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VOLUME 24 , ISSUE 6 ( June, 2020 ) > List of Articles

Original Article

Effects of Delayed Initiation of End-of-life Care in Terminally Ill Intensive Care Unit Patients

Anirban Hom Choudhuri, Ankit Sharma, Rajeev Uppal

Citation Information : Choudhuri AH, Sharma A, Uppal R. Effects of Delayed Initiation of End-of-life Care in Terminally Ill Intensive Care Unit Patients. Indian J Crit Care Med 2020; 24 (6):404-408.

DOI: 10.5005/jp-journals-10071-23454

License: CC BY-NC 4.0

Published Online: 30-07-2020

Copyright Statement:  Copyright © 2020; Jaypee Brothers Medical Publishers (P) Ltd.


Abstract

Introduction: Early initiation of end-of-life (EOL) care in terminally ill patients can reduce the administration of unnecessary medications, minimize laboratory and radiological investigations, and avoid procedures that can provoke untoward complications without substantial benefits. This retrospective observational study was performed to compare early vs late initiation of EOL care in terminally ill ICU patients after the recognition of treatment futility. Materials and methods: The medical records of all patients who were considered to be terminally ill any time after ICU admission between January 2014 and December 2018 were extracted from the ICU database. The patients who were recognized for treatment futility were eligible for inclusion. The patients who were already on EOL care prior to the ICU admission or whose diagnosis was unconfirmed were excluded from the study. The treatment futility was a subjective decision jointly undertaken by the primary physician and the intensivist based upon the disease stage and the available therapeutic options. The commencement of EOL care after recognition of treatment futility was divided into (a) early group (EG)—within 48 hours of decision of treatment futility and (b) late group (LG)—after 48 hours of recognition of treatment futility. Both the groups were compared for (a) ICU mortality, (b) length of ICU stay, (c) number of antibiotic-free days, (d) number of ventilator-free days, (e) number of medical and/or surgical interventions (insertion of central lines, drains, IABP, etc.), (f) number of blood and radiological investigations, and (g) satisfaction level of family members. Results: Out of 107 terminally ill patients with diagnosis of treatment futility, 64 patients (59.8%) underwent early initiation of EOL against delayed initiation in 43 (40.2%) patients (1.3 ± 0.4 days vs 5.1 ± 1.6 days; p = 0.01). The patients in the late initiation group were younger in age (49 ± 3.6 years vs 66 ± 5.3 years; p = 0.03). The number of antibiotic-free days was higher in the early initiation group (12 ± 5.2 days vs 6 ± 7.5; p = 0.02). The number of medical and surgical interventions was lesser in the early initiation group (3.0 ± 0.7 episodes vs 12 ± 3.9 episodes; p = 0.007). The late initiation of EOL was caused by prognostic dilemma (30.2%), reluctance of the family members (44.1%), ambivalence of the primary physician (18.6%), and hesitancy of the intensivist (6.9%). The satisfaction level of the family members was similar in both the groups. Conclusion: We conclude that delayed initiation of EOL care in terminally ill ICU patients after recognition of treatment futility can increase the antibiotic usage and medical and/or surgical interventions with no effect on the satisfaction level of the family members.


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  1. Iwashyna TJ, Kramer AA, Kahn JM. Intensive care unit occupancy and patient outcomes. Crit Care Med 2009;37(5):1545–1557. DOI: 10.1097/CCM.0b013e31819fe8f8.
  2. Tanaka Gutiez M, Ramaiah R. Demand versus supply in intensive care: an ever-growing problem. Crit Care 2014;18(Suppl 1):P9. DOI: 10.1186/cc13199.
  3. Woo JA, Maytal G, Stern TA. Clinical challenges to the delivery of end-of-life care. Prim Care Companion J Clin Psychiatry 2006;8(6):367–372. DOI: 10.4088/pcc.v08n0608.
  4. Jensen HI, Ammentorp J, Johannessen H, Ørding H. Challenges in end-of-life decisions in the intensive care unit: an ethical perspective. J Bioeth Inq 2013;10(1):93–101. DOI: 10.1007/s11673-012-9416-5.
  5. Coombs MA, Addington-Hall J, Long-Sutehall T. Challenges in transition from intervention to end of life care in intensive care: a qualitative study. Int J Nurs Stud 2012;49(5):519–527. DOI: 10.1016/j.ijnurstu.2011.10.019.
  6. van der Werf TS, Zijlstra JG, Ligtenberg JJ, Tulleken JE. Decisions around the end of life on intensive care: making the transition from curative to palliative treatment. Ned Tijdschr Geneeskd 2005;149(14):742–746.
  7. Clements JM. Patient perceptions on the use of advance directives and life prolonging technology. Am J Hosp Palliat Care 2009;26(4):270–276. DOI: 10.1177/1049909109331886.
  8. Bernal EW, Marco CA, Parkins S, Buderer N, Thum SD. End-of-life decisions: family views on advance directives. Am J Hosp Palliat Care 2007;24(4):300–307. DOI: 10.1177/1049909107302296.
  9. Lighthall GK, Vazquez-Guillamet C. Understanding decision making in critical care. Clin Med Res 2015;13(3-4):156–168. DOI: 10.3121/cmr.2015.1289.
  10. Kushniruk A, Patel V, Fleiszer D. Analysis of medical decision making: a cognitive perspective on medical informatics. Proc Annu Symp Comput Appl Med Care 1995. 193–197.
  11. Patel VL, Zhang J, Yoskowitz NA, Green R, Sayan OR. Translational cognition for decision support in critical care environments: a review. J Biomed Inform 2008;41(3):413–431. DOI: 10.1016/j.jbi.2008.01.013.
  12. Fried TR, Bradley EH, Towle VR, Allore H. Understanding the treatment preferences of seriously ill patients. N Engl J Med 2002;346(14): 1061–1066. DOI: 10.1056/NEJMsa012528.
  13. Teno JM, Fisher ES, Hamel MB, Coppola K, Dawson NV. Medical care inconsistent with patients’ treatment goals: association with 1-year medicare resource use and survival. J Am Geriatr Soc 2002;50(3): 496–500. DOI: 10.1046/j.1532-5415.2002.50116.x.
  14. Wright AA, Katz IT. Letting go of the rope--aggressive treatment, hospice care, and open access. N Engl J Med 2007;357(4):324–327. DOI: 10.1056/NEJMp078074.
  15. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med 2005;142(4):260–273. DOI: 10.7326/0003-4819-142-4-200502150-00008.
  16. Covinsky KE, Fuller JD, Yaffe K, Johnston CB, Hamel MB, Lynn J, et al. Communication and decision-making in seriously ill patients: findings of the SUPPORT project. the study to understand Prognoses and preferences for outcomes and risks of treatments. J Am Geriatr Soc 2000;48(S1):S187–S193. DOI: 10.1111/j.1532-5415.2000.tb03131.x.
  17. Cataudella DA, Zelcer S. Psychological experiences of children with brain tumours at end of life: parental perspectives. J Palliat Med 2012;15(11):1191–1197. DOI: 10.1089/jpm.2011.0479.
  18. Barling JA, Stevens JA, Davies KM. The reality of hospitalisation: stories from family members of their hospital experience for adolescents and young adults living with and dying from cancer. Contemp Nurse 2014;46(2):150–160. DOI: 10.5172/conu.2014.46.2.150.
  19. Nakagawa S, Toya Y, Okamoto Y, Tsuneto S, Goya S, Tanimukai H, et al. Can anti-infective drugs improve the infection-related symptoms of patients with cancer during the terminal stages of their lives? J Palliat Med 2010;13(5):535–540. DOI: 10.1089/jpm.2009.0336.
  20. Oh DY, Kim JH, Kim DW, Im SA, Kim TY, Heo DS, et al. Antibiotic use during the last days of life in cancer patients. Eur J Cancer Care 2006;15(1):74–79. DOI: 10.1111/j.1365-2354.2005.00603.x.
  21. Silverberg LI. Survey of medical ethics in US medical schools: a descriptive study. J Am Osteopath Assoc 2000;100(6):373–378.
  22. Dy SM, Shugarman LR, Lorenz KA, Mularski RA, Lynn J. RAND-southern California evidence-based practice center. A systematic review of satisfaction with care at the end of life. Am Geriatr Soc 2008;56(1):124–129. DOI: 10.1111/j.1532-5415.2007.01507.x.
  23. Heyland DK, Cook DJ, Rocker GM, Dodek PM, Kutsogiannis DJ, Skrobik Y, et al. Canadian researchers at the end of life network (CARENET). Defining priorities for improving end-of-life care in Canada. CMAJ 182(16):E747–E752. DOI: 10.1503/cmaj.100131.
  24. Dodek PM, Heyland DK, Rocker GM, Cook DJ. Translating family satisfaction data into quality improvement. Crit Care Med 2004;32(9):1922–1927. DOI: 10.1097/01.ccm.0000139920.53790.61.
  25. Diffin J, Spence M, Spencer R, Mellor P, Grande G. Involving healthcare professionals and family carers in setting research priorities for end-of-life care. Int J Palliat Nurs 2017;23(2):56–59. DOI: 10.12968/ijpn.2017.23.2.56.
  26. Chan RJ, Webster J. End-of-life care pathways for improving outcomes in caring for the dying. Cochrane Database Syst Rev 2013(11):CD008006. DOI: 10.1002/14651858.CD008006.pub3.
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