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23.05.2022 | Originalien

Dying in the ICU

Changes in end of life decisions from 2011 to 2018 in the ICU of a communal tertiary hospital in Germany

verfasst von: Isabel Schulmeyer, Markus A. Weigand, MD, Monika Heinzel-Gutenbrunner, PhD, Marco Gruss, MD

Erschienen in: Die Anaesthesiologie | Ausgabe 12/2022

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Abstract

Background

With modern intensive care medicine, even older patients and those with pre-existing conditions can survive critical illnesses and major operations; however, unreflected application of intensive care treatment might lead to a state called chronic critical illness. Today, withholding treatment and/or treatment withdrawal precede many deaths in the intensice care unit (ICU). We looked at changes in measures at the end of life and withholding or withdrawal of treatment in the ICU of a German tertiary hospital in 2017/2018 compared to 2011/2012.

Methods

In this retrospective explorative study, we analyzed end of life practices in adult patients who died in an intermediate care unit (IMC)/ICU of Klinikum Hanau in 2017/2018. We compared these data with data from the same hospital in 2011/2012

Results

Of the 1246 adult patients who died in Klinikum Hanau in 2017/2018, 433 (35%) died in an ICU or IMC unit. Deceased ICU patients were 74.0 ± 12.5 years and 86.6% were older than 60 years. At least one life-sustaining measure was withheld in 278 (76.2%) and withdrawn in 159 (46.3%) of patients. More than three quarters of patients (n = 276, 75.6%) had a do not resuscitate (DNR) order and in about half of the patients invasive ventilation (n = 175, 49.9%) or renal replacement therapy (n = 191, 52.3%) was limited. In 113 patients (31.0%) catecholamine treatment was withdrawn, in 72 (19.7%) patients invasive ventilation and in 49 (13.4%) patients renal replacement therapy. Compared to 2011/2012, we saw an increase by ~15% (absolute increase) in withholding and withdrawal of treatment and observed an effect of documents like advance directive or healthcare proxy.

Conclusion

In 76.2% of deceased ICU patients withholding treatment and in 43.6% treatment withdrawal preceded death. Compared to 2011/2012 treatment was withheld or withdrawn more often. Compared to 2011/2012, we saw an increase (~15% absolute) in withholding and withdrawal of treatment. After withholding or withdrawal of treatment, most patients died within 3 and 2 days, respectively.

Garrett JM, Harris RP, Norburn JK, Patrick DL, Danis M (1993) Life-sustaining treatments during terminal illness: who wants what? J Gen Intern Med 8:361–368CrossRef

Hillman K, Athari F, Forero R (2018) States worse than death. Curr Opin Crit Care 24:415–420. https://doi.org/10.1097/MCC.0000000000000529CrossRef

Angus DC, Barnato AE, Linde-Zwirble WT, Weissfeld LA, Watson RS, Rickert T, Rubenfeld GD (2004) Use of intensive care at the end of life in the United States: an epidemiologic. Crit Care Med 32:638–643CrossRef

Ely EW, Azoulay E, Sprung CL (2019) Eight things we would never do regarding end-of-life care in the ICU. Intensive Care Med. https://doi.org/10.1007/s00134-019-05562-9CrossRef

Mosenthal AC, Murphy PA, Barker LK, Lavery R, Retano A, Livingston DH (2008) Changing the culture around end-of-life care in the trauma intensive care unit. J Trauma 64:1587–1593. https://doi.org/10.1097/TA.0b013e318174f112CrossRef

Cardona-Morrell M, Kim J, Turner RM, Anstey M, Mitchell IA, Hillman K (2016) Non-beneficial treatments in hospital at the end of life: a systematic review on extent of the problem. Int J Qual Health Care 28:456–469. https://doi.org/10.1093/intqhc/mzw060CrossRef

Wiesing U, Jox RJ, Hessler H‑J, Borasio GD (2010) A new law on advance directives in Germany. J Med Ethics 36:779–783. https://doi.org/10.1136/jme.2010.036376CrossRef

Mentzelopoulos SD, Couper K, Van de Voorde P, Druwé P, Blom M, Perkins GD et al (2021) European resuscitation council guidelines 2021: ethics of resuscitation and end of life decisions. Resuscitation 161:408–432. https://doi.org/10.1016/j.resuscitation.2021.02.017CrossRef

Neitzke G, Burchardi H, Duttge G, Hartog C, Erchinger R, Gretenkort P et al (2016) Limits of the meaningfulness of intensive care medicine: position paper of the ethics section of DIVI. Med Klin Intensivmed Notfmed. https://doi.org/10.1007/s00063-016-0202-8CrossRef

10.

Ay E, Weigand MA, Röhrig R, Gruss M (2020) Dying in the intensive care unit (ICU): a retrospective descriptive analysis of deaths in the ICU in a communal tertiary hospital in Germany. Anesthesiol Res Pract 2020:2356019. https://doi.org/10.1155/2020/2356019CrossRef

11.

Sprung CL, Cohen SL, Sjokvist P, Baras M, Bulow H‑H, Hovilehto S et al (2003) End-of-life practices in European intensive care units: the ethicus study. JAMA 290:790–797. https://doi.org/10.1001/jama.290.6.790CrossRef

12.

Sprung CL, Ricou B, Hartog CS, Maia P, Mentzelopoulos SD, Weiss M et al (2019) Changes in end-of-life practices in European intensive care units from 1999 to 2016. JAMA. https://doi.org/10.1001/jama.2019.14608CrossRef

13.

Graw JA, Spies CD, Kork F, Wernecke K‑D, Braun J‑P (2015) End-of-life decisions in intensive care medicine-shared decision-making and intensive care unit length of stay. World J Surg 39:644–651. https://doi.org/10.1007/s00268-014-2884-5CrossRef

14.

Graw JA, Spies CD, Wernecke K‑D, Braun J‑P (2012) Managing end-of-life decision making in intensive care medicine—a perspective from Charité Hospital, Germany. PLoS One 7:e46446. https://doi.org/10.1371/journal.pone.0046446CrossRef

15.

Lee SI, Hong KS, Park J, Lee Y‑J (2020) Decision-making regarding withdrawal of life-sustaining treatment and the role of intensivists in the intensive care unit: a single-center study. Acute Crit Care 35:179–188. https://doi.org/10.4266/acc.2020.00136CrossRef

16.

Robert R, Le Gouge A, Kentish-Barnes N, Adda M, Audibert J, Barbier F et al (2020) Sedation practice and discomfort during withdrawal of mechanical ventilation in critically ill patients at end-of-life: a post-hoc analysis of a multicenter study. Intensive Care Med 46:1194–1203. https://doi.org/10.1007/s00134-020-05930-wCrossRef

17.

Neitzke G, Böll B, Burchardi H, Dannenberg K, Duttge G, Erchinger R et al (2017) Dokumentation der Therapiebegrenzung : Empfehlung der Sektion Ethik der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin (DIVI) unter Mitarbeit der Sektion Ethik der Deutschen Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN). Med Klin Intensivmed Notfmed 112:527–530. https://doi.org/10.1007/s00063-017-0321-xCrossRef

18.

Gruß M, Salomon F (2016) Autonomy and welfare in intensive care medicine : practical approach in difficult situations. Anaesthesist 65:875–888. https://doi.org/10.1007/s00101-016-0222-zCrossRef

19.

InEK GmbH – Institut für das Entgeltsystem im Krankenhaus (2021) German diagnosis related group system. https://www.g-drg.de/. Accessed 8 Apr 2021

20.

Dos Anjos CS, Borges RMC, Chaves AC, de Souza Lima AC, Pereira MBM, Gasparoto ML et al (2019) Religion as a determining factor for invasive care among physicians in end-of-life patients. Support Care Cancer. https://doi.org/10.1007/s00520-019-04846-6CrossRef

21.

Hartog CS, Hoffmann F, Mikolajetz A, Schröder S, Michalsen A, Dey K et al (2018) Non-beneficial therapy and emotional exhaustion in end-of-life care : results of a survey among intensive care unit personnel. [non-beneficial therapy and emotional exhaustion in end-of-life care : results of a survey among intensive care unit personnel]. Anaesthesist 67:850–858. https://doi.org/10.1007/s00101-018-0485-7CrossRef

22.

Revon-Rivière G, Pauly V, Baumstarck K, Bernard C, André N, Gentet J‑C et al (2019) High-intensity end-of-life care among children, adolescents, and young adults with cancer who die in the hospital: a population-based study from the French national hospital database. Cancer. https://doi.org/10.1002/cncr.32035CrossRef

23.

Fleischmann-Struzek C, Mikolajetz A, Reinhart K, Curtis RJ, Haase U, Thomas-Rüddel D et al (2019) Hospitalization and intensive therapy at the end of life. Dtsch Arztebl Int 116:653–660. https://doi.org/10.3238/arztebl.2019.0653CrossRef

24.

Veshi D, Neitzke G (2016) Council of Europe. Med Law Int 16:94–102. https://doi.org/10.1177/0968533216659785CrossRef

25.

Azoulay E, Timsit JF, Sprung CL, Soares M, Rusinova K, Lafabrie A et al (2009) Prevalence and factors of intensive care unit conflicts: the conflicus study. Am J Respir Crit Care Med 180:853–860CrossRef

26.

Bruno RR, Wernly B, Beil M, Muessig JM, Rahmel T, Graf T et al (2020) Therapy limitation in octogenarians in German intensive care units is associated with a longer length of stay and increased 30 days mortality: a prospective multicenter study. J Crit Care 60:58–63. https://doi.org/10.1016/j.jcrc.2020.07.024CrossRef

27.

Truog RD, Campbell ML, Curtis JR, Haas CE, Luce JM, Rubenfeld GD et al (2008) Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American college corrected of critical care medicine. Crit Care Med 36:953–963. https://doi.org/10.1097/CCM.0B013E3181659096CrossRef

28.

Lustbader D, Pekmezaris R, Frankenthaler M, Walia R, Smith F, Hussain E et al (2011) Palliative medicine consultation impacts DNR designation and length of stay for terminal medical MICU patients. Palliat Support Care 9:401–406. https://doi.org/10.1017/S1478951511000423CrossRef

29.

Hua MS, Li G, Blinderman CD, Wunsch H (2014) Estimates of the need for palliative care consultation across united states intensive care units using a trigger-based model. Am J Respir Crit Care Med 189:428–436. https://doi.org/10.1164/rccm.201307-1229OCCrossRef

30.

Rady MY, Johnson DJ (2004) Admission to intensive care unit at the end-of-life: is it an informed decision? Palliat Med 18:705–711CrossRef

Titel: Dying in the ICU
Changes in end of life decisions from 2011 to 2018 in the ICU of a communal tertiary hospital in Germany
verfasst von: Isabel Schulmeyer
Markus A. Weigand, MD
Monika Heinzel-Gutenbrunner, PhD
Marco Gruss, MD
Publikationsdatum: 23.05.2022
Verlag: Springer Medizin
Erschienen in: Die Anaesthesiologie / Ausgabe 12/2022
Print ISSN: 2731-6858
Elektronische ISSN: 2731-6866
DOI: https://doi.org/10.1007/s00101-022-01127-6

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Dying in the ICU

Changes in end of life decisions from 2011 to 2018 in the ICU of a communal tertiary hospital in Germany

Abstract

Background

Methods

Results

Conclusion

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Abstract

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Methods

Results

Conclusion

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