Limitation of life-sustaining treatment and patient involvement in decision-making: a retrospective study of a Danish COVID-19 patient cohort

Background The coronavirus (COVID-19) pandemic and the risk of an extensive overload of the healthcare systems have elucidated the need to make decisions on the level of life-sustaining treatment for patients requiring hospitalisation. The purpose of the study was to investigate the proportion and characteristics of COVID-19 patients with limitation of life-sustaining treatment decisions and the degree of patient involvement in the decisions. Methods A retrospective observational descriptive study was conducted in three Danish regional hospitals, looking at all patients ≥ 18 years of age admitted in 2020 with COVID-19 as the primary diagnosis. Lists of hospitalised patients admitted due to COVID-19 were extracted. The data registration included age, gender, comorbidities, including mental state, body mass index, frailty, recent hospital admissions, COVID-19 life-sustaining treatment, ICU admission, decisions on limitations of life-sustaining treatment before and during current hospitalisation, hospital length of stay, and hospital mortality. Results A total of 476 patients were included. For 7% (33/476), a decision about limitation of life-sustaining treatment had been made prior to hospital admission. At the time of admission, one or more limitations of life-sustaining treatment were registered for 16% (75/476) of patients. During the admission, limitation decisions were made for an additional 11 patients, totaling 18% (86/476). For 40% (34/86), the decisions were either made by or discussed with the patient. The decisions not made by patients were made by physicians. For 36% (31/86), no information was disclosed about patient involvement. Conclusions Life-sustaining treatment limitation decisions were made for 18% of a COVID-19 patient cohort. Hereof, more than a third of the decisions had been made before hospital admission. Many records lacked information on patient involvement in the decisions.

Code status documentation at admission in COVID-19 patients: a descriptive cohort study

ObjectivesThe COVID-19 pandemic pressurised healthcare with increased shortage of care. This resulted in an increase of awareness for code status documentation (ie, whether limitations to specific life-sustaining treatments are in place), both in the medical field and in public media. However, it is unknown whether the increased awareness changed the prevalence and content of code status documentation for COVID-19 patients. We aim to describe differences in code status documentation between infectious patients before the pandemic and COVID-19 patients.SettingUniversity Medical Centre of Utrecht, a tertiary care teaching academic hospital in the Netherlands.ParticipantsA total of 1715 patients were included, 129 in the COVID-19 cohort (a cohort of COVID-19 patients, admitted from March 2020 to June 2020) and 1586 in the pre-COVID-19 cohort (a cohort of patients with (suspected) infections admitted between September 2016 to September 2018).Primary and secondary outcome measuresWe described frequency of code status documentation, frequency of discussion of this code status with patient and/or family, and content of code status.ResultsFrequencies of code status documentation (69.8% vs 72.7%, respectively) and discussion (75.6% vs 73.3%, respectively) were similar in both cohorts. More patients in the COVID-19 cohort than in the before COVID-19 cohort had any treatment limitation as opposed to full code (40% vs 25%). Within the treatment limitations, ‘no intensive care admission’ (81% vs 51%) and ‘no intubation’ (69% vs 40%) were more frequently documented in the COVID-19 cohort. A smaller difference was seen in ‘other limitation’ (17% vs 9%), while ‘no resuscitation’ (96% vs 92%) was comparable between both periods.ConclusionWe observed no difference in the frequency of code status documentation or discussion in COVID-19 patients opposed to a pre-COVID-19 cohort. However, treatment limitations were more prevalent in patients with COVID-19, especially ‘no intubation’ and ‘no intensive care admission’.

Outcomes of ICU patients with and without perceptions of excessive care: a comparison between cancer and non-cancer patients

Background Whether Intensive Care Unit (ICU) clinicians display unconscious bias towards cancer patients is unknown. The aim of this study was to compare the outcomes of critically ill patients with and without perceptions of excessive care (PECs) by ICU clinicians in patients with and without cancer. Methods This study is a sub-analysis of the large multicentre DISPROPRICUS study. Clinicians of 56 ICUs in Europe and the United States completed a daily questionnaire about the appropriateness of care during a 28-day period. We compared the cumulative incidence of patients with concordant PECs, treatment limitation decisions (TLDs) and death between patients with uncontrolled and controlled cancer, and patients without cancer. Results Of the 1641 patients, 117 (7.1%) had uncontrolled cancer and 270 (16.4%) had controlled cancer. The cumulative incidence of concordant PECs in patients with uncontrolled and controlled cancer versus patients without cancer was 20.5%, 8.1%, and 9.1% (p < 0.001 and p = 0.62, respectively). In patients with concordant PECs, we found no evidence for a difference in time from admission until death (HR 1.02, 95% CI 0.60–1.72 and HR 0.87, 95% CI 0.49–1.54) and TLDs (HR 0.81, 95% CI 0.33–1.99 and HR 0.70, 95% CI 0.27–1.81) across subgroups. In patients without concordant PECs, we found differences between the time from admission until death (HR 2.23, 95% CI 1.58–3.15 and 1.66, 95% CI 1.28–2.15), without a corresponding increase in time until TLDs (NA, p = 0.3 and 0.7) across subgroups. Conclusions The absence of a difference in time from admission until TLDs and death in patients with concordant PECs makes bias by ICU clinicians towards cancer patients unlikely. However, the differences between the time from admission until death, without a corresponding increase in time until TLDs, suggest prognostic unawareness, uncertainty or optimism in ICU clinicians who did not provide PECs, more specifically in patients with uncontrolled cancer. This study highlights the need to improve intra- and interdisciplinary ethical reflection and subsequent decision-making at the ICU.

Persister Escherichia coli Cells Have a Lower Intracellular pH than Susceptible Cells but Maintain Their pH in Response to Antibiotic Treatment

Persister and VBNC cells can phenotypically survive environmental stressors, such as antibiotic treatment, limitation of nutrients, and acid stress, and have been linked to chronic infections and antimicrobial resistance. It has recently been suggested that pH regulation might play a role in an organism’s phenotypic survival to antibiotics; however, this hypothesis remains to be tested.

Evaluation of a hypothetical decision-support tool for intensive care triage of patients with coronavirus disease 2019 (COVID-19)

Background: At the start of the coronavirus disease 2019 (COVID-19) pandemic there was widespread concern about potentially overwhelming demand for intensive care and the need for intensive care unit (ICU) triage. In March 2020, a draft United Kingdom (UK) guideline proposed a decision-support tool (DST). We sought to evaluate the accuracy of the tool in patients with COVID-19. Methods: We retrospectively identified patients in two groups: referred and not referred to intensive care in a single UK national health service (NHS) trust in April 2020. Age, Clinical Frailty Scale score (CFS), and co-morbidities were collected from patients’ records and recorded, along with ceilings of treatment and outcome. We compared the DST, CFS, and age alone as predictors of mortality, and treatment ceiling decisions. Results: In total, 151 patients were included in the analysis, with 75 in the ICU and 76 in the non-ICU-reviewed groups. Age, clinical frailty and DST score were each associated with increased mortality and higher likelihood of treatment limitation (p-values all <.001). A DST cut-off score of >8 had 65% (95% confidence interval (CI) 51%-79%) sensitivity and 63% (95% CI 54%-72%) specificity for predicting mortality. It had a sensitivity of 80% (70%-88%) and specificity of 96% (95% CI 90%-100%) for predicting treatment limitation. The DST was more discriminative than age alone (p<0.001), and potentially more discriminative than CFS (p=0.08) for predicting treatment ceiling decisions. Conclusions: During the first wave of the COVID-19 pandemic, in a hospital without severe resource limitations, a hypothetical decision support tool was limited in its predictive value for mortality, but appeared to be sensitive and specific for predicting treatment limitation.

Determinant Factors for Loss to Follow-Up in Drug-Resistant Tuberculosis Patients: The Importance of Psycho-Social and Economic Aspects

Background: Drug-resistant TB (DR-TB) is the barrier for global TB elimination efforts with a lower treatment success rate. Loss to follow-up in DR-TB is a serious problem caused mortality and morbidity for patients and leads to wide spreading of DR-TB to their family and the wider community, as well as wasting health resources. Prevention and management loss to follow-up is crucial to reduce mortality, prevent further spread of DR-TB, and inhibit the development and transmission of more extensively drug-resistant strains of bacteria. Study about the factors associated with loss to follow-up is needed to develop appropriate strategies to prevent DR-TB patients become loss to follow-up. This study was conducted to identify the risk factors correlated with loss to follow-up in DR-TB patients, using questionnaires in the point of view from patients.Methods: An observational study with cross-sectional design was conducted. Study subjects were all DR-TB patients who have declared as cured and loss to follow-up from DR-TB treatment. A structured questionnaire was used to collect information by interviewing the subjects as respondents. Obtained data was analyzed potential risk factors for loss to follow-up in DR-TB patients.Results: A total of 280 subjects were included in this study. Sex, working status, income, and body mass index showed significant different between cured and loss to follow-up DR-TB patients with p-value of 0.013, 0.010, 0.007, and 0.006, respectively. Regression analysis revealed the significant association of loss to follow-up with negative attitude towards treatment (p<0.001, OR=1.201; 95% CI=1.104-1.306), limitation of social support (p<0.001, OR=1.163; 95% CI=1.072-1.262), health service (p<0.001, OR=2.193; 95% CI=1.562-3.080)), and limitation of economic status (p=0.034, OR=1.135; 95% CI=1.009-1.276)). Conclusions: Male patients, jobless, non-regular employee, lower income, and underweight BMI were found higher in LTFU patients. Negative attitude towards treatment, limitation of social support, dissatisfaction of health service, and limitation of economic status are risk factors for LTFU in DR-TB patients. Non-compliance to treatment is complex, we suggest that the involvement and support from the combination of health ministry, labor and employment ministry, and social ministry may help to resolve the complex problems of LTFU in DR-TB patients.

Patients’ treatment limitations as predictive factor for mortality in COVID-19: results from hospitalized patients of a hotspot region for SARS-CoV-2 infections

Background In hospitalized patients with SARS-CoV-2 infection, outcomes markedly differ between locations, regions and countries. One possible cause for these variations in outcomes could be differences in patient treatment limitations (PTL) in different locations. We thus studied their role as predictor for mortality in a population of hospitalized patients with COVID-19. Methods In a region with high incidence of SARS-CoV-2 infection, adult hospitalized patients with PCR-confirmed SARS-CoV-2 infection were prospectively registered and characterized regarding sex, age, vital signs, symptoms, comorbidities (including Charlson comorbidity index (CCI)), transcutaneous pulse oximetry (SpO2) and laboratory values upon admission, as well as ICU-stay including respiratory support, discharge, transfer to another hospital and death. PTL assessed by routine clinical procedures comprised the acceptance of ICU-therapy, orotracheal intubation and/or cardiopulmonary resuscitation. Results Among 526 patients included (median [quartiles] age 73 [57; 82] years, 47% female), 226 (43%) had at least one treatment limitation. Each limitation was associated with age, dementia and eGFR (p < 0.05 each), that regarding resuscitation additionally with Charlson comorbidity index (CCI) and cardiac disease. Overall mortality was 27% and lower (p < 0.001) in patients without treatment limitation (12%) compared to those with any limitation (47%). In univariate analyses, age and comorbidities (diabetes, cardiac, cerebrovascular, renal, hepatic, malignant disease, dementia), SpO2, hemoglobin, leucocyte numbers, estimated glomerular filtration rate (eGFR), C-reactive protein (CRP), Interleukin-6 and LDH were predictive for death (p < 0.05 each). In multivariate analyses, the presence of any treatment limitation was an independent predictor of death (OR 4.34, 95%-CI 2.10–12.30; p = 0.001), in addition to CCI, eGFR < 55 ml/min, neutrophil number > 5 G/l, CRP > 7 mg/l and SpO2 < 93% (p < 0.05 each). Conclusion In hospitalized patients with SARS-CoV-2, the percentage of patients with treatment limitations was high. PTL were linked to age, comorbidities and eGFR assessed upon admission and strong, independent risk factors for mortality. These findings might be useful for further understanding of COVID-19 mortality and its regional variations. Clinical trial registration ClinicalTrials.gov Identifier: NCT04344171

Early resuscitation orders in hospitalized oldest-old with COVID-19: A multicenter cohort study

Background: In particular older people are at risk of mortality due to corona virus disease 2019 (COVID-19). Advance care planning is essential to assist patient autonomy and prevent non-beneficial medical interventions. Aim: To describe early (taken within 72 h after hospital admission) resuscitation orders in oldest-old hospitalized with COVID-19. Setting/participants: A cohort of patients aged 80 years and older admitted to the acute hospital in March and April 2020 with COVID-19 were retrospectively recruited from 10 acute hospitals in Belgium. Recruitment was done through a network of geriatricians. Results: Overall, 766 octogenarians were admitted of whom 49 were excluded because no therapeutic relationship with the geriatrician and six because of incomplete case report form. Early decisions not to consider intensive care admission were taken in 474/711 (66.7%) patients. This subgroup was characterized by significantly higher age, higher number of comorbidities and higher frailty level. There was a significant association between the degree of the treatment limitation and the degree of premorbid frailty ( p < 0.001). Overall in-hospital mortality was 41.6% in patients with an early decision not to consider intensive care admission (67.1% in persons who developed respiratory failure vs 16.7% in patients without respiratory failure ( p < 0.001)). Of 104 patients without early decision not to consider intensive care admission but who developed respiratory failure, 59 were eventually not transferred to intensive care unit with in-hospital mortality of 25.4%; 45 were transferred to the intensive care unit with mortality of 64.4%. Conclusions: Geriatricians applied all levels of treatment in oldest-old hospitalized with COVID-19. Early decisions not to consider intensive care admission were taken in two thirds of the cohort of whom more than 50% survived to hospital discharge by means of conservative treatment.

The Efficiency of Manual Therapy and Sacroiliac and Lumbar Exercises in Patients with Sacroiliac Joint Dysfunction Syndrome

Background: Manual therapy, exercise therapy, and the combination of these 2 are common treatments for sacroiliac joint dysfunction syndrome. The effects of these treatments have been discussed in several studies; the superiority of one over the other for patients with sacroiliac joint dysfunction syndrome is still the subject of discussion. Objective: This study aims to assess the effects of manual therapy for sacroiliac joints, sacroiliac joints home-based exercises, and home-based lumbar exercises. Study Design: A comparative, prospective, single-blind, randomized, controlled trial. Setting: This trial was conducted at a single center at the Istanbul University, Istanbul Medical Faculty, Department of Physical Medicine and Rehabilitation. Methods: Within the scope of this study, 69 women diagnosed with sacroiliac joint dysfunction syndrome through specific sacroiliac joints clinical diagnostic tests were randomized into 3 groups. The first group was assigned manual therapy and a sacroiliac joints home-based exercise program (n = 23), the second group was assigned sacroiliac joints manual therapy and a home-based lumbar exercise program (n = 23), and the third group was assigned a home-based lumbar exercise program (n = 23). All patients who participated in the study were evaluated at the beginning of the study and on the twenty-eighth and ninetieth day. Results: All 3 groups showed a significant decrease in the sacroiliac joints -related pain parameter, which is checked with the visual analogue scale (P < 0.05) after the treatment. The Gillet test, Vorlauf test, Posterior Shear test, Compression test, and irritation Point tests after the treatment yielded a significant (P < 0.05) negative trend in all groups. Short Form-36 health survey for screening form, Modified Oswestry Pain Questionnaire, and Douleur Neuropathique 4 questions patient interview questionnaire for the assessment of neuropathic pain forms revealed a significant (P < 0.05) improvement in patients’ complaints after the treatment in all 3 groups. Significant improvement in patients with sacroiliac joint dysfunction syndrome in all 3 groups was identified after the treatment. Limitation: The absence of a healthy control group is one of the important limitations of the study. Conclusions: Manual therapy is effective in the long term in sacroiliac joint dysfunction syndrome. Adding specific exercises for sacroiliac joints to the sacroiliac joints manipulation treatment further increases this effectiveness. Key words: Sacroiliac joint, sacroiliac joint dysfunction syndrome, manual therapy, sacroiliac joint exercises, lumbar exercises