Table 1 - uploaded by Jean-Francois Timsit
Content may be subject to copyright.
Patient characteristics at ICU admission in the 223 cases (patients spending their birthday in the ICU) and 1,042 matched controls
Source publication
End-of-life decisions are based on objective and subjective criteria. Previous studies identified substantial subjective biases during end-of-life decision-making. We evaluated whether in-ICU patient's birthday influenced management decisions.
We used a case-control design in which patients spending their birthday in the ICU (cases) were matched to...
Context in source publication
Similar publications
Adverse events and medical errors (AEs/MEs) are more likely to occur in the intensive care unit (ICU). Information about the incidence and outcomes of such events is conflicting. A systematic review and meta-analysis were conducted to examine the effects of MEs/AEs on mortality and hospital and ICU lengths of stay among ICU patients. Potentially el...
Interdisciplinary collaboration in end-of-life decision-making is challenging. Guidelines developed within the interdisciplinary team may help to clarify, describe, and obtain consensus on standards for end-of-life decision-making and care. The aim of the study was to develop, implement, and evaluate guidelines for withholding and withdrawing thera...
Objectives
We aimed to investigate the association between the time to positivity of blood culture (TTP) with clinical outcome and severity of pneumococcal bacteremic pneumonia.
Methods
Prospective observational study carried out in 278 hospitalized adult CAP patients with positive blood culture for Streptococcus pneumonia (2003–2015).
Results
A...
Introduction
Micronutrient (MN) supplementation has a positive impact on clinical outcomes. However, the evidence for the impact of MN supplementation remains controversial. Therefore, our study aims to assess the impact on nutritional outcomes according to exploring the implementation of MN support with multidisciplinary collaboration.
Methods
Al...
Background
Arginine-supplemented enteral immunonutrition has been designed to optimize outcomes in critical care patients. Existing formulas may be isocaloric and isoproteic, yet differ in L-arginine content, energy distribution, and in source and amount of many other specialized ingredients. The individual contributions of each may be difficult to...
Citations
... 11% of patients of North American ICUs received care that their treating critical care specialist considered to be nonbeneficial (4), and up to 27% of surveyed European ICU staff perceived inappropriate, mostly nonbeneficial, treatment for one of their patients on the day of the study (5). Studies investigating antecedents or reasons of perceived nonbeneficial treatment on the ICU identified characteristics of the patients and their representatives and the care situation as well as aspects of the ICU work environment like poor nurse-physician collaboration (5)(6)(7). Nonbeneficial treatment may lead to negative outcomes for patients and their relatives as well as for involved ICU staff (2), being associated with high moral distress (8,9) and with increased intent to leave the job (5). Although there is currently only little empirical evidence, it may also be a major risk factor for the development of burnout (2,5,8,10). ...
Objectives:
Perceiving nonbeneficial treatment is stressful for ICU staff and may be associated with burnout. We aimed to investigate predictors and consequences of perceived nonbeneficial treatment and to compare nurses and junior and senior physicians.
Design:
Cross-sectional, multicenter paper-pencil survey on personal and work-related characteristics, perceived nonbeneficial treatment, burnout, and intention to leave the job.
Setting:
Convenience sample of 23 German ICUs.
Subjects:
ICU nurses and physicians.
Interventions:
None.
Measurements and main results:
A total of 847 questionnaires were returned (51% response); 778 had complete data for final multivariate analyses. Nonbeneficial treatment was in median perceived "sometimes." Adjusted for covariates, it was perceived more often by nurses and junior physicians (both p ≤ 0.001 in comparison to senior physicians), while emotional exhaustion was highest in junior physicians (p ≤ 0.015 in comparison to senior physicians and nurses), who also had a higher intention to leave than nurses (p = 0.024). Nonbeneficial treatment was predicted by high workload and low quality collaboration with other departments (both p ≤ 0.001). Poor nurse-physician collaboration predicted perception of nonbeneficial treatment among junior physicians and nurses (both p ≤ 0.001) but not among senior physicians (p = 0.753). Nonbeneficial treatment was independently associated with the core burnout dimension emotional exhaustion (p ≤ 0.001), which significantly mediated the effect between nonbeneficial treatment and intention to leave (indirect effect: 0.11 [95% CI, 0.06-0.18]).
Conclusions:
Perceiving nonbeneficial treatment is related to burnout and may increase intention to leave. Efforts to reduce perception of nonbeneficial treatment should improve the work environment and should be tailored to the different experiences of nurses and junior and senior physicians.
... These markers included anticipated cardiac arrest, unnecessary medication, low ECOG performance scores, treatment never reaching the patient's goals and treatment unable to improve patient's survival or quality of life. Markers incorporating health system factors were measured in eight studies: underutilization of hospice care [41,46,53], absence of palliative care consultation before ICU admission [54], delayed documentation of code blue status [38], cost savings from ICU avoidance [27], cost of hospitalization with/without ICU admission [47] and delayed decision to forgo life-sustaining treatment [34]. ...
... Ongoing blood tests on patients with DNR orders [26] 49.0% 270 Imaging on patients with DNR orders [26] 37.0% 270 Emergency imaging in last 3 months of life [22] 25.0% 71 269 Other non-beneficial management Utilization of rapid response systems [26] 5.0% 270 Use of emergency consultations in last 3 months of life [35] 50.0% 138 Hospital admission in the last month of life [40] 8.8% 113 Use of hospice for LOS shorter than 3 days [40] 3.5% 113 Median time from ICU admission to decision to forgo LST [34] 19 days 1265 Median duration of antibiotics for patients spending their birthday in ICU [34] 9 days 1265 ...
... Ongoing blood tests on patients with DNR orders [26] 49.0% 270 Imaging on patients with DNR orders [26] 37.0% 270 Emergency imaging in last 3 months of life [22] 25.0% 71 269 Other non-beneficial management Utilization of rapid response systems [26] 5.0% 270 Use of emergency consultations in last 3 months of life [35] 50.0% 138 Hospital admission in the last month of life [40] 8.8% 113 Use of hospice for LOS shorter than 3 days [40] 3.5% 113 Median time from ICU admission to decision to forgo LST [34] 19 days 1265 Median duration of antibiotics for patients spending their birthday in ICU [34] 9 days 1265 ...
Purpose
To investigate the extent of objective ‘non-beneficial treatments (NBTs)’ (too much) anytime in the last 6 months of life in routine hospital care.
Data sources
English language publications in Medline, EMBASE, PubMed, Cochrane library, and the grey literature (January 1995–April 2015).
Study selection
All study types assessing objective dimensions of non-beneficial medical or surgical diagnostic, therapeutic or non-palliative procedures administered to older adults at the end of life (EOL).
Data extraction
A 13-item quality score estimated independently by two authors.
Results of data synthesis
Evidence from 38 studies indicates that on average 33–38% of patients near the EOL received NBTs. Mean prevalence of resuscitation attempts for advanced stage patients was 28% (range 11–90%). Mean death in intensive care unit (ICU) was 42% (range 11–90%); and mean death rate in a hospital ward was 44.5% (range 29–60%). Mean prevalence of active measures including dialysis, radiotherapy, transfusions and life support treatment to terminal patient was 7–77% (mean 30%). Non-beneficial administration of antibiotics, cardiovascular, digestive and endocrine treatments to dying patients occurred in 11–75% (mean 38%). Non-beneficial tests were performed on 33–50% of patients with do-not-resuscitate orders. From meta-analyses, the pooled prevalence of non-beneficial ICU admission was 10% (95% CI 0–33%); for chemotherapy in the last six weeks of life was 33% (95% CI 24–41%).
Conclusion
This review has confirmed widespread use of NBTs at the EOL in acute hospitals. While a certain level of NBT is inevitable, its extent, variation and justification need further scrutiny.
... We conducted an observational study of the multicenter database OutcomeRea TM fed by 13 French ICUs. Data included in the database were collected by physicians with the collaboration of trained study monitors, as described elsewhere [21]. All consecutive patients older than 18 years with ICU stays longer than 24 h at a specific time during the year or admitted to certain predefined ICU beds were included, which ensured that a sample of patients was included randomly regardless of the specific disease or health status. ...
To assess the prevalence of decisions to forgo life-sustaining treatment (DFLST), the patients characteristics, and to estimate the impact of DFLST stages on mortality.
Observational study of a prospective database between 2005 and 2012 from 13 ICUs. DFLST were defined as follows: no escalation of treatment (stage 1), not to start or escalate treatment even if such treatment is considered in the future; withholding (stage 2), not to start or escalate necessary treatment; withdrawal (stage 3), to stop necessary treatment. The impact of daily DFLST stage on day-30 hospital mortality was tested with a discrete-time Cox's model and adjusted for admission severity and daily SOFA score.
Of 10,080 patients, 1290 (13 %) made DFLST. The highest DFLST stage during the ICU stay was no escalation of treatment in 339 (26 %) patients, withholding in 502 (39 %) patients, and withdrawal in 449 (35 %) patients. Older patients, patients with at least one chronic disease, and patients with greater ICU severity were significantly more numerous in the DFLST group. Day-30 mortality was 13 % for non-DFLST patients, 35 % for no escalation of treatment, 75 % for withholding, 93 % for withdrawal. After adjustment, an increase in day-30 mortality was associated with withholding and withdrawal (hazard ratio 95 % CI 5.93 [4.95-7.12] and 20.05 [15.58-25.79], P < 0.0001), but not with no escalation of treatment (HR 1.14 [0.91-1.44], P = 0.25).
DFLST were made in 13 % of ICU patients. Withholding, withdrawal, older age, more comorbidities, and higher severity of illness were associated with higher mortality. No escalation of treatment was not associated with increased mortality.
... OUTCOMEREA is an ongoing prospective observational collaborative study group that includes detailed clinical and outcome data on patients admitted to participating French ICUs. Details about the database have already been described (16,17). ...
Centers for Disease Control and Prevention built up new surveillance paradigms for the patients on mechanical ventilation and the ventilator-associated events, comprising ventilator-associated conditions and infection-related ventilator-associated complications. We assess 1) the current epidemiology of ventilator-associated event, 2) the relationship between ventilator-associated event and ventilator-associated pneumonia, and 3) the impact of ventilator-associated event on antimicrobials consumption and mechanical ventilation duration.
Inception cohort study from the longitudinal prospective French multicenter OUTCOMEREA database (1996-2012).
Patients on mechanical ventilation for greater than or equal to 5 consecutive days were classified as to the presence of a ventilator-associated event episode, using slightly modified Centers for Disease Control and Prevention definitions.
None.
Among the 3,028 patients, 2,331 patients (77%) had at least one ventilator-associated condition, and 869 patients (29%) had one infection-related ventilator-associated complication episode. Multiple causes, or the lack of identified cause, were frequent. The leading causes associated with ventilator-associated condition and infection-related ventilator-associated complication were nosocomial infections (27.3% and 43.8%), including ventilator-associated pneumonia (14.5% and 27.6%). Sensitivity and specificity of diagnosing ventilator-associated pneumonia were 0.92 and 0.28 for ventilator-associated condition and 0.67 and 0.75 for infection-related ventilator-associated complication, respectively. A good correlation was observed between ventilator-associated condition and infection-related ventilator-associated complication episodes, and ventilator-associated pneumonia occurrence: R = 0.69 and 0.82 (p < 0.0001). The median number of days alive without antibiotics and mechanical ventilation at day 28 was significantly higher in patients without any ventilator-associated event (p < 0.05). Ventilator-associated condition and infection-related ventilator-associated complication rates were closely correlated with antibiotic use within each ICU: R = 0.987 and 0.99, respectively (p < 0.0001).
Ventilator-associated event is very common in a population at risk and more importantly highly related to antimicrobial consumption and may serve as surrogate quality indicator for improvement programs.
... The usual risk factors described in the more recent predictive scores included variables that are frequent, and lead us to treat 10-20% of the ICU patients [13,30]. More than two-thirds of these treatments are given without definitive proof of invasive fungal infections [30]. ...
... The usual risk factors described in the more recent predictive scores included variables that are frequent, and lead us to treat 10-20% of the ICU patients [13,30]. More than two-thirds of these treatments are given without definitive proof of invasive fungal infections [30]. ...
The potential of the systemic antifungal treatment of non-immunocompromised patients with sepsis, extra-digestive Candida colonization and multiple organ failure is unknown, although it represents three out of four antifungal treatments prescribed in intensive care units. It may allow an early treatment of invasive fungal infection at incubation phase, but exposes patients to unnecessary antifungal treatments with subsequent costs and antifungal selection pressure. As early diagnostic tests for invasive candidiasis are still considered insufficient, the potential of this strategy needs to be demonstrated by a randomized controlled trial. Such a trial is currently ongoing.
... Over the last two decades, the use of intensive care at the end of life has increased significantly [1][2][3]. Studies have described intensive care unit (ICU) practices at the end of life [3][4][5][6][7], shed light on treatment-limitation decisions [8], identified specific needs of bereaved relatives, and determined what affects the quality of the dying experience for relatives, physicians and nurses [9][10][11][12][13][14][15][16][17]. ...
An increased proportion of deaths occur in the intensive care unit (ICU). We performed this prospective study in 41 ICUs to determine the prevalence and determinants of complicated grief after death of a loved one in the ICU. Relatives of 475 adult patients were followed up. Complicated grief was assessed at 6 and 12 months using the Inventory of Complicated Grief (cut-off score >25). Relatives also completed the Hospital Anxiety and Depression Scale at 3 months, and the Revised Impact of Event Scale for post-traumatic stress disorder symptoms at 3, 6 and 12 months. We used a mixed multivariate logistic regression model to identify determinants of complicated grief after 6 months. Among the 475 patients, 282 (59.4%) had a relative evaluated at 6 months. Complicated grief symptoms were identified in 147 (52%) relatives. Independent determinants of complicated grief symptoms were either not amenable to changes (relative of female sex, relative living alone and intensivist board certification before 2009) or potential targets for improvements (refusal of treatment by the patient, patient died while intubated, relatives present at the time of death, relatives did not say goodbye to the patient, and poor communication between physicians and relatives). End-of-life practices, communication and loneliness in bereaved relatives may be amenable to improvements.
Copyright ©ERS 2015.
... 5. How objective are we in end-of-life decision making process? [5] Patients who spend their birthday in the ICU receive a higher intensity of life-sustaining therapies and have a longer ICU stay. However, this increased therapeutic intensity does not translate into survival benefits compared to matched controls. ...
... The mortality of patients fulfilling the selection criteria has been estimated between 30% and 37% (OUTCOMEREA French database [32,33]) The candidemia related mortality in case of early treatment is 12% whereas it is 35% when the treatment is delayed (current practice) [17] According to Schuster et al. [29], IFIs should be expected to be diagnosed in 7.1% of patients receiving antifungal therapy and 20.8% of those receiving placebo (absolute difference 13.7%) Traditional sensitivity diagnostic test (blood cultures, culture of sterile site) of IFI diagnosis is 60% ...
The potential interest of antifungal treatment of non-immunocompromized patients with sepsis, extra-digestive Candida colonization and multiple organ failure is unknown. It represents three-quarters of antifungals prescribed in Intensive Care Units. It may allow early treatment of invasive fungal infection in the incubation phase but expose patients to unnecessary antifungal treatments with subsequent cost and fungal selection pressure. As early diagnostic tests for invasive candidiasis are still considered to be insufficient, the potential interest in this strategy needs to be demonstrated.
This prospective multicenter, double blind, randomized-controlled trial is conducted in 23 French Intensive Care Units. All adult patients, mechanically ventilated for more than four days with sepsis of unknown origin and with at least one extradigestive fungal colonization site and multiple organ failure are eligible for randomization. Patients with proven invasive candidiasis are not included. After a complete mycological screening, patients are allocated to receive micafungin 100 mg intravenously once a day or placebo for 14 days. We plan to enroll 260 patients. The main objective is to demonstrate that micafungin increases survival of patients without invasive candidiasis at day 28 as compared to placebo. Other outcomes include day 28 and 90 survival and organ failure evolution. Additionally, pharmacokinetics of micafungin in enrolled patients will be measured and evolution of fungal biomarkers and susceptibility profiles of infecting fungi will also be followed.
This study will help to provide guidelines for treating non-immunocompromized patients with fungal colonization multiple organ failure and sepsis of unknown origin.Trial registration: Clinicaltrials.gov number NCT01773876.
... There were two interesting studies about the provision of end-of-life care in the ICU. In the first, Azoulay and colleagues [86] examined whether patients who had a birthday during their ICU stay seemed to a receive different level of care than those who did not. They conducted a case–control design in which patients spending their birthday in the ICU (cases) were matched to controls in terms of hospital, gender, age, severity of illness, and type of admission. ...
Year in review in Intensive Care Medicine 2012. II : Pneumonia and infection, sepsis, coagulation, hemodynamics, cardiovascular and microcirculation, critical care organization, imaging, ethics and legal issues
Upon admission to an intensive care unit, doctors should engage in a discussion with their patients about the life-sustaining treatments (e.g., cardiopulmonary resuscitation and invasive mechanical ventilation) that could be needed in case of a degradation of their health condition. Documenting levels of care is a communication strategy that helps translate patients’ wishes into a treatment plan that integrates patients’ values, preferences and prognosis. Without such discussions, interventions that prolong life at the cost of decreasing its quality may be used without appropriate guidance from patients. Shared decision making
is recommended to facilitate doctors' and patients' discussions about levels of care. Patient decision aids can support shared decision making. However, there existed no French language decision aid adapted to the context of our intensive care unit serving a francophone population in the Province of Quebec.
This thesis presents the steps that led to the adaptation of a decision aid about levels of care in a single francophone intensive care unit in Lévis, Québec. We employed user-centered design to adapt a patient decision aid about cardiopulmonary resuscitation and a clinical prediction rule. The final patient decision aid includes: 1) a values-clarification section; 2) questions about the patient’s functional autonomy prior to admission to the ICU and the functional decline that they would judge acceptable upon hospital discharge; 3) risks and
benefits of cardiopulmonary resuscitation and mechanical ventilation; 4) population-level statistics about cardiopulmonary resuscitation; and 5) a summary section. We also used a wiki to program an online risk calculator based on the Good Outcome Following Attempted Resuscitation prediction rule that we linked to the IconArray.com risk representation software. The final tool and calculator are available at www.wikidecision.org. This thesis also contains a review of the scientific literature about obstacles to discussions about levels of care. It also includes our observations and our thoughts on the obstacles to discussions about levels of care.
