Withdrawal Of Life Support Research Articles

Predictors of treatment limitations in Finnish intensive care units.

Few studies have examined the factors that predict the limitations of life-sustaining treatment (LST) to patients in intensive care units (ICUs). We aimed to identify variables associated with the decision of withholding of life support (WHLS) at admission, WHLS during ICU stay and the withdrawal of ongoing life support (WDLS). This retrospective observational study comprised 17,772 adult ICU patients who were included in the nationwide Finnish ICU Registry in 2016. Factors associated with LST limitations were identified using hierarchical logistic regression. The decision of WHLS at admission was made for 822 (4.6%) patients, WHLS during ICU stay for 949 (5.3%) patients, and WDLS for 669 (3.8%) patients. Factors strongly predicting WHLS at admission included old age (adjusted odds ratio [OR] for patients aged 90years or older in reference to those younger than 40years was 95.6; 95% confidence interval [CI], 47.2-193.5), dependence on help for activities of daily living (OR, 3.55; 95% CI, 3.01-4.2), and metastatic cancer (OR, 4.34; 95% CI, 3.16-5.95). A high severity of illness predicted later decisions to limit LST. Diagnoses strongly associated with WHLS at admission were cardiac arrest, hepatic failure and chronic obstructive pulmonary disease. Later decisions were strongly associated with cardiac arrest, hepatic failure, non-traumatic intracranial hemorrhage, head trauma and stroke. Early decisions to limit LST were typically associated with old age and chronic poor health whereas later decisions were related to the severity of illness. Limitations are common for certain diagnoses, particularly cardiac arrest and hepatic failure.

Shifting and intersecting needs: Parents’ experiences during and following the withdrawal of life sustaining treatments in the paediatric intensive care unit

ObjectivesTo examine parents’ perceptions of nursing care needs; including specific concerns, preferences and supportive actions for themselves and their dying child during and following the withdrawal of life support in the paediatric intensive care unit. Research designQualitative description with content analysis. SettingInterviews with eight parents of eight children who died in the paediatric intensive care unit 7-11 years prior. Main Outcome MeasuresDescriptive categories of parents’ perceptions of end-of-life needs. FindingsParents identified four shifting and intersecting categories of needs: To be together, To make sense of the child’s evolving clinical care, To manage institutional, situational, and structural factors, and To navigate an array of emotions in a sterile context. Being closely connected with the child was highly important, but often intersected with other domains, requiring nurses’ support. Parents’ memories demonstrated persistent uncertainty about their child’s end-of-life care that influenced their long-term grief. ConclusionsIntersections between parent-identified care needs suggest potential mechanisms to strengthen nurses’ care for dying children. Equipped with the knowledge that the parent-child bond often shapes parents’ priorities; nurses should aim to facilitate connections amidst paediatric intensive care unit processes. Ongoing uncertainty in parents’ adaptation to loss suggests that attention to instances when needs intersect can have a lasting impact on parents’ grief.

Donación en asistolia controlada: cómo iniciar un programa

Introduction and objectivesDonation after circulatory death has become one of the main strategies to increase the number of donors. Until now, the heart of this type of donor was not evaluated due to the risk of ischaemic injury during the withdrawal of life support. In recent years, ex situ perfusion systems have initiated cardiac donation programmes after circulatory death that have demonstrated myocardial viability. The use of normothermic regional perfusion in our environment and the experience of other countries in cardiac recovery led us to develop a protocol for cardiac procurement in donation after circulatory death with in situ assessment and cold preservation. MethodsA multidisciplinary team was formed to create a cardiac extraction protocol with donation after circulatory death. After a phase of animal experimentation, the protocol was approved by the Ethics Committee for Health Care and by the National Transplant Organization. ResultsA protocol was drawn up establishing the criteria for donor and recipient selection and regulating the donation procedure with thoracic-abdominal perfusion after exclusion of the supra-aortic trunks. Cardiac evaluation is in situ and static preservation in cold storage. This protocol was sent to the rest of the donor hospitals and this led us to perform the first heart transplant in Spain with this donation modality. ConclusionsCardiac transplantation with donation after circulatory death is a clinical reality that will increase the number of potential donors. The technical characteristics of the procedure mean that this type of donation should be performed in experienced centres.

Critical Care Problem in a Case of Intracerebral Hemorrhage Due to Eclampsia and Its Ethics and Medicolegal Consideration

BACKGROUND: Eclampsia accompanied by hemolysis elevated liver enzymes low platelet (HELLP) syndrome is an emergency condition during late trimester pregnancy characterized by hypertension, seizures, and coma. Obstetric history is known that the patient does not conducted antenatal care regularly to the doctor so that the patient does not know she has eclampsia. One of which complications due to eclampsia is intracerebral hemorrhage which is a major cause of death and morbidity in pregnant woman. This case report discusses how ethical and medicolegal decision-making for procedures to withholding or withdrawing life support for the critical care problem. The ethical dilemma faced by neuroanesthesia and critical care (NACC) consultants is whether to continue to treat patients in the intensive care unit (ICU) even though the results will be in vain or to restrict critical care because they concluded that the condition of the patient has a terminal stage. CASE REPORT: A reported case of a 23-year-old woman, pregnant, and had a caesarian section for the indication of eclampsia accompanied by HELLP syndrome in rural hospital. Because the patient’s condition worsened, she was referred to Zainoel Abidin hospital due to decrease in consciousness and a computed tomography scan of the head showed extensive bleeding. The results of the neuroanesthesia and neurosurgery team’s assessment stated that there was no indication of surgery on the patient because extensive bleeding had occurred accompanied by brain edema. The patient then undergoes treatment in the ICU to improve the patient’s critical condition. In an effort to overcome this problem, the NACC consultant consults with an ethics and medicolegal consultant as a representation of the medical committee and ethical committee to determine the withholding or withdrawing of life support therapy to the patient. CONCLUSION: Life support therapies that can be withhold or withdraw are simply an extraordinary treatment that provides no benefit. The basic principles of ethics in making decisions to do withholding and withdrawing life support in these patients are beneficence and non-maleficence, while the medicolegal principle in these patients lies in the patient’s condition being medically incurable (terminal state) and medical treatment is useless (futile treatment).

Donation after circulatory death donors in lung transplantation.

Transplantation of any organ into a recipient requires a donor. Lung transplant has a long history of an inadequate number of suitable donors to meet demand, leading to deaths on the waiting list annually since national data was collected, and strict listing criteria. Before the Uniform Determination of Death Act (UDDA), passed in 1980, legally defined brain death in the U.S., all donors for lung transplant came from sudden death victims [uncontrolled Donation after Circulatory Death donors (uDCDs)] in the recipient’s hospital emergency department. After passage of the UDDA, uDCDs were abandoned to Donation after Brain Death donors (DBDs)—perhaps prematurely. Compared to livers and kidneys, many DBDs have lungs that are unsuitable for transplant, due to aspiration pneumonia, neurogenic pulmonary edema, trauma, and the effects of brain death on lung function. Another group of donors has become available—patients with a devastating irrecoverable brain injury that do not meet criteria for brain death. If a decision is made by next-of-kin (NOK) to withdraw life support and allow death to occur by asphyxiation, with NOK consent, these individuals can have organs recovered if death occurs relatively quickly after cessation of mechanical ventilation and maintenance of their airway. These are known as controlled Donation after Circulatory Death donors (cDCDs). For a variety of reasons, in the U.S., lungs are recovered from cDCDs at a much lower rate than kidneys and livers. Ex-vivo lung perfusion (EVLP) in the last decade has had a modest impact on increasing the number of lungs for transplant from DBDs, but may have had a larger impact on lungs from cDCDs, and may be indispensable for safe transplantation of lungs from uDCDs. In the next decade, DCDs may have a substantial impact on the number of lung transplants performed in the U.S. and around the world.

Serum Neuron-Specific Enolase Thresholds for Predicting Postcardiac Arrest Outcome: A Systematic Review and Meta-analysis.

To determine thresholds of serum neuron-specific enolase (NSE) for prediction of poor outcome after cardiac arrest with >95% specificity using a unique method of multiple thresholds meta-analysis. Data from a systematic review by the European Resuscitation Council (ERC 2014) were updated with literature searches from PubMed, Cochrane, and Scopus until August 2020. Search terms included the MeSH terms "heart arrest" and "biomarkers" and the text words "cardiac arrest," "neuron specific enolase," "coma" and "prognosis." Cohort studies with comatose cardiac arrest survivors aged >16 years undergoing targeted temperature management (TTM) and NSE levels within 96 hours of resuscitation were included. Poor outcome was defined as cerebral performance category 3-5 at hospital discharge or later. Studies without extractable contingency tables were excluded. A multiple thresholds meta-analysis model was used to generate summary receiver operating characteristic curves for various time points. NSE thresholds (and 95% prediction intervals) for >95% specificity were calculated. Evidence appraisal was performed using a method adapted from the American Academy of Neurology grading criteria. Data from 11 studies (n = 1,982) at 0-24 hours, 21 studies (n = 2,815) at 24-48 hours, and 13 studies (n = 2,557) at 48-72 hours was analyzed. Areas under the curve for prediction of poor outcomes were significantly larger at 24-48 hours and 48-72 hours compared to 0-24 hours (0.82 and 0.83 vs 0.64). Quality of evidence was very low for most studies because of the risk of incorporation bias-knowledge of NSE levels potentially influenced life support withdrawal decisions. To minimize falsely pessimistic predictions, NSE thresholds at the upper 95% limit of prediction intervals are reported. For prediction of poor outcome with specificity >95%, upper limits of the prediction interval for NSE were 70.4 ng/mL at 24-48 hours and 58.6 ng/mL at 48-72 hours. Sensitivity analyses excluding studies with inconsistent TTM use or different outcome criteria did not substantially alter the results. NSE thresholds for highly specific prediction of poor outcome are much higher than generally used. Future studies must minimize bias by masking treatment teams to the results of potential predictors and by prespecifying criteria for withdrawal of life support.

Blunt Traumatic Retropharyngeal Hematoma with Respiratory Symptoms: A Systematic Review of Reported Cases.

Background In patients with blunt trauma, particularly geriatric patients and those with minor trauma, an insidious retropharyngeal hematoma (RH) may deteriorate and have lethal consequences. We review the relevant literature to elucidate the clinical characteristics, treatment, complications, and outcomes of blunt traumatic RH with respiratory symptoms. Data Resources. We reviewed 57 case reports and added one case from our hospital for data analysis. A total of 68 cases were included in this review. Results The ages of patients ranged from 13 to 94 years, and geriatric patients (age >66 years) constituted 61.2% of the reviewed patients. Falls (54.4%) and traffic accidents (35.3%) were the major trauma mechanisms. Most patients' symptoms developed within 24 hours of blunt trauma (95.2%), and 73.5% of patients with RH had at least one associated injury. Many patients underwent conservative treatment for RH (63.2%). Surgical treatment (23.5%) and transarterial embolization (8.8%) were used to control retropharyngeal hemorrhage. Twelve patients died; RH and cervical spinal injury were the direct causes of death in 5 patients, whereas the other 7 patients died because of cardiac, pulmonary, or gastrointestinal causes or withdrawal of life support. Conclusions Geriatric patients constituted the largest proportion of patients with RH, and minor trauma was adequate to result in RH in elderly people. The cornerstone of RH management is airway management. Surgery and transarterial embolization are commonly used to control active bleeding in patients with RH. The long-term outcome depends on patients' associated injuries and in-hospital complications.

Appropriate care for the elderly in the ICU.

Life expectancy is rising worldwide and increasing numbers of elderly patients are being admitted to the intensive care unit (ICU). Because ageing is associated with changes in organ function, increased frailty, reduced activities of daily living, reduced mobility, and reduced cognition, elderly patients represent a particular subgroup of ICU patients. Ethical decisions related to the appropriateness of intensive care and/or life-sustaining interventions, the withdrawing and withholding of life support, and terminal sedation are more frequent in these patients and will be discussed in this review. Such decisions must be tailored to the individual to take into consideration personal beliefs and wishes.

MALIGNANT HEMISPHERIC INFARCTION AFTER SUBTLE TRACHEAL RUPTURE

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Tracheal rupture after endotracheal intubation is a rare but life-threatening complication with an incidence of approximately 0.005%. Predisposing factor can be a weakness of the membranous trachea secondary to chronic illness or steroid use. Herein we present a case of a young woman who developed a distal tracheal rupture after emergent endotracheal intubation with devastating consequences. CASE PRESENTATION: A 48-year-old female with a medical history of hypertension, epilepsy, and panhypopituitarism secondary to a respected craniopharyngioma was admitted to the intensive care unit with a diagnostic impression of obstructive uropathy with septic shock and multiorgan failure. Supportive management with aggressive fluids resuscitation, antibiotics, dual vasopressor therapy, and endotracheal intubation was given. Hours later, the patient became hemodynamically unstable requiring increased vasopressor therapy with increased demand in ventilation parameters. Physical examination was positive for massive subcutaneous emphysema from her chest tracking through facial and neck planes. A chest computerized tomography (CT) scan was performed and showed a distal tracheal rupture as the most likely cause of the massive pneumothorax that progressed to tension subcutaneous emphysema. Upon acute neurological deterioration, a head CT scan was performed, revealing a left pan-hemispheric malignant ischemic stroke involving the left anterior, middle, and posterior cerebral arteries suggestive of a left internal carotid artery (ICA) complete occlusion. The patient had a National Institutes of Health Stroke Scale score above 20, a left hemisphere infarction, and a GCS 3/11, conferring a poor clinical outcome. As poor prognosis and poor quality of life were expected, the family members opted to withdraw life support. DISCUSSION: Malignant hemispheric infarction has a mortality rate as high as 80 percent with catastrophic neurologic sequelae. Its incidence is less than ten percent of all ischemic infarcts and it's generally caused by embolic occlusion of the ICA. CONCLUSIONS: To our knowledge, there are no malignant hemorrhagic strokes provoked by traumatic intubation resulted from tracheal rupture documented to this day. We presume the etiology of this event to be subcutaneous air that exerted enough pressure between the fascial and cervical planes to result in significant vascular compression. Tracheal rupture is one of the most feared immediate complications of intubation as it could result in increased morbidity and mortality. There is no established consensus for the treatment yet, but early surgical repair has been the mainstay of treatment. However, conservative management has been chosen in cases of small ruptures with similar outcomes. REFERENCE #1: JOSEPH, M. M., & LEWIS, S. (2002). Stroke after penetrating trauma of the oropharynx. Pediatric Emergency Care, 18(3), 179–181.doi:10.1097/00006565-200206000-00007 DISCLOSURES: No relevant relationships by Ian Da Silva Lugo, source=Web Response No relevant relationships by Juan Feliciano-FIgueroa, source=Web Response No relevant relationships by Hector Nunez Medina, source=Web Response No relevant relationships by Héctor Oliveras-Cordero, source=Web Response No relevant relationships by Juan Santiago, source=Web Response

A CASE OF DISSEMINATED INTRAVASCULAR LYMPHOMA PRESENTING AS SEPSIS WITH MULTIORGAN FAILURE

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Intravascular lymphoma (IVL) is a rare subtype of lymphoma proliferating in the lumen causing small vessel occlusion. Antemortem diagnosis is difficult. The majority of cases are diagnosed from autopsy. We report a patient with IVL who presented with sepsis of unknown source complicated by multiorgan failure. CASE PRESENTATION: A 58-year-old male with hypertension and chronic obstructive lung disease presented with fever for 3 weeks and was found to be hypotensive. Laboratory investigation was remarkable for platelet count of 84,000 per microliter, serum creatinine 3 mg/dl, aspartate aminotransferase of 50 units per liter (U/L), total bilirubin of 5 mg/dl, ferritin of 1265 microgram per liter, lactate dehydrogenase of 2051 U/L. Blood, respiratory and urine cultures were negative. CT abdomen and pelvis did not reveal a septisis source. Transthoracic echocardiogram showed a preserve ejection fraction without tamponade. Hemodynamic data from pulmonary artery catheter showed wedge pressure of 14, and mixed venous oxygen saturation of 72. He was diagnosed with septic shock with unknown source and multiorgan failure. He was treated with broad spectrum antimicrobials including Meropenem, Vancomycin and Micafungin. He was started on continuous renal replacement therapy. His clinical course continued to deteriorate. The family decided to withdraw life support. He expired on hospital day 11. An autopsy revealed intravascular large B-cell lymphoma. DISCUSSION: IVL is an extremely rare extranodal lymphoma, predominantly affecting elderly patients. The incidence remains unknown due to its rarity. The clinical presentation is variable, ranging from asymptomatic, constitutional B symptoms to multiorgan failure caused by vessel occlusion. IVL can be diagnosed by the presence of large lymphoma cells within small-to-medium blood vessels. Antemortem diagnosis of IVL is difficult due to lack of pathognomonic features or tumor markers. Symptoms could mimic other more common diseases since the clinical manifestations are heterogeneous which could lead to a delayed or missed diagnosis. IVL is aggressive and usually disseminated at the time of diagnosis. Treatment is systemic chemotherapy. CONCLUSIONS: While IVL is an extremely rare subtype of lymphoma, it should be considered in the differential diagnosis of unexplained multiorgan failure with no other clear cause. The diagnosis of IVL requires a high index of suspicion and should be suspected in patients suggestive relevant clinical findings which may lead to early treatment and better outcomes. REFERENCE #1: Bouzani M et al., "Disseminated intravascular b-cell lymphoma: clinicopathological features and outcome of three cases treated with anthracycline-based immunochemotherapy," The Oncologist, vol. 11, no. 8, pp. 923–928, 2006. REFERENCE #2: Ferreri AJ, Campo E, Seymour JF; International Extranodal Lymphoma Study Group (IELSG). Intravascular lymphoma: clinical presentation, natural history, management and prognostic factors in a series of 38 cases, with special emphasis on the 'cutaneous variant'. Br J Haematol. 2004 Oct;127(2):173-83. REFERENCE #3: Murase T, Yamaguchi M, Suzuki R et al. Intravascular large B-cell lymphoma (IVLBCL): a clinicopathologic study of 96 cases with special reference to the immunophenotypic heterogeneity of CD5. Blood. 2007 Jan 15;109(2):478-85. DISCLOSURES: No relevant relationships by Maythawee Bintvihok, source=Web Response No relevant relationships by Parneet Dhaliwal, source=Web Response No relevant relationships by Joseph Guileyardo, source=Web Response No relevant relationships by Adam Hayek, source=Web Response No relevant relationships by Adan (Adam) Mora, source=Web Response

Withdrawing Life Support and Medical Futility

Life support technologies have the potential to save many lives. However, in some cases – particularly when disease is advanced or incurable – the use of these interventions may simply prolong the dying process while causing significant pain and suffering. The ethical basis for withdraw of life support has been clearly elucidated in medical ethics and the law, but given the emotions surrounding these issues, it is not surprising that controversy still exists. This review discusses withdrawal of life support and withdrawal of artificial nutrition. Additionally, this review explores medical futility, including the historical background, futility and the law, focus on process: hospital futility policies and ethics committees, and current practice and the future of medical futility. Illustrative case reports are presented. The table lists some examples of responding to requests for non-beneficial care from patients or surrogates. This review contains 1 figure, 3 tables, and 27 references. Key Words: Withdrawal of life support; Withdrawal of care; Medical futility

Withdrawing Life Support and Medical Futility

Withdrawing Life Support and Medical Futility

Withdrawing Life Support and Medical Futility

Withdrawing Life Support and Medical Futility

Extracorporeal Membrane Oxygenation for Adults and Children With Severe Respiratory Failure


 This review used a framework analysis to synthesize 9 included studies on the perspectives and experiences of patients, family members, and providers on extracorporeal membrane oxygenation (ECMO).
 Patients’ perspectives on their experiences are limited due to their sedated status when treated with ECMO.
 Supporting a relative treated with ECMO is stressful for family members. They feel anxious and worried about their relative because of the patient’s critical condition, and they struggle to juggle multiple roles at work and home while supporting their relative receiving ECMO.
 Family members often have to travel to see their critically ill relative. Financial and logistical support for temporary relocation near the ECMO centre may ease the burden of travel.
 Family members benefit from clear and frequent communication from health care providers as a source of support and reassurance while their loved ones are being treated with ECMO. There may be a role for informal or formal peer support for family members of patients receiving ECMO.
 Clinicians’ decisions to offer, continue, and withdraw ECMO are based on their assessments of prognostic factors from patients’ medical histories and clinical conditions. Additional clinical research and/or refinements of prognostic guidance for ECMO may further support evidence-informed decision-making around ECMO.
 Patients, family members, and clinical team members may differ in their assessment of the limits of ECMO treatment and the decision to transition from active treatment to the withdrawal of life support. These findings point to the role of ethical considerations and processes when engaging in transitioning to end-of-life support in the provision of ECMO.
 After discharge, patients who had received ECMO and their family members continued to have feelings of anxiety, intrusive thoughts, and a need to process the event. ECMO programs that can offer continued or ongoing support or referral for patients and their family members’ mental health may help address these needs.

Palliative extubation: obstacles, challenges and solutions

Life support withdrawal can be a challenging decision, but it should be considered as an option when death is inevitable or recovery to an acceptable quality of life is not possible. The process is beset by obstacles that must be overcome to finally offer patients comfort and a peaceful death.In this article, we offer a series of tools that seek to solve the challenges of palliative extubation, as well as a protocol that could facilitate the decision to withdraw life support, making palliative extubation an alternative to consider instead of artificially prolonging life at the expense of unacceptable human and economic costs.

KAJIAN HUKUM PENGHENTIAN TERAPI BANTUAN HIDUP (WITHDRAWING OF LIFE SUPPORT) DALAM PERAWATAN PALIATIF

Abstract— Withdrawing of life support was chosen as a preventive measure for the suffering of a person with an incurable disease. This action was taken because there is no other way that can help a person to escape the terrible suffering at the end of his life. Withdrawing of life support should observe the principle of Palliative Care, it does not aim to accelerate or prolong the patient's life. This research analyzes the legal norms of Withdrawing of life support using a statute approach, a conceptual approach and a comparative approach. The aim is to examine whether this action can be classified as an illegal act and what is the legal responsibility for the doctor who did it. Withdrawing of life support as Palliative Care is still continuing the normal treatment as a form of maintaining the quality of life for patients, while extraordinary treatments that are felt to be useless and futile. Determining what is ordinary or extraordinary is very important so that doctors and nurses can be sure that their professional actions do not violate ethics or law. Doctors as perpetrators of withdrawing of life support in Indonesia cannot be classified as a criminal crime against life. In outward acts (actus reus), these actions can result in the loss of a person's life. But the mental attitude (mens rea) to Withdrawing of Life Support is very different from murder. Civil liability arises when there is a violation of the rights of others, a violation of the perpetrator's legal obligations, violates decency and morality and violates the behavior of a good citizen. Good citizen behavior for a doctor refers to professional standards, standard operating procedures, medical code of ethics and the behavior of other colleagues.Keyword: legal aspect; responsibility; withdrawing of life support; palliative care

Research Highlights

Research Highlights

Pre-Ischemic Lactate Levels Affect Post-Ischemic Functional Recovery in an Isolated Rat Heart Model of Donation after Circulatory Death (DCD)

Purpose Donation after circulatory death (DCD) could substantially improve donor heart availability. In DCD, the heart is not only exposed to a period of warm ischemia, but also to a damaging pre-ischemic phase after withdrawal of life support. We investigated the effects of different pre-ischemic lactate levels on post-ischemic recovery using an isolated rat heart model of DCD. Methods Isolated, working rat hearts underwent 20’ aerobic perfusion, 28.5’ global ischemia, and 60’ reperfusion. In addition to 11 mM glucose and 1.2 mM palmitate, three pre-ischemic lactate levels were tested: no lactate (0 Lac), physiologic lactate (0.5 mM; 0.5 Lac), or DCD-relevant lactate (1 mM; 1 Lac). Contractile function, mitochondrial integrity and potential mediators of injury were evaluated. Results During reperfusion, left ventricular work (heart rate-developed pressure product) was significantly greater in 0.5 Lac hearts compared to 0 Lac or 1 Lac. In 0.5 Lac vs 0 Lac hearts, in parallel with increased function, cytochrome c release and carbonylated protein levels were significantly reduced, indicating less mitochondrial damage and oxidative stress, respectively. In 1 Lac vs 0.5 Lac hearts, in parallel with decreased function, cytochrome c release tended to increase, but carbonylated protein levels tended to decrease. Conclusion DCD-relevant levels of pre-ischemic lactate (1 mM) reduce contractile recovery during reperfusion compared to physiologic levels. Although increased pre-ischemic lactate tends to lower oxidative stress during reperfusion; this, alone, is insufficient to maintain functional recovery at DCD-relevant levels. Further investigations are ongoing to clarify underlying mechanisms.

Scale-up and sustainability of a personalized end-of-life care intervention: a longitudinal mixed-methods study

BackgroundScaling-up and sustaining healthcare interventions can be challenging. Our objective was to describe how the 3 Wishes Project (3WP), a personalized end-of-life intervention, was scaled-up and sustained in an intensive care unit (ICU).MethodsIn a longitudinal mixed-methods study from January 12,013 - December 31, 2018, dying patients and families were invited to participate if the probability of patient death was > 95% or after a decision to withdraw life support. A research team member or bedside clinician learned more about each of the patients and their family, then elicited and implemented at least 3 personalized wishes for patients and/or family members. We used a qualitative descriptive approach to analyze interviews and focus groups conducted with 25 clinicians who cared for the enrolled patients. We used descriptive statistics to summarize patient, wish, and clinician characteristics, and analyzed outcome data in quarters using Statistical Process Control charts. The primary outcome was enrollment of terminally ill patients and respective families; the secondary outcome was the number of wishes per patient; tertiary outcomes included wish features and stakeholder involvement.ResultsBoth qualitative and quantitative analyses suggested a three-phase approach to the scale-up of this intervention during which 369 dying patients were enrolled, having 2039 terminal wishes implemented. From a research project to clinical program to an approach to practice, we documented a three-fold increase in enrolment with a five-fold increase in total wishes implemented, without a change in cost. Beginning as a study, the protocol provided structure; starting gradually enabled frontline staff to experience and recognize the value of acts of compassion for patients, families, and clinicians. The transition to a clinical program was marked by handover from the research staff to bedside staff, whereby project catalysts mentored project champions to create staff partnerships, and family engagement became more intentional. The final transition involved empowering staff to integrate the program as an approach to care, expanding it within and beyond the organization.ConclusionsThe 3WP is an end-of-life intervention which was implemented as a study, scaled-up into a clinical program, and sustained by becoming integrated into practice as an approach to care.

Sugammadex to Reverse Neuromuscular Blockade Prior to Withdrawal of Life Support

In certain end-of-life scenarios, pharmacologic reversal of neuromuscular blockade may be indicated. However, given the depth of blockade frequently necessitated in the ICU setting, rapid reversal of neuromuscular blockade is generally not feasible with conventional reversal agents such as neostigmine that inhibit acetylcholinesterase. Sugammadex is a novel pharmacologic agent for the reversal of neuromuscular blockade that acts by directly encapsulating steroidal neuromuscular blocking agents and providing effective 1:1 binding of rocuronium or vecuronium. This unique mechanism of action is rapid and allows for complete reversal and recovery of neuromuscular function. We report the use of sugammadex to reverse neuromuscular blockade prior to compassionate extubation in three pediatric patients. Its clinical use in children is reviewed, potential applications in the palliative care arena discussed, and dosing algorithms presented.