Withdrawal Of Life-sustaining Treatment Research Articles

간호대학생의 죽음불안과 품위 있는 죽음에 대한 태도가 연명치료중단 태도에 미치는 영향

Purpose: This study aimed to examine the level of death anxiety, attitudes toward dignified death and withdrawal of lifesustaining treatment (WLST), and to analyze factors that influence these perspectives on WLST among nursing students. Methods: 141 nursing students were selected from five universities in C city as study participants. Data were collected from May to July 2019 and analyzed using unpaired t-test, one-way ANOVA, Pearson s correlation coefficient and stepwise multiple regression analysis with IBM SPSS Statistics 23.0 (IBM Corp., Armonk, NY). Results: Nursing students who experienced WLST among family, friends and acquaintances had significantly positive attitude toward WLST than students who did not (t=2.62, p =.010). Attitude toward dignified death was positively correlated with attitude toward WLST (r=.26, p =.002) and death anxiety (r=.18, p =.038). Factors that influenced perspectives on WLST were attitude toward dignified death (=.26, p =.001) and experience of WLST (=.25, p =.002). The combined explanatory power of the two factors was 12% (F=7.08, p ＜.001). Conclusion: The right
 attitude towards withdrawal of life-sustaining treatment are essential ethical values for nursing students. These results suggest the inclusion of thanatology and enhanced ethical education on life and death in the nursing curriculum.

The Disposability of Life through the Withdrawal of Life-Sustaining Treatments ― In case of the regulations and discussions in Japan ―

생명권은 가장 대표적인 근대적 인권에 해당한다. 따라서 모든 인간은 그 누구나 평등하게 생명권을 갖는다. 모든 인간은 이러한 생명권에 힘입어 자신의 생명을 보호할 수 있다. 그런데 이러한 생명권의 규범적 의미 안에 자신의 생명을 스스로 처분할 수 있는 권리도 포함되는지가 문제된다. 이는 특히 연명의료중단 문제와 관련하여 논란이 된다. 다만 현재 우리는 연명의료결정법을 제정하여 실정법으로 이 문제에 대응하고 있다. 물론 연명의료결정법이 선택한 해법이 만족스러운 것은 아니다. 그 때문에 연명의료결정법에 관해 다양한 비판이 제기된다. 이러한 상황에서 이 글은 연명의료결정법의 개선방안에 관해 유익한 시사점을 얻기 위한 일환으로 연명의료중단에 대한 일본의 법적 규제 현황을 검토한다. 이에 따르면 다음과 같은 시사점을 얻을 수 있다. 첫째, 연명의료중단 문제에 관해서는 일본에서도 우리처럼 판례가 주도적으로 이 문제에 대응해 왔다는 점이다. 둘째, 일본은 우리와는 달리 ‘가이드라인’을 통해 이 문제에 대응하고 있다는 점이다. 셋째, 일본의 가이드라인은 명시적으로 적극적 안락사를 배제하고 있다는 점이다. 이 점에서 일본의 가이드라인은 여전히 ‘보수적’이라고 평가할 수 있다. 넷째, 일본의 가이드라인은 우리의 연명의료결정법과는 달리 ‘절차주의적 정당화 모델’을 수용하고 있다는 점이다. 이 점에서 일본의 가이드라인은 ‘진보적’이라고 평가할 수 있다. 이는 우리 연명의료결정법이 나아가야 할 방향이 무엇인지에 관해 의미 있는 시사점을 제공한다.

Withdrawing treatment from patients with prolonged disorders of consciousness: the wrong answer is what the wrong question begets

In a recent paper, Charles Foster argued that the epistemic uncertainties surrounding prolonged disorders of consciousness (PDOC) make it impossible to prove that the withdrawal of life-sustaining treatment can be...

Abstract 17: An Evaluation of Patient Disposition and Long-term Health-related Quality of Life In MISTIE III: Opportunities to Improve Decision Making for Critically Ill Intracerebral Hemorrhage Patients

Introduction: Recovery in intracerebral hemorrhage (ICH) is prolonged and unpredictable, resulting in challenges in estimating health-related quality of life (HRQoL). We describe HRQoL and patient disposition for ICH survivors with similar clinical characteristics to ICH patients who had withdrawal of life-sustaining treatment (WoLST). Methods: Using MISTIE III trial data (N = 499), we performed a matched cohort analysis using a published modified severity index (mSI) to compare ICH survivors (N = 379) with WoLST patients (N = 61). We used multivariable logistic regression adjusting for age, Glasgow Coma Score, deep ICH location, stability ICH and intraventricular hemorrhage volume and ≥ 3 comorbidities to create the mSI. After matching survivors with equal mSI to WoLST patients, we compared EuroQoL (EQ) visual analog scale (VAS) scores (US norm 69-76; range 0-100) by mSI quartile and patient disposition. Results: We matched 224 survivors to WoLST patients by mSI (range 0-6.5), with data at all timepoints. Given the large mSI range, EQ VAS scores and patient disposition were evaluated by mSI quartile groups. The median (interquartile range [IQR]) EQ VAS score increase for all mSI groups from day 30 (D30) to 180 (D180) was 20 (0-35.5, p < 0.0001), and 23.5 (5-40, p < 0.0001) for D30 to 365 (D365). The highest percentage of survivors for all mSI groups were home by D365 (G1 55%, G2 88%, G3 84.5%, G4 90%). Median (IQR) EQ VAS scores by mSI quartile, patient disposition and timepoint are reported below. Conclusion: ICH survivors, matching WoLST individuals, in all mSI groups demonstrated improvement in HRQoL over time, and the majority were home by D365. This study challenges current practice of identifying poor outcomes in concert with decision making employing WoLST in ICH. If goals of care are to include return to home and HRQoL, these results strongly suggest that prognostication can be improved. Prospective studies of ICH prognostication and decision making are needed.

Maintaining the permanence principle for death during in situ normothermic regional perfusion for donation after circulatory death organ recovery: A United Kingdom and Canadian proposal.

There is international variability in the determination of death. Death in donation after circulatory death (DCD) can be defined by the permanent cessation of brain circulation. Post‐mortem interventions that restore brain perfusion should be prohibited as they invalidate the diagnosis of death. Retrieval teams should develop protocols that ensure the continued absence of brain perfusion during DCD organ recovery. In situ normothermic regional perfusion (NRP) or restarting the heart in the donor's body may interrupt the permanent cessation of brain perfusion because, theoretically, collateral circulations may restore it. We propose refinements to current protocols to monitor and exclude brain reperfusion during in situ NRP. In abdominal NRP, complete occlusion of the descending aorta prevents brain perfusion in most cases. Inserting a cannula in the ascending aorta identifies inadequate occlusion of the descending aorta or any collateral flow and diverts flow away from the brain. In thoracoabdominal NRP opening the aortic arch vessels to atmosphere allows collateral flow to be diverted away from the brain, maintaining the permanence standard for death and respecting the dead donor rule. We propose that these hypotheses are correct when using techniques that simultaneously occlude the descending aorta and open the aortic arch vessels to atmosphere.

How Long Will This Take, Doc? Timing from End-of-Life Orders Until Death (QI628)

•Justify use of an order set for withdrawal of life-sustaining treatment in the intensive care unit.•Propose means to reduce unwarranted variation in practice. Withdrawal of life-sustaining treatment (WLST) is a critically important time in the life of a patient and family and presents unique emotional pressure to all involved. The decision to redirect goals of inpatient care to focus on comfort is best supported by clear, evidence-based treatment. Use of an order set in the electronic health record (EHR) can facilitate best care for the dying patient. Assess time from use of a WLST order set to inpatient death with the goal of reducing variation in practice. One-year, single-center, retrospective cohort study across a large, nonprofit health system in central Ohio. All inpatient decedents for whom care measures were entered using an available WLST order set. Primary outcome was timing from orders being entered until death. Secondary analyses included stratification by presence of palliative consultation and by specialty of ordering provider. 690 patients met inclusion criteria. The median time from WLST orders to death was 3.8 hours. Of 690 patients, 312 (45%) received palliative consultation and median time was 3.9 hours; 378 (55%) without palliative consultation had median time of 3.6 hours (not statistically significantly different). There was no statistically significant difference in time from WLST orders to death between the three mutually exclusive groups: orders by palliative provider and palliative consult, orders by nonpalliative provider and palliative consult, and orders by nonpalliative provider and no palliative consult. Timing from use of a WLST order set to inpatient death was consistent with published studies. There were no statistically significant differences in our secondary analyses. We conclude appropriate timing from WLST to death and reduced variation in practice associated with use of an order set. Next steps include order set optimization as well as detailed analysis of medications received.

Risk Factors for Withdrawal of Life-Sustaining Treatment in Severe Traumatic Brain Injury

Studies demonstrate a significant variation in decision-making regarding withdrawal of life-sustaining treatment (WLST) practices for patients with severe traumatic brain injury (TBI). We investigated risk factors associated with WLST in severe TBI. We hypothesized age ≥65 years would be an independent risk factor. In addition, we compared survivors with patients who died in hospital after WLST to identify potential factors associated with in-hospital mortality. The Trauma Quality Improvement Program (2010-2016) was queried for patients with severe TBI of the head. Patients were compared by age (age < 65 and age ≥ 65 years) and survival after WLST (survivors versus non-survivors) at hospitalization discharge. A multivariable logistic regression model was used for analysis. From 1,403,466 trauma admissions, 328,588 (23.4%) patients had severe TBI. Age ≥ 65 years was associated with increased WLST (odds ratio: 1.76, confidence interval: 1.59-1.94, P < 0.001), whereas nonwhite race was associated with decreased WLST (odds ratio: 0.60, confidence interval: 0.55-0.65, P < 0.001). Compared with non-survivors of WLST, survivors were older (74 vs 61 years, P < 0.001) and more likely to have comorbidities such as hypertension (57% vs 38.5%, P < 0.001). Age ≥ 65 years was an independent risk factor for WLST, and nonwhite race was associated with decreased WLST. Patients surviving until discharge after WLST decision were older (≥74 years) and had multiple comorbidities.

Nurses' Experiences and Factors Related to Their Attitudes Regarding Discussions with Patients and Family Members about Do-Not-Resuscitate Decisions and Life-Sustaining Treatment Withdrawal: A Hospital-Based Cross-Sectional Study.

This study aimed to evaluate nurses’ experiences and factors related to their attitudes regarding discussions of do-not-resuscitate (DNR) and withdrawal of life-sustaining treatment (LST) with patients and their families. A cross-sectional survey was conducted in a tertiary hospital in Taiwan. Nurses aged ≥ 20 years who were in charge of acute inpatient care were randomly recruited. A semi-structured questionnaire was used to evaluate participants’ experiences and attitudes regarding discussions of DNR and LST withdrawal for terminal patients. Logistic regression with adjustment for covariates was used to analyze factors related to participants’ attitudes toward discussions about DNR and LST withdrawal with patients and families in the future care of terminal patients. The participants were 132 nurses. They had significantly more discussions about DNR and LST withdrawal with patients’ families than with patients. Regression analysis showed that participants who had past experiences in actively initiating DNR discussions with patients or patients’ families were significantly more likely to discuss DNR with patients in the future care of terminal patients, but participants aged 40.0 to 60.0 years were significantly less likely to have DNR discussions than those aged 20.0 to 29.9 years. Experiences of actively initiated DNR or LST discussions with patients’ families were significantly more likely to discuss DNR with patients’ families, but those aged 40.0 to 60.0 years were also significantly less likely to have DNR discussions than those aged 20.0 to 29.9 years. Experience in actively initiating discussions about LST withdrawal with patients’ families, being male, and possessing an education level higher than university were significantly related to LST withdrawal discussions with terminal patients or their families in the future. In conclusion, there need to be more discussions about DNR and LST withdrawal with patients. To protect patients’ autonomy and their rights to make decisions about their DNR and LST, measures are needed to facilitate DNR and LST discussions with patients to ensure better end-of-life care.

ORGAN TRANSPLANTATION MEDICINE: RELIGIOUS AND ETHICAL CONSIDERATIONS

There are not enough solid organs available to meet the needs of patients with organ failure. Thousands of patients every year die on the waiting lists for transplantation. Yet there is currently available, underutilized, potential source of organs. Many patients die in intensive care following withdrawal of life-sustaining treatment whose organs could be used to save the lives of others. At present the majority of these organs go to waste. In this paper, I consider and evaluate a range of religious and ethical responses to improve the quality of organ transplantations available today. The responses of four world religions (Christianity, Islam, Buddhism and Hinduism) towards organ transplantation are considered. We argue that religious involvement in medical technologies like transplantation medicine gives to individuals the greatest chance of being able to help others with their organs after death under well-guided means. It is believed that attempts to increase patient autonomy will be realised in the light of religion and ethics.

Withholding and withdrawal of life-sustaining treatments for neonate in Japan: Are hospital practices associated with physicians' beliefs, practices, or perceived barriers?

ObjectiveTo describe the current status of withholding or withdrawal of life-sustaining interventions (LSI) for neonates in Japan and to identify physician- and institutional-related factors that may affect advance care planning (ACP) practices with parents. Study designA self-reported questionnaire was administered to assess frequency of withholding and withdrawing intensive care at the respondent's facility, the physician's degree of affirming various beliefs about end-of-life care that was compared to 7 European countries, their self-reported ACP practices and perceived barriers to ACP. Three neonatologists at all 298 facilities accredited by the Japan Society for Neonatal Health and Development were surveyed, with 572 neonatologists at 217 facilities responding. ResultsAt 76% of facilities, withdrawing intensive care treatments was “never” done, while withholding intensive care had been done “sometimes” or more frequently at 82% of facilities. Japanese neonatologists differed from European neonatologists regarding their degree of affirmation of 3 out of 7 queried beliefs about end-of-life care. In hospitals that were more likely to “sometimes” (or more often) withdraw treatments, respondents were less likely to affirm beliefs about doing “everything possible” or providing the “maximum of intensive care”. Self-reported ACP practices did not vary between neonatologists based on their hospital's overall pattern of withholding or withdrawing treatments. ConclusionAmong NICU facilities in Japan, 21% had been sometimes withdrawing LSI and 82% had been “sometimes” withholding LSI. Institutional treatment practices may have a strong association with physicians' beliefs that then affect end-of-life discussions, but not with self-reported ACP practices.

Neurophysiology for predicting good and poor neurological outcome at 12 and 72 h after cardiac arrest: The ProNeCA multicentre prospective study

AimsTo assess the accuracy of electroencephalogram (EEG) and somatosensory evoked potentials (SEPs) recorded at 12 and 72 h from resuscitation for predicting six-months neurological outcome in patients who are comatose after cardiac arrest. MethodsProspective multicentre prognostication study. EEG was classified according to the American Clinical Neurophysiology Society terminology. SEPs were graded according to the presence and amplitude of their cortical responses. Neurological outcome was defined as good (cerebral performance categories [CPC] 1–3) vs. poor (CPC 4–5). None of the patients underwent withdrawal of life-sustaining treatment. ResultsA total of 351 patients were included, of whom 134 (38%) had good neurological outcome. At 12 h, a continuous, nearly continuous and low-voltage EEG pattern predicted good neurological outcome with 71[61–80]% sensitivity, while an isoelectric EEG and a bilaterally absent/absent-pathological amplitude (AA/AP) cortical SEP pattern predicted poor neurological outcome with 14[8–21]% and 59[50–68]% sensitivity, respectively. Specificity was 100[97–100]% for all predictors. At 72 h, both an isoelectric, suppression or burst-suppression pattern on EEG and an AA/AP SEP pattern predicted poor outcome with 100[97–100]% specificity. Their sensitivities were 63[55–70]% and 66[58–74]%, respectively. When EEG and SEPs were combined, sensitivity for poor outcome prediction increased to 79%. ConclusionsIn comatose resuscitated patients, EEG and SEPs predicted good and poor neurological outcome respectively, with 100% specificity as early as 12 h after cardiac arrest. At 72 h after arrest, unfavourable EEG and SEP patterns predicted poor neurological outcome with 100% specificity and high sensitivity, which further increased after their combination.

Infrared pupillometry to help predict neurological outcome for patients achieving return of spontaneous circulation following cardiac arrest: a systematic review protocol

BackgroundDespite advances in resuscitation care, mortality rates following cardiac arrest (CA) remain high. Between one-quarter (in-hospital CA) and two-thirds (out of hospital CA) of patients admitted comatose to intensive care die of neurological injury. Neuroprognostication determines an informed and timely withdrawal of life sustaining treatment (WLST), sparing the patient unnecessary suffering, alleviating family distress and allowing a more utilitarian use of resources. The latest Resuscitation Council UK (2015) guidance on post-resuscitation care provides the current multi-modal neuroprognostication strategy to predict neurological outcome. Its modalities include neurological examination, neurophysiological tests, biomarkers and radiology. Despite each of the current strategy’s predictive modalities exhibiting limitations, meta-analyses show that three, namely PLR (pupillary light reflex), CR (corneal reflex) and N20 SSEP (somatosensory-evoked potential), accurately predict poor neurological outcome with low false positive rates. However, the quality of evidence is low, reducing confidence in the strategy’s results. While infrared pupillometry (IRP) is not currently used as a prognostication modality, it can provide a quantitative and objective measure of pupillary size and PLR, giving a definitive view of the second and third cranial nerve activity, a predictor of neurological outcome.MethodsThe proposed study will test the hypothesis, “in those patients who remain comatose following return of spontaneous circulation (ROSC) after CA, IRP can be used early to help predict poor neurological outcome”. A comprehensive review of the evidence using a PRISMA-P (2015) compliant methodology will be underpinned by systematic searching of electronic databases and the two authors selecting and screening eligible studies using the Cochrane data extraction and assessment template. Randomised controlled trials and retrospective and prospective studies will be included, and the quality and strength of evidence will be assessed using the Grading of Recommendation, Assessment and Evaluation (GRADE) approach.DiscussionIRP requires rudimentary skill and is objective and repeatable. As a clinical prognostication modality, it may be utilised early, when the strategy’s other modalities are not recommended. Corroboration in the evidence would promote early use of IRP and a reduction in ICU bed days.Systematic review registrationPROSPERO CRD42018118180

Abstract 428: Cause of Death Among Patients Resuscitated From Out-Of-Hospital Cardiac Arrest at a Single Urban Academic Hospital

Background: Approximately 30% of patients resuscitated following Out of Hospital Cardiac Arrest (OHCA) survive to hospital admission, but only 10% of these patients survive to hospital discharge. Reasons for in hospital death of these patients is not well known or categorized. Understanding the principle reason for death among successfully resuscitated OHCA patients could guide the development of therapeutic and management strategies Methods: Using a retrospective OHCA cohort database at a single urban academic hospital, death of admitted adult OHCA patients from January 1, 2016 until June 30, 2019 was classified as primarily due to withdrawal of life-sustaining treatments (WOLST), in-hospital cardiac arrest, or formal declaration of death by neurologic criteria (brain death). Family/caregiver decisions to WOLST were categorized as occurring primarily in the setting of isolated severe neurological injury, multi-organ failure, in hospital cardiac arrest, severe hemodynamic shock, pre-existing comorbidities/terminal health condition, or prior unknown DNR status. Traumatic arrests were excluded. Results: During the study period there were 578 cardiac arrests brought to the emergency department; 291 (50%) patients survived to hospital admission. Of admitted patients, 95 patients (33%) survived to hospital discharge and 194 patients (67%) died. In non-surviving patients, death was attributable to WOLST (77%), brain death 25 (13%), in-hospital cardiac arrest (9%), and failure to achieve return of spontaneous circulation on ECMO 1 (1%). Decisions to WOLST by family members were complex and multi-factorial but were determined in the context of poor neurologic prognosis 93 (62%), multi-organ failure 27 (18%), in hospital cardiac arrest 11 (7%), severe shock 11 (7%), unknown prior DNR status 7 (5%), and pre-existing terminal illness 2 (1%). Conclusion: In this single center study, the majority of OHCA patients who survived to hospital admission from the emergency department subsequently died in the hospital due to the severity of their neurological injury in the context of WOLST. Death in the setting of multiorgan failure, re-arrest, or severe hemodynamic shock was less common.

Intensive care nurses’ experiences of withdrawal of life-sustaining treatments in intensive care patients: A qualitative study

ObjectiveTo explore the experience of intensive care nurses when participating in the withdrawal of life-sustaining treatments from intensive care unit patients. Design and methodsA qualitative descriptive and explorative design. Data were collected in 2017 and 2018 by interviewing nine intensive care nurses. The data were analysed by using systematic text condensation. SettingThe nine intensive care nurses interviewed worked in four different intensive care units located in one university hospital and one local hospital. Main outcome measuresExperiences when participating in the process of withdrawing life-sustaining treatments. FindingsThree categories emerged from the data analysis: ICU nurses’ experiences of stress in the process of treatment withdrawal; a requirement for interdisciplinary support and cooperation; and elements to achieve a dignified treatment withdrawal process. ConclusionThe intensive care nurses experienced challenges and emotional reactions when patients were overtreated or when they had to participate in treatments they did not agree with. They considered debriefings to be helpful in dealing with emotions. Thorough planning, good communication, pain relief, and the creation of a peaceful environment were perceived as important elements in achieving a dignified treatment withdrawal process.

Early prognostication of neurological outcome by heart rate variability in adult patients with out-of-hospital sudden cardiac arrest

BackgroundMost deaths of comatose survivors of out-of-hospital sudden cardiac arrest result from withdrawal of life-sustaining treatment (WLST) decisions based on poor neurological prognostication and the family’s intention. Thus, accurate prognostication is crucial to avoid premature WLST decisions. However, targeted temperature management (TTM) with sedation or neuromuscular blockade against shivering significantly affects early prognostication. In this study, we investigated whether heart rate variability (HRV) analysis could prognosticate poor neurological outcome in comatose patients undergoing hypothermic TTM.MethodsBetween January 2015 and December 2017, adult patients with out-of-hospital sudden cardiac arrest, successfully resuscitated in the emergency department and admitted to the intensive care unit of the Niigata University in Japan, were prospectively included. All patients had an initial Glasgow Coma Scale motor score of 1 and received hypothermic TTM (at 34 °C). Twenty HRV-related variables (deceleration capacity; 4 time-, 3 geometric-, and 7 frequency-domain; and 5 complexity variables) were computed based on RR intervals between 0:00 and 8:00 am within 24 h after return of spontaneous circulation (ROSC). Based on Glasgow Outcome Scale (GOS) at 2 weeks after ROSC, patients were divided into good outcome (GOS 1–2) and poor outcome (GOS 3–5) groups.ResultsSeventy-six patients were recruited and allocated to the good (n = 22) or poor (n = 54) outcome groups. Of the 20 HRV-related variables, ln very-low frequency (ln VLF) power, detrended fluctuation analysis (DFA) (α1), and multiscale entropy (MSE) index significantly differed between the groups (p = 0.001), with a statistically significant odds ratio (OR) by univariate logistic regression analysis (p = 0.001). Multivariate logistic regression analysis of the 3 variables identified ln VLF power and DFA (α1) as significant predictors for poor outcome (OR = 0.436, p = 0.006 and OR = 0.709, p = 0.024, respectively). The area under the receiver operating characteristic curve for ln VLF power and DFA (α1) in predicting poor outcome was 0.84 and 0.82, respectively. In addition, the minimum value of ln VLF power or DFA (α1) for the good outcome group predicted poor outcome with sensitivity = 61% and specificity = 100%.ConclusionsThe present data indicate that HRV analysis could be useful for prognostication for comatose patients during hypothermic TTM.

Withholding and Withdrawal of Life-Sustaining Treatments in critically ill ICU patients: A study on attitude of Physicians of Bangladesh

Background : This study is a sub analysis of data submitted on behalf of Bangladesh in an International study ( ACME 2012) involving physicians working in Asian ICUs.&#x0D; Objective : To describe attitude of physicians of ICUs of Bangladesh toward withholding and withdrawal of life sustaining treatments in end of life care, to assess factors associated with these observations and to compare the findings especially with those of physicians of low – middle income Asian ICUs.&#x0D; Method : Self-administered pre-set structured and scenario based survey conducted among 101 physicians working in 38 ICUs of Bangladesh.&#x0D; Results : For patients with no real chance of recovering a meaningful life, 20 of 101 respondents reported that they almost always or often withheld life-sustaining treatments and 18 of 101 respondents almost always or often withdrew life-sustaining treatments.44 respondents in our study reported that they almost always or often withheld life sustaining treatments whereas 10 respondents almost always or often withdrew life sustaining treatments. 72% of all our respondents would implement DNR orders. In Bangladesh, religion (Islam) does not influence decision of complying with DNR order requested by family. Our study showed 71% of physicians were more likely to “do everything” if a patient with hypoxic-ischaemic encephalopathy developed septic shock. In our study, physicians were more ready to withdraw vasopressors and hemo dialysis than enteral feeding and intravenous fluids. Physicians from Bangladesh generally perceived more legal risk with limitation of life sustaining treatments because of lack of legislation for such practices. When it comes to limit aggressive lifesaving treatments, Bangladeshi physicians were less likely accede to families request to withdraw them on financial ground.&#x0D; Conclusion : Like physicians of low-middle income countries of Asia, Bangladeshi ICU physicians’ self-reported practice of limiting life sustaining treatments, role of families and surrogates and perception of legal rights were significantly different than physicians of high income countries of Asia. However unlike physicians from other low income Asian countries, physicians from Bangladesh were less likely to accede to families request to withdraw life sustaining treatments on financial ground.&#x0D; Bangladesh Crit Care J September 2019; 7(2): 66-72

Predict cardiac death after withdrawal of life-supporting treatment in the neurocritical patients: a neurological score

Background: Accurate prediction the time of death after withdrawal of life-supporting treatment (WLST) in the neurocritical patients is important for donation after cardiac death. We aimed to establish a new neurological scoring system to predict the probability of death within 60 minutes after WLST.Methods: We retrospectively reviewed the clinical data from a cohort of 231 neurocritical patients from June 2016 to July 2018. The patients were divided into training and external validation sets. In the training set, we used univariate and multivariable logistic regression analyses to assess associations between death within 60 minutes after WLST and these variables. Points attributed to each variable were summed to create a predictive score for cardiac death. We assessed performance of the score using ROC analysis. Finally, we validated the predictive ability of the score in an external validation set.Results: Multivariable logistic regression analysis showed that absent corneal reflexes, absent cough reflexes, extensor or absent motor response and anisocoric or bilaterally dilated pupil were associated with death within 60 minutes in training set (all p&lt;0.05). The area under curve for the score was 0.839 (95% CI 0.763-0.916) for prediction of death within 60 minutes. A score of 4-6 had a sensitivity of 95.88% and a specificity of 69.05% to predict death within 60 minutes after WSLT. In external validation set, the prevalence of these predictors was similar with training sample.Conclusions: The neurological score may be useful to predict time of death after WLST in neurocritical patients.

Withdrawing life-sustaining treatment: a stock-take of the legal and ethical position

This article, prompted by an extended essay published in the Journal of Medical Ethics by Charles Foster, and the current controversy surrounding the case of Vincent Lambert, analyses the legal...

Causes of Death in Status Epilepticus.

To determine the causes of death in patients with status epilepticus. To analyze the relative contributions of seizure etiology, seizure refractoriness, use of mechanical ventilation, anesthetic drugs for seizure control, and medical complications to in-hospital and 90-day mortality, hospital length of stay, and discharge disposition. Retrospective cohort. Single-center neuroscience ICU. Patients with status epilepticus were identified by retrospective search of electronic database from January 1, 2011, to December 31, 2016. Review of electronic medical records. Demographics, clinical characteristics, treatments, and outcomes were collected. Univariable and multivariable logistic regression analysis were used to determine whether the use of anesthetic drugs, mechanical ventilation, Status Epilepticus Severity Score, refractoriness of seizures, etiology of seizures, or medical complications were associated with in-hospital, 90-day mortality or discharge disposition. Among 244 patients with status epilepticus (mean age was 64 yr [interquartile range, 42-76], 55% male, median Status Epilepticus Severity Score 3 [interquartile range, 2-4]), 24 received anesthetic drug infusions for seizure control. In-hospital and 90-day mortality rates were 9.2% and 19.2%, respectively. Death was preceded by withdrawal of life-sustaining treatment in 19 patients (86.3%) and cardiac arrest in three (13.7%). Only Status Epilepticus Severity Score was associated with in-hospital and 90-day mortality, whereas the use of anesthetic drugs for seizure control, mechanical ventilation, medical complications, etiology, and refractoriness of seizures were not. Hospital length of stay was longer in patients with medical complications (p = 0.0091), refractory seizures (p = 0.0077), and in those who required anesthetic drugs for seizure control (p = 0.0035). Patients who had refractory seizures were less likely to be discharged home (odds ratio, 0.295; CI, 0.143-0.608; p = 0.0009). In this cohort, death primarily resulted from the underlying neurologic disease and withdrawal of life-sustaining treatment and not from our treatment choices. Use of anesthetic drugs, medical complications, and mechanical ventilation were not associated with in-hospital and 90-day mortality.

Neurocritical care physicians\u2019 doubt about whether to withdraw life-sustaining treatment the first days after devastating brain injury: an interview study

BackgroundMultilevel uncertainty exists in the treatment of devastating brain injury and variation in end-of-life decision-making is a concern. Cognitive and emotional doubt linked to making challenging decisions have not received much attention. The aim of this study was to explore physicians´ doubt related to decisions to withhold or withdraw life-sustaining treatment within the first 72 h after devastating brain injury and to identify the strategies used to address doubt.MethodSemi-structured interviews were conducted with 18 neurocritical care physicians in a Norwegian trauma centre (neurosurgeons, intensivists and rehabilitation specialists) followed by a qualitative thematic analysis.ResultAll physicians described feelings of doubt. The degree of doubt and how they dealt with it varied. Institutional culture, ethics climate and individual physicians´ values, experiences and emotions seemed to impact judgements and decisions. Common strategies applied by physicians across specialities when dealing with uncertainty and doubt were: 1. Provision of treatment trials 2. Using time as a coping strategy 3. Collegial counselling and interdisciplinary consensus seeking 4. Framing decisions as purely medical.ConclusionDecisions regarding life-sustaining treatment after devastating brain injury are crafted in a stepwise manner. Feelings of doubt are frequent and seem to be linked to the recognition of fallibility. Doubt can be seen as positive and can foster open-mindedness towards the view of others, which is one of the prerequisites for a good ethical climate. Doubt in this context tends to be mitigated by open interdisciplinary discussions acknowledging doubt as rational and a normal feature of complex decision-making.