Simon L. Cohen

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

Continuous venovenous haemofiltration using polyacrylonitrile filters does not activate contact system and intrinsic coagulation pathways

AbstractObjectives: To investigate whether continuous venovenous haemofiltration using polyacrylonitrile filters causes activation of the contact system and intrinsic coagulation pathways and if this, and/or low plasma levels of endogenous anticoagulants, influences filter lifespan. Design: Observational study. Setting: University Teaching Hospital Intensive Care Unit. Patients: Twelve critically ill patients with acute renal failure receiving continuous venovenous haemofiltration. Interventions: Blood samples were taken before starting haemofiltration, at 15 min, 1 h, 3–4 h, 8–12 h, 24 h and at 24-h intervals thereafter until filter blockage occurred. Measurement was made of the contact and intrinsic coagulation system proteins factor XII, activated factor XII and prekallikrein and the protease inhibitors antithrombin III, heparin co-factor II, alpha2-macroglobulin and C1-esterase inhibitor. Thrombin-antithrombin complex levels were measured to provide evidence of thrombin generation. Results: (i) Factor XII, prekallikrein and contact system inhibitors were subnormal in 10/12 and activated factor XII raised in 11/12 patients at baseline, implying pre-existing contact pathway activation. (ii) No change occurred during haemofiltration in the intrinsic coagulation pathway factor or inhibitor levels. (iii) Clotting of the filter circuit within the first 24 h occurred in 5/12 and was associated with low baseline levels of antithrombin III and heparin co-factor II. Only in these patients did thrombin-antithrombin complex levels rise significantly. Conclusions: The contact system was not activated further by continuous venovenous haemofiltration using polyacrylonitrile filters in critically ill patients. Premature clotting of the haemofilter circuit was more common in patients with very low levels of antithrombin III and heparin co-factor II; although this was related to thrombin generation, the intrinsic coagulation pathway does not appear to be implicated.

Heparin clearance during continuous veno-venous haemofiltration

ObjectiveTo determine whether premature clotting of haemofiltration circuits could be related to heparin removal across the filter membrane into the ultrafiltrate.DesignRandomised study using either unfractionated (n=8) or low molecular weight (n=7) heparin for anticoagulation of the haemofiltration circuit at 1000 and 600U/h respectively. Samples were drawn at 1 and 2 h from arterial and venous limbs of the haemofilter circuit for measurement of plasma heparin (as anti-Factor Xa activity), antithrombin III and haematocrit. Ultrafiltrate samples were collected at the same time for measurement of anti-Xa activity.SettingIntensive care unit.PatientsPatients in acute renal failure requiring haemofiltration.ResultsBoth unfractionated and low molecular weight heparin plasma levels were within the range required for therapeutic anticoaguation in all but one patient at 2 h. Ultrafiltrate anti-Xa levels were insignificant. Antithrombin III levels in these critically ill patients were subnormal in 11 of the 15 studies.ConclusionsDespite their small sizes, neither unfractionated nor low molecular weight heparins cross the haemofilter membrane into the ultrafiltrate in any measurable quantity. Both heparins were present in plasma at a level suitable for therapeutic anticoagulation. Subnormal levels of antithrombin III may be an important factor in determining filter longevity.

Attitudes of European physicians, nurses, patients and families regarding end-of-life decisions: the ETHICATT study. Reply to A.M. Vrakking

Sweden Terminal illness 120 32 257 68 Permanent unconsciousness 135 36 241 64 England Terminal illness 85 34 165 66 Permanent unconsciousness 104 42 144 58 Holland Terminal illness 137 43 179 57 Permanent unconsciousness 202 65 107 35 Czech Republic Terminal illness 113 53 101 47 Permanent unconsciousness 98 47 112 53 Portugal Terminal illness 153 50 153 50 Permanent unconsciousness 129 43 172 57 Israel Terminal illness 167 46 194 54 Permanent unconsciousness 175 49 181 51 Total Terminal illness 775 43 1049 58 Permanent unconsciousness 843 47 957 53