, and transitional care at release. Ninety percent of jails contracted with private companies to provide health care. We identified two broad staffing models and four variations of the medical intake process. Detention officers often had medical duties, and jails routinely used community resources (e.g., emergency departments) to fill gaps in on-site care. Reentry transitional services were uncommon. Jails' strategies for delivering health care were often influenced by a scarcity of on-site resources, particularly in the smaller facilities. Some strategies (e.g., officers performing medical duties) have not been well documented previously and raise immediate questions about safety and effectiveness, and broader questions about the adequacy of jail funding and impact of contracting with private health care companies. Beyond these findings, our description of jail health care newly provides researchers and policymakers a common foundation from which to understand and study the delivery of jail health care.

513 Fluid Over-Resuscitation in Burn Patients After Initial 24-Hours of Care is Associated with Increased Mortality

IntroductionFluid resuscitation is a cornerstone of modern burn care. Despite the use of well-established formulae to determine the appropriate amount of fluid resuscitation for the first 24 hours of care, there is increasing recognition that patients receive fluids in excess of predicted volumes, a phenomenon termed fluid creep. Underscoring the significance of this phenomenon is the association between large volumes of fluid resuscitation and adverse outcomes. Although research in non-burn ICU patients reveals a clear association between overall fluid intake and increased morbidity, minimal burn-related literature exists regarding fluid patterns after the initial 24-hour period and their impact on outcomes. We hypothesized that increased fluid administration after the standard initial resuscitation period is associated with increased morbidity and mortality.MethodsA retrospective chart review was performed for 113 patients with ≥20% TBSA burns admitted to an American Burn Association-verified burn center between 2010 and 2020. Patients admitted with Stevens-Johnson Syndrome and/or Toxic Epidermal Necrolysis, with length of stay ≤ 72 hours, who required renal replacement therapy (RRT) within 72 hours of admission, and those with withdrawal of care ≤ 7 days of admission were excluded. Univariate and multivariate logistic regression was used to determine the association between the primary outcome of in-hospital mortality and secondary outcomes of increased ventilator days, acute kidney injury, need for RRT, and hospital length of stay, with increasing total and net fluid volumes from days 2 through 7 of treatment. Additionally, the association between first OR day and total fluid volumes in the first week were assessed.ResultsMedian age was 41 years (IQR 23-55) and TBSA was 31% (IQR 24-43). 21 patients (18.6%) died during hospitalization. Increase in net fluid balance from days 2-7 were associated with increased mortality (OR 1.016, 95% CI 1.00 – 1.03, p = 0.013). Increasing total fluid volumes were significantly associated with increased ventilator days (OR 1.027, 95% CI 1.008-1.047, p = 0.006) and acute kidney injury (OR 1.003, 95% CI 1.000-1.006, p = 0.017). Early first OR day was associated with decreased net fluid balance between hospital days 2-7 (OR 0.993, 95% CI 0.989-0.997, p = 0.001).ConclusionsSimilar to studies on other ICU populations, increasing total fluid volumes and net fluid balance is associated with adverse outcomes in critically ill burn patients. Additionally, earlier initial OR is associated with less total fluid volumes and lower net fluid balance in the first week of hospitalization. Further investigation is needed to elucidate optimal markers of resuscitation in burn patients in an effort to decrease adverse fluid administration.

480 Deep Learning Analysis of Early MRI Scans After Severe Traumatic Brain Injury Predicts Long-term Outcomes

INTRODUCTION: Nearly three quarters of deaths in clinical trials of severe traumatic brain injury (TBI) occur due to withdrawal of life sustaining therapies, often due to perceived poor neurological prognosis. Most of these deaths occur within the first week when physicians historically lack enough accuracy to make these decisions. Prognostic models, such as the International Mission for Prognosis and Analysis of Clinical Trials in TBI, are designed to prognose outcomes upon admission and fail to utilize clinical information accumulated after admission. Quantitative prognostic models capturing this informaiton are needed to help guide care decisions. METHODS: We built our model using 266 patients from a prospective database of severe TBI patients from 2002 through 2018 with an MRI obtained 1 to 9 days post-trauma. We developed a customized, multi-channel, deep convolutional neural network model with an AlexNet backbone and pre-trained with ImageNet. The cohort was split into 80% training, 10% validation, and 10% independent testing set. We built separate models using T2 FLAIR and DWI sequences. To reduce the heterogeneity of imaging after a decompressive hemicraniectomy (DHC), we only used DHC patients for model training. RESULTS: No adverse clinical events occurred while obtaining early MRIs. The overall mortality was 25% (68) and 20% (34) in the 170 patients who did not have a DHC. In the independent test cohort, the T2 FLAIR model performed best, with an area under the curve (AUC) of 0.80 (95% Confidence Interval: 0.57-0.94) and accuracy of 83%. The DWI model had an AUC of 0.64 (0.50 – 0.79) with an accuracy of 78%. With a specificity of 100% (i.e., never recommending withdrawal of care in a patient who would otherwise survive), the sensitivity for mortality was 57%. For identifying patients with favorable recovery potential, the sensitivity was 83% with a specificity of 80%. CONCLUSION: Early MRIs are safe to obtain in the severe TBI patient population. Deep learning analysis of these MRIs can predict 6-month mortality to help guide neurological prognostication.

Patient’s Self-Decision and Death in Court Decisions and the Law of Decision of Life-Sustaining Medical Care

The South Korean Supreme Court decision (2009Da17471), May 21, 2009, on removing life-sustaining medical care from persistent vegetative patients gave consent to death with dignity and initiated a lively debate in South Korea. The legal grounds for this decision were based on dignity, worth, and the right to pursue happiness regulated in Article 10 of the Constitution, The Death with Dignity Act was legislated as a law for life-sustaining medical care through debate and agreement on February 3, 2016, and has since been revised four times. However, there are some issues to discuss with this Act. First, the definition of the process of dying is unclear because the determining point of the dying process is different from the status of the attachment or detachment of an artificial ventilator. Second, the purpose of this law is the protection of dignity, worth, and the right to pursue happiness. As nutrition, fluid, and oxygen must be continuously supplied, even if the artificial ventilator is removed, is it reasonable to suggest that supplying these continuously achieves Article 10 of the Constitution? Third, if the withdrawal of life-sustaining medical care is possible or permitted without the patient’s approval, what is the legal value of advance directives? Fourth, it is whether death with dignity could be extended to the euthanasia. Conclusively, it may be necessary to partially revise the law for life-sustaining medical care through further debate and agreement.

External ventricular drainage for intracranial hypertension after traumatic brain injury: is it really useful?

External ventricular drainage (EVD) is frequently used to control raised intracranial pressure after traumatic brain injury. However, the available evidence about its effectiveness in this context is limited. The aim of this study is to evaluate the effectiveness of EVD to control intracranial pressure and to identify the clinical and radiological factors associated with its success. For this retrospective cohort study conducted in a Level 1 traumacenter in Paris area between May 2011 and March 2019, all patients with intracranial hypertension and treated with EVD were included. EVD success was defined as an efficient and continuous control of intracranial hypertension avoiding the use of third tier therapies (therapeutic hypothermia, decompressive craniectomy, and barbiturate coma) or avoiding a decision to withdraw life sustaining treatment due to both refractory intracranial hypertension and severity of brain injury lesions. 83 patients with EVD were included. EVD was successful in 33 patients (40%). Thirty-two patients (39%) required a decompressive craniectomy, eight patients (9%) received barbiturate coma. In ten cases (12%) refractory intracranial hypertension prompted a protocolized withdrawal of care. Complications occurred in nine patients (11%) (three cases of ventriculitis, six cases of catheter occlusion). Multivariate analysis identified no independent factors associated with EVD success. In a protocol-based management for traumatic brain injury, EVD allowed intracranial pressure control and avoided third tier therapeutic measures in 40% of cases with a favorable risk-benefit ratio.

Prognostic Value of the Neurological Pupil Index in Patients With Acute Subarachnoid Hemorrhage.

The Neurological Pupil index (NPi) provides a quantitative assessment of pupil reactivity and may have prognostic value in patients with subarachnoid hemorrhage (SAH). We aimed to explore associations between the NPi and clinical outcomes in patients with SAH. A retrospective analysis of 79 consecutive patients with acute SAH. Age, sex, Acute Physiology and Chronic Health Evaluation-II score, and respiratory failure and NPi in each eye were recorded at admission. The primary outcomes included death and poor clinical outcome (defined as inpatient death, care withdrawal, or discharge Glasgow Outcome Score <4). Groups were compared using the Fisher exact test, and predictive models developed with fast-and-frugal trees (FFTs). A total of 53 patients were included: 21 (40%) had poor clinical outcomes and 2 (4%) died. Univariate analysis found that only APACHE-II score (P < 0.001) and respiratory failure (P = 0.04) were significantly associated with poor clinical outcomes. NPi was lower among patients with poor clinical outcomes (mean 4.3 in the right eye and 4.2 in the left eye) vs those without (mean 4.5 in the right eye and 4.5 in the left eye), but neither was significant. However, the most accurate FFTs for death and poor clinical outcome included NPi after accounting for age in the death FFT and APACHE-II score in the poor outcome FFT (sensitivity [sn] = 100%, specificity [sp] = 94%, and accuracy (ac) = 94% in a model for death; sn = 100%, sp = 50%, and ac = 70%) in a model for poor clinical outcome. Our study supports the NPi as a useful prognostic marker for poor outcomes in acute SAH after accounting for age and APACHE-II score.

Association of Acute Alteration of Consciousness in Patients With Acute Ischemic Stroke With Outcomes and Early Withdrawal of Care.

Early consciousness disorder (ECD) after acute ischemic stroke (AIS) is understudied. ECD may influence outcomes and the decision to withhold or withdraw life-sustaining treatment. We studied patients with AIS from 2010 to 2019 across 122 hospitals participating in the Florida Stroke Registry. We studied the effect of ECD on in-hospital mortality, withholding or withdrawal of life-sustaining treatment (WLST), ambulation status on discharge, hospital length of stay, and discharge disposition. Of 238,989 patients with AIS, 32,861 (14%) had ECD at stroke presentation. Overall, average age was 72 years (Q1 61, Q3 82), 49% were women, 63% were White, 18% were Black, and 14% were Hispanic. Compared to patients without ECD, patients with ECD were older (77 vs 72 years), were more often female (54% vs 48%), had more comorbidities, had greater stroke severity as assessed by the National Institutes of Health Stroke Scale (score ≥5 49% vs 27%), had higher WLST rates (21% vs 6%), and had greater in-hospital mortality (9% vs 3%). Using adjusted models accounting for basic characteristics, patients with ECD had greater in-hospital mortality (odds ratio [OR] 2.23, 95% CI 1.98-2.51), had longer hospitalization (OR 1.37, 95% CI 1.33-1.44), were less likely to be discharged home or to rehabilitation (OR 0.54, 95% CI 0.52-0.57), and were less likely to ambulate independently (OR 0.61, 95% CI 0.57-0.64). WLST significantly mediated the effect of ECD on mortality (mediation effect 265; 95% CI 217-314). In temporal trend analysis, we found a significant decrease in early WLST (<2 days) (R2 0.7, p = 0.002) and an increase in late WLST (≥2 days) (R2 0.7, p = 0.004). In this large prospective multicenter stroke registry, patients with AIS presenting with ECD had greater mortality and worse discharge outcomes. Mortality was largely influenced by the WLST decision.

Emerging Treatments for Disorders of Consciousness in Paediatric Age.

The number of paediatric patients living with a prolonged Disorder of Consciousness (DoC) is growing in high-income countries, thanks to substantial improvement in intensive care. Life expectancy is extending due to the clinical and nursing management achievements of chronic phase needs, including infections. However, long-known pharmacological therapies such as amantadine and zolpidem, as well as novel instrumental approaches using direct current stimulation and, more recently, stem cell transplantation, are applied in the absence of large paediatric clinical trials and rigorous age-balanced and dose-escalated validations. With evidence building up mainly through case reports and observational studies, there is a need for well-designed paediatric clinical trials and specific research on 0–4-year-old children. At such an early age, assessing residual and recovered abilities is most challenging due to the early developmental stage, incompletely learnt motor and cognitive skills, and unreliable communication; treatment options are also less explored in early age. In middle-income countries, the lack of rehabilitation services and professionals focusing on paediatric age hampers the overall good assistance provision. Young and fast-evolving health insurance systems prevent universal access to chronic care in some countries. In low-income countries, rescue networks are often inadequate, and there is a lack of specialised and intensive care, difficulty in providing specific pharmaceuticals, and lower compliance to intensive care hygiene standards. Despite this, paediatric cases with DoC are reported, albeit in fewer numbers than in countries with better-resourced healthcare systems. For patients with a poor prospect of recovery, withdrawal of care is inhomogeneous across countries and still heavily conditioned by treatment costs as well as ethical and cultural factors, rather than reliant on protocols for assessment and standardised treatments. In summary, there is a strong call for multicentric, international, and global health initiatives on DoC to devote resources to the paediatric age, as there is now scope for funders to invest in themes specific to DoC affecting the early years of the life course.

Factors associated with limitation of care after fatal injury.

There is variability in end-of-life care of trauma patients. Many survive resuscitation but die after limitation of care (LoC). This study investigated LoC at a level I center. Adult trauma deaths between January 2016 and June 2020 were reviewed. Patients were stratified into "full code" versus any LoC (i.e., do not resuscitate, no escalation, or withdrawal of care) and by timing to LoC. Emergency department and "brain" deaths were excluded. Unadjusted logistic regression and Cox proportional hazards were used for analyses. Results include n (%) and odds ratios (ORs) with 95% confidence intervals (CIs), with α = 0.05. A total of 173 patients were included; 15 patients (8%) died full code and 158 (91%) died after LoC. Seventy-seven patients (48%) underwent incremental LoC. Age (OR, 1.05; 95% CI, 1.02-1.08; p = 0.0010) and female sex (OR, 3.71; 95% CI, 1.01-13.64; p = 0.0487) increased the odds of LoC; number of anatomic injuries (OR, 0.91; 95% CI, 0.85-0.98; p = 0.0146), chest injuries (Abbreviated Injury Scale [AIS] score chest, >3) (OR, 0.02; 95% CI, 0.01-0.26; p = 0.0021), extremity injury (AIS score, >3) (OR, 0.08; 95% CI, 0.01-0.64; p = 0.0170), and hospital complications equal to 1 (OR, 0.21; 95% CI, 0.06-0.78; p = 0.0201) or ≥2 (OR, 0.19; 95% CI, 0.04-0.87; p = 0.0319) decreased the odds of LoC. For those having LoC, final limitations were implemented in <14 days for 83% of patients; markers of injury severity (e.g., Injury Severity Score, Glasgow Coma Scale score, and AIS score) increased the odds of early LoC implementation. Most patients died after LoC was implemented in a timely fashion. Significant head injury increased the odds of LoC. The number of injuries, severe chest and extremity injuries, and increasing number of complications decreased the odds of LoC, presumably because patients died before LoCs were initiated. Understanding factors contributing to end-of-life care could help guide discussions regarding LoCs. Prognostic and Epidemiologic; Level III.

We Should Widen Access to Physician-Assisted Death

Abstract Typical philosophical discussions of physician-assisted death (“pad”) have focused on whether the practice can be permissible. We address a different question: assuming that pad can be morally permissible, how far does that permission extend? We will argue that granting requests for pad may be permissible even when the pad recipient can no longer speak for themselves. In particular, we argue against the ‘competency requirement’ that constrains pad-eligibility to presently-competent patients in most countries that have legalized pad. We think pad on terminally ill, incapacitated patients can be morally permissible in cases where advance directives or suitable surrogate decision-makers are available, and should be legally permissible in such cases as well. We argue that this view should be accepted on pain of inconsistency: by allowing surrogate decision-makers to request withdrawal of life-sustaining care on behalf of patients and by allowing patients to request pad, we rule out any plausible justification for imposing a competency requirement on pad.

1140. Impact of a Rapid Molecular Bloodstream Diagnostic Test on Optimal Antibiotic Use in Infants

Abstract Background Rapid molecular bloodstream diagnostics have been shown to decrease time-to-optimal antibiotic therapy in adult and pediatric patients. The purpose of the study was to compare the time-to-optimal antimicrobial therapy both pre-and post- implementation of rapid diagnostic testing in infants. Methods This was a single-center quasi-experimental study conducted from December 2018 to December 2020 at Children’s Hospital New Orleans. A rapid, multiplex polymerase chain reaction bloodstream diagnostic was implemented in January 2019. Antimicrobial Stewardship performed a daily review of all antimicrobials during both periods and made recommendations when necessary. The primary outcome was the difference in time-to-optimal therapy. Secondary outcomes included time-to-effective therapy, 30-day all-cause mortality rate, 30-day recurrent bacteremia rate, and time-to-microbiologic clearance. Patients were excluded if they had an unrelated concomitant infection, withdrawal of care before the result, bacteria not identified by the panel, or were over 6 months of age. Results Thirty-five and forty-three patients met inclusion criteria pre-and post-implementation. The median post-natal age was 2 months and median PRISM score was 12 in both groups. Median time-to-optimal therapy was 53.1 hours in the pre-intervention and 24.4 hours in the post-intervention group (-28.7 hours, P = 0.03). Median time-to-effective therapy was 0 and 1.4 hours, respectively (+1.4 hours, P = 0.02). There was no significant difference in 30-day all-cause mortality (3 vs. 4 patients, P = 0.62), 30-day recurrent bacteremia (0 vs. 2 patients, P = 0.2), or microbiologic clearance (37.3 vs. 26.2 hours, P = 0.09). Conclusion Implementation of a rapid, multiplex bloodstream diagnostic lead to a significant decrease in time-to-optimal antibiotic therapy in infants when compared to standard microbiological techniques. Disclosures All Authors: No reported disclosures

Why supporting the safety of lone working nurses must be a priority

Community practitioners who work alone are particularly vulnerable to physical and verbal abuse. Managers and teams must prioritise safety – even if that means withdrawal of care from patients