Division of Critical Care, Respiratory Epidemiology and Clinical Research Unit, McGill University Faculty of Medicine, Montreal, Québec, Canada
Research Institute of the McGill University Health Centre, Montreal, Québec, Canada.
BMJ Open. 2023 Aug 18;13(8):e069536. doi: 10.1136/bmjopen-2022-069536.
To investigate whether observable differences exist between patterns of withdrawal of life-sustaining measures (WLSM) for patients eligible for donation after circulatory death (DCD) in whom donation was attempted compared with those patients in whom no donation attempts were made.
Adult intensive care units from 20 centres in Canada, the Czech Republic and the Netherlands.
Secondary analysis of quantitative data collected as part of a large, prospective, cohort study (the Death Prediction and Physiology after Removal of Therapy study).
Patients ≥18 years of age who died after a controlled WLSM in an intensive care unit. Patients were classified as not DCD eligible, DCD eligible with DCD attempted or DCD eligible but DCD was not attempted.
The process of WLSM (timing and type and, if applicable, dosages of measures withdrawn, dosages of analgesics/sedatives) was compared between groups.
Of the 635 patients analysed, 85% had either cardiovascular support stopped or were extubated immediately on WLSM. Of the DCD eligible patients, more were immediately extubated at the initiation of WLSM when DCD was attempted compared with when DCD was not attempted (95% vs 61%, p<0.0001). Initiation of WLSM with the immediate cessation of cardiovascular measures or early extubation was associated with earlier time to death, even after adjusting for confounders (OR 2.94, 95% CI 1.39 to 6.23, at 30 min). Other than in a few patients who received propofol, analgesic and sedative dosing after WLSM between DCD attempted and DCD eligible but not attempted patients was not significantly different. All patients died.
Patients in whom DCD is attempted may receive a different process of WLSM. This highlights the need for a standardised and transparent process for end-of-life care across the spectrum of critically ill patients and potential organ donors.
研究在尝试进行捐赠后循环死亡（DCD）的患者与未进行捐赠尝试的患者之间，是否存在可观察到的生命支持措施（WLSM）撤回模式的差异。
来自加拿大、捷克共和国和荷兰的 20 个中心的成人重症监护病房。
作为一项大型前瞻性队列研究（撤除治疗后的死亡预测和生理学研究）的一部分，对收集的定量数据进行的二次分析。
在重症监护病房接受控制 WLSM 后死亡的年龄≥18 岁的患者。患者被分为不符合 DCD 资格、符合 DCD 资格但尝试进行 DCD 和符合 DCD 资格但未尝试进行 DCD。
比较了各组之间 WLSM 的过程（时间和类型，以及如果适用，撤回措施的剂量、镇痛/镇静剂的剂量）。
在分析的 635 名患者中，85%的患者在 WLSM 时要么停止心血管支持，要么立即拔管。在符合 DCD 资格的患者中，当尝试 DCD 时，在 WLSM 开始时更倾向于立即拔管，而不是当不尝试 DCD 时（95% vs 61%，p<0.0001）。即使在调整混杂因素后，WLSM 立即停止心血管措施或早期拔管与更早的死亡时间相关（OR 2.94，95%CI 1.39 至 6.23，在 30 分钟时）。除了少数接受异丙酚的患者外，尝试 DCD 和符合 DCD 但未尝试 DCD 患者的 WLSM 后镇痛和镇静剂剂量没有显著差异。所有患者均死亡。
尝试 DCD 的患者可能会接受不同的 WLSM 过程。这突显了在整个重症患者和潜在器官供体范围内，需要对生命末期护理进行标准化和透明的处理。
