David M. Linton

Contradictions in end-of-life decisions for self and other, expressed by relatives of chronically ventilated patients

OBJECTIVES In certain populations, social, legal, and religious factors may influence end-of-life decisions in ventilator-dependent patients. This study aims to evaluate attitudes of first-degree relatives of chronically ventilated patients in Israel, toward end-of-life decisions regarding their loved ones, themselves, and unrelated others. MATERIALS AND METHODS The study was conducted in a chronic ventilation unit. First-degree family members of chronically ventilated patients were interviewed about their end-of-life attitudes for patients with end-stage diseases. Distinctions were made between attitudes in the case of their ventilated relatives, themselves, and unrelated others; between conscious and unconscious patients; and between a variety of interventions. RESULTS Thirty-one family members of 25 patients were interviewed. Median length of ventilation at the time of the interview was 13.4 months. Most interviewees wanted further interventions for their ventilated relatives, yet, for themselves, only 21% and 18% supported chronic ventilation and resuscitation, respectively, and 48% would want to be disconnected from the ventilator. Interventions were more likely to be endorsed for others (vs self), for the conscious self (vs unconscious self), and for artificial feeding (vs chronic ventilation and resuscitation). Interviewees were reluctant to disconnect patients from a ventilator. CONCLUSIONS Family members often want escalation of treatment for their ventilated relatives; however, most would not wish to be chronically ventilated or resuscitated under similar circumstances. Advance directives may reconcile peoples wishes at the end of their own lives with their reticence to make decisions regarding others.

Nurse-Led Implementation of a Safe and Effective Intravenous Insulin Protocol in a Medical Intensive Care Unit

BACKGROUND Recent evidence has linked tight glucose control to worsened clinical outcomes among adults in intensive care units. OBJECTIVE To evaluate the effectiveness and safety of a nurse-led intravenous insulin protocol designed to achieve conservative blood glucose control in patients in a medical intensive care unit. METHODS A nurse-led intravenous insulin protocol was developed, targeting blood glucose levels at 110 to 149 mg/dL. Hypoglycemia was defined as a blood glucose level less than 70 mg/dL. Patients admitted to the medical intensive care unit who required an insulin infusion were enrolled in the study. Blood glucose levels in those patients were compared with levels in 153 historical control patients admitted to the unit in the 12 months before the protocol was implemented who required an insulin infusion. RESULTS Ninety-six patients were enrolled and treated with the protocol. The protocol and control groups had similar characteristics at baseline. More measurements in the protocol group than in the control group (46.3% vs 36.1%, P<.001) were within the target glucose range (110-149 mg/dL). Hyperglycemia (blood glucose ≥200 mg/dL) occurred less often in the protocol group than in the control group (14.8% vs 20.1%, P=.003). Hypoglycemic events (blood glucose <70 mg/dL) also occurred less often in the protocol group (0.07% vs 0.83%, P<.001). CONCLUSIONS Implementation of a nurse-led, conservative intravenous insulin protocol in the medical intensive care unit is effective and safe and markedly reduces the rate of hypoglycemia.

Plasmapheresis for Thrombotic Thrombocytopenic Purpura following Bone Marrow Transplantation

Recognition of thrombotic thrombocytopenic purpura (TTP)/hemolytic uremic syndrome (HUS) following bone marrow transplantation (BMT) has increased in recent years. The use of plasma exchange has greatly improved the outlook of de novo TTP. Fewer data are available on its use in post-BMT TTP but small uncontrolled series showed poor results with low response rates. We present here a case of a young patient who developed manifestations of TTP 10 months after BMT with complete recovery following treatment with plasma exchange for 1 month. This case suggests that plasma exchange could be life saving and should be tried in every patient with post-BMT TTP.

The legal guardians' dilemma: Decision making associated with invasive non-life-saving procedures

BackgroundICU patients frequently undergo non-life-saving invasive procedures. When patient informed consent cannot be obtained, legal guardianship (LG), often from a close relative, may be required by law. The objective of this cohort study was to investigate the attitudes of LGs of ICU patients regarding the process of decision making for invasive non-life-saving procedures.MethodsThe study was conducted from May 2009 until June 2010 in general medical/surgical ICUs in two large Israeli medical centers. All 64 LGs who met the study criteria agreed to participate in the study. Three questionnaires were administered: a demographic data questionnaire, the Family Satisfaction with ICU 34 Questionnaire, and the Attitudes towards the LG Decision Making Process questionnaire, developed by the authors.ResultsThe sample consisted of 64 LGs. Most participants were married (n = 56, 87.5%), male (n = 33, 51.6%), who had either a high school (n = 24, 37.5%) or college (n = 19, 29.7%) education, and were at a mean age of 49.2 (±11.22). Almost all of the procedures performed were tracheotomies (n = 63, 98.4%). About two-thirds of the LGs preferred decisions to be made by the medical staff after discussing options with them (n = 42, 65.6%) and about three-fifths stated that decisions could be made without the need for the appointment of an LG (n = 37, 57.8%). Attitudes towards ease of obtaining information and honesty of information were more positive compared to those of consistency and understanding of information.ConclusionsThe legal guardianship process requires better communication and more understandable information in order to assist LGs in making decisions for others in at times vague and stressful situations.