Mario Baras

Evaluation of triage decisions for intensive care admission

OBJECTIVE To assess physician decision-making in triage for intensive care and how judgments impact on patient survival. DESIGN Prospective, descriptive study. SETTING General intensive care unit, university medical center. INTERVENTIONS All patients triaged for admission to a general intensive care unit were studied. Information was collected for the patients age, diagnoses, surgical status, admission purpose, Acute Physiology and Chronic Health Evaluation (APACHE) II score, and mortality. The number of available beds at the time of triage and reasons for refused admission were obtained. MEASUREMENTS AND MAIN RESULTS Of 382 patients, 290 were admitted, 92 (24%) were refused admission, and 31 were admitted at a later time. Differences between admission diagnoses were found between patients admitted or not admitted (p < .001). Patients refused admission had higher APACHE II scores (15.6+/-1.5 admitted later and 15.8+/-1.4 never admitted) than did admitted patients (12.1+/-.4; p < .001). The frequency of admitting patients decreased when the intensive care unit was full (p < .001). Multivariate analysis revealed that triage to intensive care correlated with age, a full unit, surgical status, and diagnoses. Hospital mortality was lower in admitted (14%) than in refused patients (36% admitted later and 46% never admitted; p < .01) and in admitted patients with APACHE II scores of 11 to 20 (p = .02). The 28-day survival of patients was greater for admitted patients compared with patients never admitted (p = .01). CONCLUSIONS Physicians triage patients to intensive care based on the number of beds available, the admission diagnosis, severity of disease, age, and operative status. Admitting patients to intensive care is associated with a lower mortality rate, especially in patients with APACHE scores of 11 to 20.

Communication of end-of-life decisions in European intensive care units.

ObjectiveTo examine end-of-life (EOL) practices in European ICUs: who makes these decisions, how they are made, communication of these decisions and questions on communication between the physicians, nurses, patients and families.DesignData collected prospectively on EOL decisions facilitated by a questionnaire including EOL decision categories, geographical regions, mental competency, information about patient wishes, and discussions with patients, families and health care professionals.Setting37 European ICUs in 17 countriesPatientsICU physicians collected data on 4,248 patients.Results95% of patients lacked decision making capacity at the time of EOL decision and patient’s wishes were known in only 20% of cases. EOL decisions were discussed with the family in 68% of cases. Physicians reported having more information about patients’ wishes and discussions in the northern countries (31%, 88%) than central (16%, 70%) or southern (13%, 48%) countries. The family was more often told (88%) than asked (38%) about EOL decisions. Physicians’ reasons for not discussing EOL care with the family included the fact that the patient was unresponsive to therapy (39%), the family was unavailable (28%), and the family was thought not to understand (25%).ConclusionsICU patients typically lack decision-making capacity, and physicians know patients’ wishes in only 20% of EOL decisions. There were regional differences in discussions of EOL decisions with families and other physicians. In European ICUs there seems to be a need to improve communication

The Eldicus prospective, observational study of triage decision making in European intensive care units. Part II: intensive care benefit for the elderly.

Rationale:Life and death triage decisions are made daily by intensive care unit physicians. Admission to an intensive care unit is denied when intensive care unit resources are constrained, especially for the elderly. Objective:To determine the effect of intensive care unit triage decisions on mortality and intensive care unit benefit, specifically for elderly patients. Design:Prospective, observational study of triage decisions from September 2003 until March 2005. Setting:Eleven intensive care units in seven European countries. Patients:All patients >18 yrs with an explicit request for intensive care unit admission. Interventions:Admission or rejection to intensive care unit. Measurements and Main Results:Demographic, clinical, hospital, physiologic variables, and 28-day mortality were obtained on consecutive patients. There were 8,472 triages in 6,796 patients, 5,602 (82%) were accepted to the intensive care unit, 1,194 (18%) rejected; 3,795 (49%) were ≥65 yrs. Refusal rate increased with increasing patient age (18–44: 11%; 45–64: 15%; 65–74: 18%; 75–84: 23%; >84: 36%). Mortality was higher for older patients (18–44: 11%; 45–64: 21%; 65–74: 29%; 75–84: 37%; >84: 48%). Differences between mortalities of accepted vs. rejected patients, however, were greatest for older patients (18–44: 10.2% vs. 12.5%; 45–64: 21.2% vs. 22.3%; 65–74: 27.9% vs. 34.6%; 75–84: 35.5% vs. 40.4%; >84: 41.5% vs. 58.5%). Logistic regression showed a greater mortality reduction for accepted vs. rejected patients corrected for disease severity for elderly patients (age >65 [odds ratio 0.65, 95% confidence interval 0.55–0.78, p < .0001]) than younger patients (age <65 [odds ratio 0.74, 95% confidence interval 0.57–0.97, p = .01]). Conclusions:Despite the fact that elderly patients have more intensive care unit rejections than younger patients and have a higher mortality when admitted, the mortality benefit appears greater for the elderly. Physicians should consider changing their intensive care unit triage practices for the elderly. (Crit Care Med 2012; 40:132–138)

Nurse involvement in end-of-life decision making: the ETHICUS Study

ObjectiveThe purpose was to investigate physicians’ perceptions of the role of European intensive care nurses in end-of-life decision making.DesignThis study was part of a larger study sponsored by the Ethics Section of the European Society of Intensive Care Medicine, the ETHICUS Study. Physicians described whether they thought nurses were involved in such decisions, whether nurses initiated such a discussion and whether there was agreement between physicians and nurses. The items were analyzed and comparisons were made between different regions within Europe.SettingThe study took place in 37 intensive care units in 17 European countries.Patients and participantsPhysician investigators reported data related to patients from 37 centers in 17 European countries.InterventionsNone.Measurements and resultsPhysicians perceived nurses as involved in 2,412 (78.3%) of the 3,086 end-of-life decisions (EOLD) made. Nurses were thought to initiate the discussion in 66 cases (2.1%), while ICU physicians were cited in 2,438 cases (79.3%), the primary physician in 328 cases (10.7%), the consulting physician in 105 cases (3.4%), the family in 119 cases (3.9%) and the patient in 19 cases (0.6%). In only 20 responses (0.6%) did physicians report disagreement between physicians and nurses related to EOLD. A significant association was found between the region and responses to the items related to nursing. Physicians in more northern regions reported more nurse involvement.ConclusionsPhysicians perceive nurses as involved to a large extent in EOLDs, but not as initiating the discussion. Once a decision is made, there is a sense of agreement. The level of perceived participation is different for different regions.

Relieving suffering or intentionally hastening death: where do you draw the line?

Objective:End-of-life practices vary worldwide. The objective was to demonstrate that there is no clear-cut distinction between treatments administered to relieve pain and suffering and those intended to shorten the dying process. Design:Secondary analysis of a prospective, observational study. Setting:Thirty-seven intensive care units in 17 European countries. Patients:Consecutive patients dying or with any limitation of therapy. Interventions:Evaluation of the type of end-of-life category; dates and times of intensive care unit admission, death, or discharge; and decisions to limit therapy, medication, and doses used for active shortening of the dying process and the intent of the doctors prescribing the medication. Measurements and Main Results:Limitation of life-sustaining therapy occurred in 3,086 (72.6%) of 4,248 patients, and 94 (2.2%) underwent active shortening of the dying process. Medication for active shortening of the dying process included administration of opiates (morphine to 71 patients) or benzodiazepines (diazepam to 54 patients) alone or in combination. The median dosage for morphine was 25.0 mg/hr and for diazepam 20.8 mg/hr. Doses of opiates and benzodiazepines were no higher than mean doses used with withdrawal in previous studies in 20 of 66 patients and were within the ranges of doses used in all but one patient. Doctors considered that medications for active shortening of the dying process definitely led to the patients death in 72 patients (77%), probably led to the patients death in 11 (12%), and were unlikely to have led to death in 11 (12%) patients. Conclusions:There is a gray area in end-of-life care between treatments administered to relieve pain and suffering and those intended to shorten the dying process.

The Eldicus prospective, observational study of triage decision making in European intensive care units: Part I—European Intensive Care Admission Triage Scores*

Objective:Life and death triage decisions are made daily by intensive care unit physicians. Scoring systems have been developed for prognosticating intensive care unit mortality but none for intensive care unit triage. The objective of this study was to develop an intensive care unit triage decision rule based on 28-day mortality rates of admitted and refused patients. Design:Prospective, observational study of triage decisions from September 2003 until March 2005. Setting:Eleven intensive care units in seven European countries. Patients:All patients >18 yrs with a request for intensive care unit admission. Interventions:Admission or rejection to an intensive care unit. Measurements and Main Results:Clinical, laboratory, and physiological variables and data from severity scores were collected. Separate scores for accepted and rejected patients with 28-day mortality end point were built. Values for variables were grouped into categories determined by the locally weighted least squares graphical method applied to the logit of the mortality and by univariate logistic regressions for reducing candidates for the score. Multivariate logistic regression was used to construct the final score. Cutoff values for 99.5% specificity were determined. Of 6796 patients, 5602 were admitted and 1194 rejected. The initial refusal score included age, diagnosis, systolic blood pressure, pulse, respirations, creatinine, bilirubin, PaO2, bicarbonate, albumin, use of vasopressors, Glasgow Coma Scale score, Karnofsky Scale, operative status and chronic disorder, and the initial refusal receiver operating characteristics were area under the curve 0.77 (95% confidence interval 0.76–0.79). The final triage score included age, diagnosis, creatinine, white blood cells, platelets, albumin, use of vasopressors, Glasgow Coma Scale score, Karnofsky Scale, operative status and chronic disorder, and the final score receiver operating characteristics were area under the curve 0.83 (95% confidence interval 0.80–0.86). Patients with initial refusal scores >173.5 or final triage scores = 0 should be rejected. Conclusions:The initial refusal score and final triage score provide objective data for rejecting patients that will die even if admitted to the intensive care unit and survive if refused intensive care unit admission. (Crit Care Med 2012; 40:125–131)

Physical Activities and Low Back Pain: A Community-based Study

PURPOSE Very little is known about the relationship between physical activity and low back pain (LBP) in general populations. This study aimed to evaluate the relationship between different dimensions of physical activity and LBP among all adults of a defined community. METHODS A cross-sectional survey addressed all adults aged 22-70 of a single town. Inhabitants were asked to complete a self-administered questionnaire regarding physical activities, LBP, and related characteristics. The Beacke Physical Activity Questionnaire evaluated physical activity, and the Modified Roland and Morris Disability Questionnaire, a pain severity scale, and the Pain Symptoms Frequency and Bothersomeness Indices evaluated LBP. RESULTS High occupational activity demands contributed to increased LBP prevalence, and, conversely, high sporting activity participation contributed to a decline in all LBP measures. Subjects free of LBP and subjects who participate in sporting activities are more likely not to smoke and not to participate in high occupational activity demands. Type of sporting activity was not associated with LBP prevalence or severity. CONCLUSIONS Different dimensions of physical activity yield different relationships to LBP. There are several shared characteristics of those participating in sport on a regular basis and those free of LBP. Both groups present a healthier lifestyle. Although LBP was less frequent among those who participate in sporting activities, participating in sporting activities did not contribute independently to a lower prevalence of LBP. However, once LBP was established, participating in sporting activities contributed indirectly to its severity.

Are religion and religiosity important to end-of-life decisions and patient autonomy in the ICU? The Ethicatt study

PurposeThis study explored differences in end-of-life (EOL) decisions and respect for patient autonomy of religious members versus those only affiliated to that particular religion (affiliated is a member without strong religious feelings).MethodsIn 2005 structured questionnaires regarding EOL decisions were distributed in six European countries to ICUs in 142 hospital ICUs. This sub-study of the original data analyzed answers from Protestants, Catholics and Jews.ResultsA total of 304 physicians, 386 nurses, 248 patients and 330 family members were included in the study. Professionals wanted less treatment (ICU admission, CPR, ventilator treatment) than patients and family members. Religious respondents wanted more treatment and were more in favor of life prolongation, and they were less likely to want active euthanasia than those affiliated. Southern nurses and doctors favored euthanasia more than their Northern colleagues. Three quarters of doctors and nurses would respect a competent patient’s refusal of a potentially life-saving treatment. No differences were found between religious and affiliated professionals regarding patient’s autonomy. Inter-religious differences were detected, with Protestants most likely to follow competent patients’ wishes and the Jewish respondents least likely to do so, and Jewish professionals more frequently accepting patients’ wishes for futile treatment. However, these findings on autonomy were due to regional differences, not religious ones.ConclusionsHealth-care professionals, families and patients who are religious will frequently want more extensive treatment than affiliated individuals. Views on active euthanasia are influenced by both religion and region, whereas views on patient autonomy are apparently more influenced by region.

Implications of ICU triage decisions on patient mortality: a cost-effectiveness analysis

IntroductionIntensive care is generally regarded as expensive, and as a result beds are limited. This has raised serious questions about rationing when there are insufficient beds for all those referred. However, the evidence for the cost effectiveness of intensive care is weak and the work that does exist usually assumes that those who are not admitted do not survive, which is not always the case. Randomised studies of the effectiveness of intensive care are difficult to justify on ethical grounds; therefore, this observational study examined the cost effectiveness of ICU admission by comparing patients who were accepted into ICU after ICU triage to those who were not accepted, while attempting to adjust such comparison for confounding factors.MethodsThis multi-centre observational cohort study involved 11 hospitals in 7 EU countries and was designed to assess the cost effectiveness of admission to intensive care after ICU triage. A total of 7,659 consecutive patients referred to the intensive care unit (ICU) were divided into those accepted for admission and those not accepted. The two groups were compared in terms of cost and mortality using multilevel regression models to account for differences across centres, and after adjusting for age, Karnofsky score and indication for ICU admission. The analyses were also stratified by categories of Simplified Acute Physiology Score (SAPS) II predicted mortality (< 5%, 5% to 40% and >40%). Cost effectiveness was evaluated as cost per life saved and cost per life-year saved.ResultsAdmission to ICU produced a relative reduction in mortality risk, expressed as odds ratio, of 0.70 (0.52 to 0.94) at 28 days. When stratified by predicted mortality, the odds ratio was 1.49 (0.79 to 2.81), 0.7 (0.51 to 0.97) and 0.55 (0.37 to 0.83) for <5%, 5% to 40% and >40% predicted mortality, respectively. Average cost per life saved for all patients was

Rubeosis lridis in Retinoblastoma: Histologic Findings and the Possible Role of Vascular Endothelial Growth Factor in Its Induction

103,771 (€82,358) and cost per life-year saved was