Withdrawal Of Life Support Research Articles

P.089 A literature search using titles and key terms was conducted for articles containing brain death ancillary testing diagnosis, and CTP as primary focus

Background: Ancillary testing assist in the diagnosis of brain death. While traditionally, lack of blood flow (BF) in the intracranial arteries constitutes conclusive evidence that the brain is dead, there is apparent discrepancy between the BF, and sufficient cerebral perfusion; In 15% of patients with confirmed clinical diagnosis of brain death, BF is still preserved. In these patients, cerebral perfusion is significantly impaired suggesting that cerebral perfusion rather than BF more accurately assesses brain function. We aim to present a history of brain death, its pathophysiology, and ancillary tests utilized for its diagnosis- specifically CT Perfusion studies. Methods: A literature search using titles and key terms was conducted for articles containing brain death ancillary testing diagnosis, and CTP as primary focus. Results: Across selected studies, CTP diagnosed brain death with 100% positive predictive value, as none of the patients were proven not-dead on follow-up. The early prediction of mortality outcome in these patients with proven high mortality rate may help decisions for withdrawal of life support. It may also facilitate procurement of organs for transplants. Conclusions: Although clinical assessment is the gold standard method of brain death determination, CTP has shown promising results that could alter our current clinical approach.

The Future Is Now: OrganEx Technology and Its Implications for Transplant Medicine.

The Future Is Now: OrganEx Technology and Its Implications for Transplant Medicine.

Forced Organ Harvesting

Forced Organ Harvesting

The selflessness of an 8-year-old.

This short 55-word story highlights an Internal Medicine resident's experience talking to the family of a patient dying while on life support in the ICU, and the family dynamic while the resident discusses end of life care and withdrawal of life support. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

La muerte de los niños. Debates éticos en torno a la limitación del esfuerzo terapéutico

Ethical dilemmas take importance in current medical practice, especially at the end of life. Limitation of therapeutic effort, understood as not starting or withdrawing life support measures, is an alternative to preserve patient dignity when death approaches. Ethical dilemmas in this context have been widely studied in adults; not in children, in which the big psychological tension experienced by parents and professionals makes difficult to take accepted and consensual ethical decisions. The objective of this work has been to understand the concept of limitation of therapeutic effort and the deontological principles that support them in the pediatric field. The purpose was none other than to establish improvements in dying children whom peculiar life-end makes necessary a different approach of adults and an ethical conceptual clarification which justify LET practice in youngers.

Legal issues in end-of-life care

End-of-life (EOL) care is a multidisciplinary approach to provide 'whole person care' to individuals with advanced, progressive, incurable or life-limiting illnesses to prevent or relieve suffering with a goal to reduce suffering as much as possible while respecting the patient's wishes. The focus is on comfort, symptom control and quality of death (QOD) rather than actual treatment or prolonging life. It includes withholding or withdrawing life support treatments and initiating palliative care in terminally ill patients. However, lack of awareness amongst people and healthcare workers and inadequate legal framework are barriers to ensuring good QOD. All these issues result in a prolonged stay of terminally ill patients in intensive care units, high financial costs and emotional stress to the family, resulting in an excessive burden on the healthcare system. EOL care poses numerous legal and ethical problems for physicians. It is critical in therapeutic decision-making to protect the rights, dignity and vigour of all individuals concerned, including the patient's family members and the society. Physicians must comprehend the concepts of relevant legal and biomedical ethics to solve EOL care issues.

Hyperammonemia in a pregnant woman with citrullinemia type I: a case report and literature review

BackgroundCitrullinemia type I (CTLN1) is a rare urea cycle disorder (UCD) with few adult cases described so far. Diagnosis of late-onset CTLN1 is difficult, and delayed treatment may increase the risk of severe hyperammonemia. Pregnancy is an important risk factor for women with CTLN1. However, the clinical manifestations of CTLN1 in a pregnant woman may be mistaken for pregnancy side effects and ultimately delay a timely diagnosis.Case presentationA 34-year-old woman developed vomiting and disturbance of consciousness after 12 weeks of gestation. A blood test showed hyperammonemia (454 μg/dL) with normal liver function tests. She fell into a deep coma, and her serum ammonia level increased to 800 μg/dL. Continuous renal replacement therapy (CRRT) was administered as a diagnostic treatment for UCD and serum ammonia. This patient’s case was complicated by co-infection; her dependents decided to withdraw life support and the patient died. She was diagnosed with CTLN1 by analyses of plasma amino acids, urinary orotic acid, and second-generation gene sequencing.Discussion and conclusionWhen a patient displays symptoms of emesis and disturbance of consciousness in early pregnancy, blood ammonia should be monitored, and UCD should be considered, particularly for patients with hyperammonemia in the absence of severe liver function abnormalities.

280: TRANSPORT OF THE CRITICAL CARE PATIENT FOR WITHDRAWAL OF CARE IN THE HOME: A SCOPING REVIEW

Introduction: While most people state they want to die at home, evidence shows that many die in an institutional setting. Deaths in the intensive care unit contribute to family distress, moral distress of staff, and organizational strain. Transport of the critical care patient to their home for withdrawal of care and death is a possible, understudied, underutilized option. The authors performed a search and scoping review to determine the current practice and trends globally. Methods: Search terms discharge of ICU patients for home hospice were searched among the databases PubMed, CINAHL, Embase, Cochrane, Web of Science and Scopus. Results were filtered to the last ten years and in the English language, which yielded 312 articles. Article abstracts were independently reviewed by two authors for the appropriate intervention: Transport of the ICU patient to home for withdrawal of care, yielding 19 articles. The authors added 6 articles via hand-searching which yielded 25 total articles for review. Results: 25 articles were reviewed published between the years 2011-2021. Most articles were case studies or retrospective chart reviews. Qualitative studies were beneficial to explore the healthcare provider perspective as well as that of the family. Most articles came from the United States and United Kingdom, with some from Australia, New Zealand, Canada and Singapore. The practice was most commonly discussed within the pediatric population, though some centers were offering the intervention to adults. Benefits discussed included: Increased ease in end-of-life discussions when the family saw the opportunity for a “better” death, enhanced family bereavement, privacy and memory making during the dying process in the home, and decreased moral distress in staff. Barriers identified include the complex interdisciplinary teamwork necessary for implementation, the varying scope of EMS across states and countries, perceived medical complexity of the patient, and caregiver support once the patient returns home. Conclusions: Critical care transport to home for the aim of withdrawal of life support and death is a safe, feasible, compassionate option for patients and their families. If this option is pursued, it involves complex multidisciplinary planning and contingency planning to mitigate challenges and maintain safety.

CAUSES OF DEATH AMONG MEDICAL ICU (MICU) PATIENTS WITH PNEUMONIA DUE TO COVID-19 IN A SAFETY NET HOSPITAL

CAUSES OF DEATH AMONG MEDICAL ICU (MICU) PATIENTS WITH PNEUMONIA DUE TO COVID-19 IN A SAFETY NET HOSPITAL

NON-HODGKIN FOLLICULAR LYMPHOMA COMPLICATED BY HISTOPLASMOSIS-INDUCED CHYLOTHORAX AND PNEUMOHYDROPERICARDITIS SECONDARY TO AN ESOPHAGOPERICARDIAL FISTULA

NON-HODGKIN FOLLICULAR LYMPHOMA COMPLICATED BY HISTOPLASMOSIS-INDUCED CHYLOTHORAX AND PNEUMOHYDROPERICARDITIS SECONDARY TO AN ESOPHAGOPERICARDIAL FISTULA

Self-destruction or surrender? Religiosity and active versus passive euthanasia

Previous research suggests that people, especially religious people, are more opposed to active euthanasia, such as a lethal injection, than to passive euthanasia, such as withdrawing life support. The current research proposes a possible explanation for this finding—that active euthanasia is viewed as interfering with the natural course of life and death, but passive euthanasia is viewed as allowing it to take place. Two studies yielded results consistent with this hypothesis and found that how people think about the natural course of life and death substantially explained the greater opposition to active euthanasia among more religious people.

Organ donation by Maastricht-III pediatric patients: Recommendations of the Groupe Francophone de Réanimation et Urgences Pédiatriques (GFRUP) and Association des Anesthésistes Réanimateurs Pédiatriques d'Expression Française (ADARPEF) Part I: Ethical considerations and family care

The French Transplant Health Authority (Agence de la Biomédecine) has broadened its organ- and tissue-donation criteria to include pediatric patients whose death is defined by circulatory criteria and after the planned withdrawal of life-sustaining therapies (WLST) (Maastricht category III). A panel of pediatric experts convened to translate data in the international literature into recommendations for organ and tissue donation in this patient subgroup. The panel estimated that, among children aged 5 years or over with severe irreversible neurological injury (due to primary neurological injury or post-anoxic brain injury) and no progression to brain death, the number of potential donors, although small, deserves attention. The experts emphasized the importance of adhering strictly to the collegial procedure for deciding to withdraw life support. Once this decision is made, the available data should be used to evaluate whether the patient might be a potential donor, before suggesting organ donation to the parents. This suggestion should be reserved for parents who have unequivocally manifested their acceptance of WLST. The discussion with the parents should include both the pediatric intensive care unit (PICU) team under the responsibility of a senior physician and the hospital organ- and tissue-procurement team. All recommendations about family care during the end of life of a child in the PICU must be followed. The course and potential challenges of organ donation in Maastricht-III pediatric patients must be anticipated. The panel of experts recommended strict compliance with French recommendations (by the Groupe Francophone de Réanimation et Urgences Pédiatriques) about WLST and providing deep and continuous sedation until circulatory arrest. The experts identified the PICU as the best place to implement life-support discontinuation and emphasized the importance of returning the body to the PICU after organ donation. French law prohibits the transfer of these patients from one hospital to another. A description of the expert-panel recommendations regarding the organization and techniques appropriate for children who die after controlled circulatory arrest (Maastricht III) is published simultaneously in the current issue of this journal..

Ethical-Medicolegal Aspects of Installation and Removal of Ventilator in Life Support Efforts for Critical Patients during Covid-19 Pandemic

This study aims to analyze the procedures and considerations of medical and medicolegal aspects regarding the installation and removal of the use of ventilators in life support for patients during the COVID-19 pandemic. This study uses a normative juridical legal research method. The results showed that the ethical aspects regarding the installation and removal of the use of ventilators in the effort to support patients’ life during the COVID-19 pandemic were based on an agreement that was born by agreement (therapeutic agreement). The decision to stop or postpone life support therapy for medical treatment for patients is made by a team of doctors who treats patients after consulting a team of doctors appointed by the Medical Committee or the Ethics Committee based on Permenkes Number 37 of 2014. Meanwhile, the legal basis of procedures is in the process of making the installation decision and releasing the use of ventilators in critical patients during the COVID-19 pandemic, referring to the provisions of Permenkes No. 37/2014, Permenkes No. 290 of 2008, and Permenkes RI No. 290 of 2008 concerning the rejection of medical action, which patients and or their closest relatives can do. The legal basis refers to the medicolegal aspect in critical patients when installing and removing a ventilator. It is used as an indicator for determining whether to withdraw life support or withhold life support. Besides being adjusted to the validity of an agreement according to the Civil Code as stipulated in Article 1320, a doctor can initiate to understand a patient in the preparation and legal consequences of this agreement

Revisiting the Timeline of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage: Toward a Temporal Risk Profile

BackgroundDelayed cerebral ischemia (DCI) is one of the main determinants of clinical outcome after aneurysmal subarachnoid hemorrhage (SAH). The classical description of risk for DCI over time is currently based on the outdated concept of angiographic vasospasm. The goal of this study was to assess the temporal risk profile of DCI, defined by extended clinical and radiological criteria, as well as the impact the time point of DCI onset has on clinical outcome.MethodsAll patients with aneurysmal SAH referred to a single tertiary care center between 2010 and 2018 were considered for inclusion. This study was designed as a retrospective cohort analysis and data were extracted from existing patient files. In conscious patients, DCI was diagnosed clinically, and in unconscious patients, diagnosis was based on perfusion computed tomography imaging and multimodal neuromonitoring. Extended Glasgow Outcome Scale scores were assessed after 12 months and compared between patients with early (< day 7) and late (≥ day 7) DCI onset.ResultsThe median delay from day of the hemorrhage (day 0) until detection of the first DCI event was 7.0 days, with an interquartile range of 5 days. The probability of DCI development over time demonstrated a bimodal distribution with a peak risk on day 5 (0.084; confidence interval 0.05.5–0.122) and a second peak on day 9 (0.077; confidence interval 0.045–0.120). A total of 27 patients (15.6%) suffered dominant hemispheric or severe bilateral DCI-related infarctions, resulting in the withdrawal of technical life support. Of those, the majority (20 patients, 22.2%) presented with early DCI onset (vs. late onset: 7 patients, 8.4%; p = 0.013).ConclusionsThe risk profile of DCI over time mirrors the description of angiographic vasospasm; however, it comes with an added timely delay of 1 to 2 days. Early occurrence of DCI (before day 7) is associated with a higher infarct load and DCI-related mortality. Although the exact causal relationship remains to be determined, the time point of DCI onset may serve as an independent prognostic criterion in decision-making.

Three-year outcome following neonatal encephalopathy in a high-survival cohort

This study investigated the 3-year clinical outcomes in relation to the severity of encephalopathy in high-survival infants who underwent therapeutic hypothermia. This retrospective observational study was conducted in level II/III neonatal intensive care units in Japan. The nationwide cohort included 474 infants registered in the Baby Cooling Registry of Japan between January 2012 and December 2016. Clinical characteristics, mortality rate and severe neurological impairment at age 3 years were evaluated. Of the infants, 48 (10.4%), 291 (63.1%) and 122 (26.5%) had mild, moderate and severe encephalopathy, respectively, upon admission. By age 3, 53 (11.2%) infants died, whereas 110 (26.1%) developed major disabilities. The mild group survived up to age 3. In the moderate group, 13 (4.5%) died and 44 (15.8%) developed major disabilities. In the severe group, 39 (32.0%) died by age 3. Adverse outcomes were observed in 100 (82.0%) infants. Mortality was relatively low in all subgroups, but the incidence of major disabilities was relatively high in the severe group. The relatively low mortality and high morbidity may be due to Japanese social and ethical norms, which rarely encourage the withdrawal of intensive life support. Cultural and ethical backgrounds may need to be considered when assessing the effect of therapeutic interventions.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Nursing Care at End of Life in Pediatric Intensive Care Unit Patients Requiring Mechanical Ventilation.

Parents' perceptions of critical care during the final days of their child's life shape their grief for decades. Little is known about nursing care needs of children actively dying in the pediatric intensive care unit (PICU). To examine associations between patient characteristics, circumstances of death, and nursing care requirements for children who died in the PICU. A secondary analysis of the data set from the Randomized Evaluation of Sedation Titration for Respiratory Failure trial was conducted. This analysis included 104 children; 67 died after withdrawal of life-sustaining treatments; 21, after failed resuscitation; and 16, after brain death. Patients had a median age of 7.5 years, were cognitively appropriate, and were intubated for acute respiratory failure. Daily pain and sedation scores indicated patients' comfort was well managed (mean pain scores: modal, 0; peak, 2; mean sedation scores: modal, -2; peak, -1). Patients with longer PICU stays more often experienced pain and agitation on the day of death. Illness trajectory (acute, complex chronic condition, or cancer) was associated with pain scores (P = .04). Specifically, children with cancer had higher pain scores than children with acute illness trajectories (P = .01). Many patients (62%) had no change in critical care devices in their last days of life (median, 5 devices). Patterns of pain, sedation, comfort medications, and nursing care requirements did not differ by circumstances of death. Children with cancer and longer PICU stays may need comprehensive comfort management. Invasive devices left in place during withdrawal of life support may have inhibited parents' ability to connect with their child. Future research should incorporate parents' perspectives.

Improving ABCDEF Bundle Compliance and Clinical Outcomes in the ICU: Randomized Control Trial to Assess the Impact of Performance Measurement, Feedback, and Data Literacy Training.

OBJECTIVES:Describe the effects of data literacy training and continuous performance reports on ICU staff compliance with the 6-element ICU quality bundle approach known as the ABCDEF (A–F) bundle and patient outcomes.DESIGN:Stepped-wedge cluster randomized trial conducted during an institutional A–F bundle implementation program.SETTING:Single-center study conducted in eight adult ICUs.PATIENTS:Adult patients admitted for at least 24 hours, not undergoing active withdrawal of life support or palliative care.INTERVENTIONS:Four ICUs in the intervention group received bundle-related staff education, data literacy training, and weekly bundle performance reports during the 12-month study period. The four ICUs in the nonintervention group received none of these interventions. Bundle compliance and patient outcomes were tracked, including ICU and hospital mortality, transfer and discharge, discharge disposition, mechanical ventilation, and ICU delirium.MEASUREMENT AND RESULTS:In the intervention group, staff education alone increased bundle compliance from 9% to 16% (p < 0.0001); data literacy training further increased compliance from 16% to 21% (p = 0.03). This improvement was sustained throughout the study period including the onset of the COVID-19 pandemic and was greater than improvement in the nonintervention group (p < 0.001). Full A–F bundle compliance was associated with a lower likelihood of next-day ICU and hospital mortality, discharge to a facility other than home, and was associated with a higher likelihood of next-day extubation in patients. Next-day ICU and hospital discharge likelihood decreased, and delirium frequency was not affected.CONCLUSIONS:This is the first study demonstrating that the combination of staff education, data literacy training, and access to performance data improves A–F bundle compliance, sustains performance, and improves ICU patient outcomes (ICU and hospital mortality, mechanical ventilation duration, and home discharge rates). In contrast to previous studies, increased bundle compliance did not hasten ICU or hospital discharges or reduce delirium frequency in patients.

Longitudinal Echocardiographic Assessment of Donor Hearts in DCD Donors Using Thoracoabdominal Normothermic Regional Perfusion

<h3>Purpose</h3> In the U.S., multiple centers are beginning to develop protocols for DCD organ donation. We describe our intraoperative echo thoracoabdominal normothermic regional perfusion (TA-NRP) DCD protocol for initial donor acceptance and mid-term follow up <h3>Methods</h3> After identification of a suitable DCD donor, withdrawal of life support is performed in the OR until circulatory death occurs. After 5 minutes of observation, circulatory death is declared. The sternum is opened, cerebral vessels are ligated, and cardiopulmonary bypass (CPB) is initiated. Transesophageal echocardiogram (TEE) monitors the following parameters to ensure the heart is acceptable: left ventricular ejection fraction (LVEF) ≥50%, mitral valve annulus lateral S wave (MV S wave) ≥10 cm/sec, left ventricular outflow tract time integral (LVOT VTI) ≥15 cm, and right ventricular systolic function (RVEF) normal by visual estimation. The recipient's LVEF and global longitudinal strain rate (GLS) were followed longitudinally for up to 18 months <h3>Results</h3> From January 2020 to October 2021, 10 TA-NRP DCD transplants were performed: 7 isolated hearts, 2 heart-bilateral lung, and 1heart-kidney. Median donor age was 43.5 years (26-51) and there were 9 males (90%). Fifty percent of donors had a history of opioid drug overdose. The mean preoperative donor LVEF was 68%. Mean TEE parameters while weaning off CPB: LVEF 65%, MV lateral S wave 12 cm/sec, and LVOT VTI 19 cm. RVSF was normal for all donors. None of the donors required inotropic support. The recipient median age was 54 years (44-72) and 70% were male. None of the recipients developed cardiac graft failure. At mean follow-up of 392 days, mean LVEF is 64% and mean GLS is -16.7% and all patients are alive. <h3>Conclusion</h3> A standardized intraoperative TEE protocol to assess TA-NRP DCD donor heart function while weaning CPB is of paramount importance to ensure excellent longitudinal recipient graft function.

Risk factors for renal allograft survival with China novel donation category: Donation after brain death followed by cardiac arrest

IntroductionTo meet the need for transplantable organs, a new donation program was initiated by the Chinese government. This novel policy created three categories for deceased organ donations: donation after circulatory death cardiac death (DCD), donation after brain death (DBD), and donation after brain death followed by circulatory death (DBCD) meaning complete cardiac arrest. In fact, the DBCD method is a combination of both DBD and DCD methods. A DBCD donor meets the criteria of for brain death, but the organ procurement begins after the withdrawal of life support and the subsequent cardiac arrest death. The purpose of this study was to evaluate the long-term outcomes of kidney transplantation in our center with the DBCD policy. Potential risk factors for affecting the renal allograft survival were also analyzed based on our data. MethodA retrospective study, involving 421 kidney transplants derived from 214 donors, was conducted between December 2011 and October 2019. In particular, 373 (88.6%) transplanted organs met the criteria for DBCD, and 48 (11.4%) for DCD. The log-rank test was used to compare the difference in survival. The Cox regression analysis was used for risk factor screening. ResultAnalysis showed that the DBCD group was better than the DCD group in terms of overall (p = 0.031) as well as death-censored (p = 0.026) allograft survival using the log-rank test. A Cox regression analysis revealed that increasing donor age (p = 0.002, HR = 1.820/10 years incremental older), increasing recipient age (p = 0.028, HR = 1.521/10 years increment older), prolonged dialysis duration (p = 0.007, HR = 1.018), occurrence episodes of acute rejection (p = 0.016, HR = 2.697), delayed graft function (p = 0.012, HR = 2.962), mismatch ≥4 HLA loci (p = 0.038, HR = 3.606), and warm ischemia time > 15 min (p = 0.022, HR = 2.915), were all independent risk factors affecting the graft survival. ConclusionThe new DBCD policy of donation produced acceptable results similar or even better than the DCD practice. Based on our analysis, the graft survival of DBCD transplants may be better than DCD transplants. The main risk factors for allograft loss included an increasing donor age, recipient age, warm ischemia time > 15 min, prolonged dialysis duration, acute rejection, delayed graft function, and HLA mismatch ≥4 HLA loci.