Jean-Philippe Rigaud

Complicated grief after death of a relative in the intensive care unit

An increased proportion of deaths occur in the intensive care unit (ICU). We performed this prospective study in 41 ICUs to determine the prevalence and determinants of complicated grief after death of a loved one in the ICU. Relatives of 475 adult patients were followed up. Complicated grief was assessed at 6 and 12 months using the Inventory of Complicated Grief (cut-off score >25). Relatives also completed the Hospital Anxiety and Depression Scale at 3 months, and the Revised Impact of Event Scale for post-traumatic stress disorder symptoms at 3, 6 and 12 months. We used a mixed multivariate logistic regression model to identify determinants of complicated grief after 6 months. Among the 475 patients, 282 (59.4%) had a relative evaluated at 6 months. Complicated grief symptoms were identified in 147 (52%) relatives. Independent determinants of complicated grief symptoms were either not amenable to changes (relative of female sex, relative living alone and intensivist board certification before 2009) or potential targets for improvements (refusal of treatment by the patient, patient died while intubated, relatives present at the time of death, relatives did not say goodbye to the patient, and poor communication between physicians and relatives). End-of-life practices, communication and loneliness in bereaved relatives may be amenable to improvements. End-of-life care and communication in the ICU are associated with the prevalence of complicated grief http://ow.ly/DCqjB

Bedside adherence to clinical practice guidelines for enteral nutrition in critically ill patients receiving mechanical ventilation: a prospective, multi-centre, observational study

IntroductionThe primary aim was to measure the amount of nutrients required, prescribed and actually administered in critically ill patients. Secondary aims were to assess adherence to clinical practice guidelines, and investigate factors leading to non-adherence.MethodsObservational, multicenter, prospective study, including 203 patients in a total of 19 intensive care units in France. The prescribed calorie supply was compared with the theoretical minimal required calorie intake (25 Kcal/Kg/day) and with the supply actually delivered to the patient to calculate the ratio of calories prescribed/required and the ratio of calories delivered/prescribed. Clinical factors suspected to influence enteral nutrition were analyzed by univariate and multivariate analysis.ResultsThe median ratio of prescribed/required calories per day was 43 [37-54] at day 1 and increased until day 7. From day 4 until the end of the study, the median ratio was > 80%. The median ratio of delivered/prescribed per day was > 80% for all 7 days from the start of enteral nutrition. Among the variables tested (hospital type, use of a local nutrition protocol, sedation, vasoactive drugs, number of interruptions of enteral nutrition and measurement of gastric residual volume), only measurement of residual volume was significant by univariate analysis. This was confirmed by multivariate analysis, where gastric residual volume measurement was the only variable independently associated with the ratio of delivered/prescribed calories (OR = 1.38; 95%CI, 1.12-2.10, p = .024).ConclusionsThe translation of clinical research and recommendations for enteral nutrition into routine bedside practice in critically ill patients receiving mechanical ventilation was satisfactory, but could probably be improved with a multidisciplinary approach.

Intensive care unit strain should not rush physicians into making inappropriate decisions, but merely reduce the time to the right decisions being made

Deaths in the intensive care unit (ICU) are preceded in 53% to 90% of cases by a decision to withhold or withdraw life-sustaining therapies (1-3). The most common reasons justifying this decision include the patient’s age, previous autonomy, comorbidities, expected future quality of life, diagnosis at admission, non-response to maximal therapy and multi-organ failure (1,3,4).

“It Was the Only Thing I Could Hold Onto, But…”: Receiving a Letter of Condolence After Loss of a Loved One in the ICU

Objectives: Family members of patients who die in the ICU often remain with unanswered questions and suffer from lack of closure. A letter of condolence may help bereaved relatives, but little is known about their experience of receiving such a letter. The objective of the study was to understand bereaved family members’ experience of receiving a letter of condolence. Design: Qualitative study using interviews with bereaved family members who received a letter of condolence and letters written by these family members to the ICU team. This study was designed to provide insight into the results of a larger randomized, controlled, multicenter study. Setting: Twenty-two ICUs in France. Subjects: Family members who lost a loved one in the ICU and who received a letter of condolence. Measurements and Main Results: Thematic analysis was used and was based on 52 interviews and 26 letters. Six themes emerged: 1) a feeling of support, 2) humanization of the medical system, 3) an opportunity for reflection, 4) an opportunity to describe their loved one, 5) continuity and closure, and 6) doubts and ambivalence. Possible difficulties emerged, notably the re-experience of the trauma, highlighting the absence of further support. Conclusions: This study describes the benefits of receiving a letter of condolence; mainly, it humanizes the medical institution (feeling of support, confirmation of the role played by the relative, supplemental information). However, this study also shows a common ambivalence about the letter of condolence’s benefit. Healthcare workers must strive to adapt bereavement follow-up to each individual situation.

Non-readmission decisions in the intensive care unit under French rules: A nationwide survey of practices

Purpose We investigated, using a multicentre survey of practices in France, the practices of ICU physicians concerning the decision not to readmit to the ICU, in light of current legislation. Materials and methods Multicentre survey of practices among French ICU physicians via electronic questionnaire in January 2016. Questions related to respondents’ practices regarding re-admission of patients to the ICU and how these decisions were made. Criteria were evaluated by the health care professionals as regards importance for non-readmission. Results In total, 167 physicians agreed to participate, of whom 165 (99%) actually returned a completed questionnaire from 58 ICUs. Forty-five percent were aged <35 years, 74% were full-time physicians. The findings show that decisions for non-readmission are taken at the end of the patient’s stay (87%), using a collegial decision-making procedure (89% of cases); 93% reported that this decision was noted in the patient’s medical file. While 73% indicated that the family/relatives were informed of non-readmission decisions, only 29% reported informing the patient, and 91% considered that non-readmission decisions are an integral part of the French legislative framework. Conclusion This study shows that decisions not to re-admit a patient to the ICU need to be formally materialized, and anticipated by involving the patient and family in the discussions, as well as the other healthcare providers that usually care for the patient. The optimal time to undertake these conversations is likely best decided on a case-by-case basis according to each patient’s individual characteristics.

Diffuse digestive bezoar: a rare and severe complication of enteral nutrition in the intensive care unit (ICU)

Dear Editor, Digestive bezoars are a rare complication in intensive care unit (ICU) patients, although several cases in patients with enteral feeding have been described [1–4]. We describe a case of diffuse digestive bezoar including gastric, small bowel and colon localizations. A 65-year-old male was admitted to the ICU for severe hypoxemic legionella pneumonia with hypertension and no history of digestive disorders. Pulmonary function deteriorated rapidly, requiring mechanical ventilation, worsening to acute respiratory distress syndrome (ARDS) and finally pneumonia and septic shock. Norepinephrine was introduced for 8 days. The patient was sedated with midazolam and sufentanil. Parenteral antacid treatment (esomeprazole, 40 mg per day) was initiated on day 1. Enteral nasogastric feeding was started 24 h after admission and was initially well tolerated, but was interrupted after 5 days after accidental removal of the nasogastric tube. As it was impossible to replace the tube, parenteral nutrition was initiated. Seventeen days after admission, a new nasogastric tube with enteral nutrition was inserted. Enteral nutrition was interrupted on day 24 because of fecaloid regurgitations. Echographic and biologic investigations confirmed a diagnosis of acute cholecystis, surgically treated by laparotomy. In the postoperative period, nasogastric aspirations remained fecaloid. Parenteral nutrition was continued until day 42 (17 days after surgery). Favorable clinical evolution prompted re-introduction of enteral nutrition, which seemed well tolerated. At day 46, an abdominal mass in the right flank was noticed. Tomodensitometry showed sigmoid colon distention, pneumoperitoneum and pelvic effusion. A second laparotomy discovered fecal peritonitis, and sigmoid and small bowel perforation. Multiple gastric and small bowel bezoars were surgically removed (Fig. 1) through perforation of the small intestine and a gastric incision. The surgical procedure also consisted of left colectomy and small bowel and colonic stoma. The outcome was favorable. The patient was discharged after 4 months. The causes of bezoar formation as a complication of enteral nutrition are unclear. The most probable cause appears to be reduced intestinal motility secondary to postoperative paralytic ileus (cholecystectomy), likely aggravated by the use of high doses of morphine [3]. Furthermore, high of doses norepinephrine could also exacerbate this phenomenon through ensuing mesenteric ischemia. However, of the total 24 days of treatment with norepinephrine, only 6 overlapped with enteral feeding (the first 6 days, with a maximum norepinephrine dose of 0.6 lg/kg/min). There are few reports of nonesophageal bezoars in the ICU. To our knowledge, this is the first description of a disseminated bezoar, despite compliance with dietary recommendations [5] and the small volume of total enteral feeding [16 days, average volume 1,310 ml per day (\60 ml/h) for a total of 21 l over 46 days]. Increased flow rate may also lead to intraluminal accumulation of enteral nutrition and subsequent bezoar formation. In conclusion, gastrointestinal bezoar is a rare but potentially severe complication of enteral feeding and can occur even in patients receiving low doses of enteral feeding. We suggest that this diagnosis might be considered in case of unexplained abdominal symptomatology in the