Choudhuri Anirban H, Sharma Ankit, Uppal Rajeev
Department of Anesthesiology and Intensive Care, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India.
Indian J Crit Care Med. 2020 Jun;24(6):404-408. doi: 10.5005/jp-journals-10071-23454.
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.
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.
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; = 0.01). The patients in the late initiation group were younger in age (49 ± 3.6 years vs 66 ± 5.3 years; = 0.03). The number of antibiotic-free days was higher in the early initiation group (12 ± 5.2 days vs 6 ± 7.5; = 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; = 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.
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.
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.
对晚期患者尽早启动临终关怀（EOL）可减少不必要药物的使用，尽量减少实验室检查和影像学检查，并避免那些会引发不良并发症且无实质益处的操作。本回顾性观察研究旨在比较在确认治疗无效后，晚期重症监护病房（ICU）患者临终关怀的早期启动与晚期启动情况。
从ICU数据库中提取2014年1月至2018年12月期间入住ICU后任何时间被视为晚期患者的所有病历。被确认治疗无效的患者符合纳入标准。在ICU入院前已接受临终关怀或诊断未确诊的患者被排除在研究之外。治疗无效是由主治医师和重症监护医生根据疾病阶段和可用治疗方案共同做出的主观决定。在确认治疗无效后开始的临终关怀分为：（a）早期组（EG）——在决定治疗无效后的48小时内；（b）晚期组（LG）——在确认治疗无效48小时后。比较两组的以下指标：（a）ICU死亡率；（b）ICU住院时间；（c）无抗生素使用天数；（d）无呼吸机使用天数；（e）医疗和/或外科干预次数（中心静脉置管、引流管、主动脉内球囊反搏等的插入）；（f）血液和影像学检查次数；（g）家庭成员满意度。
在107例被诊断为治疗无效的晚期患者中，64例（59.8%）患者较早启动临终关怀，43例（40.2%）患者延迟启动（1.3±0.4天对5.1±1.6天；P=0.01）。延迟启动组患者年龄较轻（49±3.6岁对66±5.3岁；P=0.03）。早期启动组无抗生素使用天数更多（12±5.2天对6±7.5天；P=0.02）。早期启动组医疗和外科干预次数较少（3.0±0.7次对12±3.9次；P=0.007）。临终关怀延迟启动的原因包括预后困境（30.2%）、家庭成员的不情愿（44.1%）、主治医师的矛盾心理（18.6%）和重症监护医生的犹豫（6.9%）。两组家庭成员的满意度相似。
我们得出结论，在确认治疗无效后，晚期ICU患者临终关怀的延迟启动会增加抗生素使用以及医疗和/或外科干预次数，且对家庭成员的满意度没有影响。
Choudhuri AH, Sharma A, Uppal R. 晚期重症监护病房患者临终关怀延迟启动的影响。《印度重症医学杂志》2020；24(6):404 - 408。
