1 / 20

Ri Chia-Po Fu/VS Huang

Who had life-sustaining therapy withdrawn after injury The journal of TRAUMA injury, infection and critical care December 2005. Ri Chia-Po Fu/VS Huang. Background (1).

hope
Download Presentation

Ri Chia-Po Fu/VS Huang

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Who had life-sustaining therapy withdrawn after injury The journal of TRAUMA injury, infection and critical care December 2005 Ri Chia-Po Fu/VS Huang

  2. Background (1) • Trauma, the 5th leading cause of deaths in adults>65 y/o • ↑ age→ Mortality↑ after injury • MICU and SICU differences • Traumatic patients do not have ability to communicate their wishes as to how aggressive their care should be.

  3. Background (2) • How to make accurate prognoses regarding the risk of death, disability due to severe injury? • It’s difficult→ trauma scoring systems→ to help determine patient’s survival probabilities. • No scoring systems take into account whether life-sustaining therapy was DC. • It’s also difficult to predict whether an individualized patient will live or die purely based on physiologic, injury severity, and age

  4. Background (3) • Scoring systems are difficult to use • Patients respond to insults differentially • Physicians differ • Convey inaccurate risks of death • Physician risk stratification affects palliative or aggressive therapy

  5. Purpose of the study • Examine factors associated with withdrawal of life-sustaining therapy (WLST) • Its hypothesis: patients with --advanced age, --comorbid medical illness --increased injury severity --complications during hospitalization --preinjury advance directives • would be likely to have undergone WLST→ palliative care

  6. Patients and methods • Patients>55 y/o→ injury→ admitted in ICU→ died in hospital • Medical record reviews to identify factors associated WLST

  7. Results (1) • 330 patients, 20% died (n=66) • 64/66 patients have complete records • Family discussion: 50/64 (78.1%), no patients participated • Average time of 1st family discussion: 4.6 days (0~32 days) • 53/64 had DNR, average time 0.78 days • 25/53 died on the same day • 21/53 did not undergo WLST

  8. Result (2) • Factors associated with/without family discussion, not age, injury severity, specific brain or chest injury, and comorbidities, but advance directives and higher TRISS • Timing of first discussion did not correlate with patient age, ISS, head AIS, chest AIS, or number of comorbidities

  9. Result (3) • Only presence of family discussion was significantly associated with WLST • WLST was associated with higher opioid and BZD usage on the immediate predeath day.

  10. Discussion (1) • The Patient Self-Determination Act (PSDA) assumes: each person has a fundamental right to control his own body • PSDA’s purpose: to encourage patients to decide early about the types and extent of medical care in case they become unable to make decisions

  11. Discussion (2) • Primary care physician and geriatricians v.s. emergency and trauma surgeons --more opportunity to address end-of-life issues and advance directives • If injured patient are awake on arrival →discuss advance directives • Trunkey et al: --specific variables including age, ISS, pre-existing comorbidities, and GSC on admission did not predict WLST --Family discussion predicted withdraw of care • Plaisier et al: age was not a factor in therapy withdraw, despite a higher frequency of comorbid medical illness

  12. Discussion (3) • 4 principles provide the framework for WLST --Establish the source of authority for decision making --Achieve effective communication with patient and family --Make an early determination and ongoing review of the patient’s desire --Recognize the patient’s rights

  13. Discussion (4) • In contrast to trauma population, WLST was well studied in MICU • WLST↑ in last decade • 1990, Smedira et al: 5% patients in MICU underwent WLST • Brain death and poor prognosis were the primary indication • Contributing factors: futility of tx, extreme suffering, patient or surrogate request

  14. Discussion (5) • We assumed: the practice of WLST was driven by advanced age, injury severity, comorbid medical illness, and complication. • It was wrong and corroborate Trunkey and Plaisier’s findings.

  15. Conclusion • In the patients who underwent WLST, the dosage of administered analgesics and sedatives was higher. • No significant associations between age, comorbid medical illness, ISS, or complications and WLST • Documented family discussion clearly shows an association with WLST

  16. Thank you!!

More Related