The surgical intensivist as mediator of end-of-life issues in the care of critically ill patients

Aims: One of the major ethical challenges posed by the Covid-19 pandemic comes in the form of fair triage decisions for critically ill patients in situations where life-saving resources are limited. In Spring 2020, the Swiss Academy of Medical Sciences (SAMS) issued specific guidelines on triage for intensive-care treatment in the context of the Covid-19 pandemic. While evidence has shown that the capacities of intensive care medicine throughout Switzerland were sufficient to take care of all critically ill patients during the first wave of the outbreak, no evidence is available regarding the acceptance of these guidelines by ICU staff. The aim of this qualitative study was to explore the acceptance and perceived implementation of the SAMS guidelines among a sample of senior physicians involved in the care of Covid-19 patients in the Canton of Ticino. Specific objectives included capturing and describing physicians' attitudes toward the guidelines, any challenges experienced in their application, and any perceived factors that facilitated or would facilitate their application.Methods: We conducted face-to-face and telephone interviews with a purposive sample of nine senior physicians employed as either head of unity, deputy-head of unit, or medical director in either one of the two Covid-19 hospitals in the Canton of Ticino during the peak of the outbreak. Interviews were transcribed verbatim and thematically analyzed using an inductive approach.Results: We found that participants held different views regarding the nature of the guidelines, saw decisions on admission as a matter of collective responsibility, argued that decisions should be based on a medical futility principle rather than an age criterion, and found that difficulties to address end-of-life issues led to a comeback of paternalism.Conclusions: Results highlight the importance of clarifying the nature of the guidelines, establishing authority, and responsibility during triaging decisions, recognizing and addressing sources of interference with patients' autonomy, and the need of a cultural shift in timely and efficiently addressing end-of-life issues.

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End-of-Life Issues in Critically Ill Cancer Patients

Critical Care Clinics ◽

10.1016/j.ccc.2009.10.002 ◽

2010 ◽

Vol 26 (1) ◽

pp. 219-227 ◽

Cited By ~ 15

Author(s):

Susan Gaeta ◽

Kristen J. Price

Keyword(s):

End Of Life ◽

Cancer Patients ◽

Critically Ill ◽

Life Issues ◽

End Of Life Issues

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A Prospective Determination of the Incidence of Perceived Inappropriate Care in Critically Ill Patients

Canadian Respiratory Journal ◽

10.1155/2014/429789 ◽

2014 ◽

Vol 21 (3) ◽

pp. 165-170 ◽

Cited By ~ 16

Author(s):

Rohit K Singal ◽

Robert Sibbald ◽

Brenda Morgan ◽

Mel Quinlan ◽

Neil Parry ◽

...

Keyword(s):

Health Care ◽

End Of Life ◽

Critically Ill ◽

Health Care Providers ◽

Critically Ill Patients ◽

Public Awareness ◽

Surgical Trauma ◽

Care Providers ◽

Inappropriate Care ◽

End Of Life Issues

BACKGROUND: Health care providers’ perceptions regarding appropriateness in end-of-life treatments have been widely studied. While nurses and physicians believe that rationing and other cost-related practices sometimes occur in the intensive care unit (ICU), they allege that treatment is often excessive.OBJECTIVE: To prospectively determine the incidence and causes of health care providers’ perceptions regarding appropriateness of end-of-life treatments.METHODS: The present prospective study collected data from patients admitted to the medical-surgical trauma ICU of a 30-bed, Canadian teaching hospital over a three-month period. Daily surveys were completed independently by bedside nurses, charge nurses and attending physician.RESULTS: In total, 5224 of 6558 expected surveys (representing 294 patients) were analyzed, yielding a response rate of 79.7%. The incidence of perceived inappropriate care in the present study was 6.5% (19 of 294 patients), with ongoing treatment for >2 days after this determination occurring in 1% (three of 294 patients). However, at least one caregiver perceived inappropriate care at some point in 110 of 294 (37.5%) patients. In these cases, in which processes to address care were not already underway, respondents believed that important issues resulting in provision of inappropriate treatments included patient-family issues and communication before or in the ICU. Caregivers did not know their patients’ wishes 22% (1129 of 5224) of the time.CONCLUSIONS: Although ongoing inappropriate care appeared to be a rare occurrence, the issue was a concern to at least one caregiver in one-third of cases. Public awareness for end-of-life issues, adequate communication, and up-to-date knowledge and practice in determining the wishes of critically ill patients are potential target areas to improve end-of-life care and reduce inappropriate care in the ICU. A daily, prospective survey of multidisciplinary caregivers, such as the survey used in the present study, is a viable and valuable means of determining the scope and causes of inappropriate care in the ICU.

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