ETHICS CONSULTATIONS IN ICUS HELP REDUCE NONBENEFICIAL TREATMENTS
Schneiderman LJ, Gilmer T, Teetzel HD, et al. Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting. A randomized controlled trial. JAMA. 2003;290:1166-1172.
Ethics committees function within the healthcare setting to help the patient, family, and healthcare providers to make treatment decisions at times when the outcome of care is not clear. This is especially important for those instances where therapy may attempt to extend life in cases where the treatment would not benefit the patient.
This study assessed whether ethics consultations affected the length of stay in intensive care units (ICUs) for persons who did not live to discharge from the hospital. Six ICUs from hospitals from across the United States participated in the study. During the period from November 2000 to December 2002, 551 patients (N = 551) were enrolled in the study. Each was randomly assigned to one of 2 groups: intervention group, which received ethics consultations (n = 278), and usual care group (n = 273) which received the standard of care in the ICU but were not offered ethics consultations.
Criteria for inclusion into the study were determined by several factors. Nurses in the ICU identified patients whose care indicated that conflicts in treatment might occur. These patients had conflicts in at least 1 of the following areas:
* Aggressive life-sustaining treatment was desired by the healthcare team.
* Whether treatments were in the best interest of the patient according to the healthcare team when there was no decision maker available.
* Futile treatments were desired by the healthcare team.
* Confusion about who of the patient's family or friends was the surrogate decision maker.
* Differences between the healthcare team's and the decision maker's opinions regarding the futility of treatment.
Once the data collection began, patients who were in the intervention group received ethics consultations regarding the feasibility and appropriateness of treatment. The researchers were careful to maintain the standard of care for the usual care patients as well; when ethics consultations were requested by either the physician or family for a patient in the usual group, this was provided for the situation regardless of the study protocols.
Following record reviews by a research assistant regarding the demographic characteristics of the patients, length of stay in the ICU, and outcomes of treatment, 2 interviews were conducted of the healthcare team and the decision maker at approximately 1 week and then again at 1 month after the initial data collection to determine whether the healthcare members and the family/friends were satisfied with the ethics consultation process.
Analysis of the data showed that there were no differences in the characteristics of the patients within the study with regard to age, gender, diagnosis, and race. At least 90% of the patients had a family member as their surrogate decision maker.
Patients who died during this hospitalization were 62.7% of the intervention group and 57.8% of the usual care group. When these data were compared with the length of stay in the ICU, it was found that patients who had the ethics consultations and who died in the hospital had fewer ICU days, fewer hospital days, and fewer days receiving ventilation compared to those with usual care who also died in the hospital. There was no difference between the groups for patients who survived to discharge from the hospital.
The implications for healthcare are interesting. While the limitations within the study relating to the potential for different ethics consultations existed, the data clearly showed that those instances where care could not have been beneficial to the patient were made clearer following ethics consultations than those that did not. Both the healthcare teams and the family/friends who were interviewed found the ethics consultations helpful and gave clear information to help the decision-making process regarding life-sustaining treatment for patients who may not have benefited from the care. Further research needs to be done to determine whether a broader use of ethics consultations will help reduce futile healthcare treatments and also help family and friends cope with the burden of decision making in cases where patients are seriously ill.
COMPUTER TOMOGRAPHY SCANS CAN REVEAL THE PRESENCE OF LOW ATTENUATION SUBDURAL FLUID
Wells RG, Sty JR. Traumatic low attenuation subdural fluid collections in children younger than 3 years. Arch Pediatr Adolescent Med. 2003;157:1005-1010.
Traumatic brain injury can be seen on computer tomography (CT scan). During these tests, nonhemic subdural fluids consisting of liquid or clotted blood can be seen. The presence of this type of fluid can help in determining the age and extent of the injury. In cases of child abuse, the presence of this low attenuation subdural fluid can be diagnostic of prior traumatic head injuries.
The research retrospectively reviewed the CT records of 55 children who had been under 3 years of age at the time of their injuries. Over 260 CT scans were reviewed from these children from their first scan to their last, counting the days from the injury to the development of the low attenuation subdural fluid.
Assessment of the CT scans showed that the low attenuation fluid was mostly found in the frontal part of the brain (98%) and the parietal area (85%) that developed in 80% of the sample within the first week after the injury. There was also a concurrent subdural hemorrhage in 87% of the children. Further evidence of the negative effect of the brain injury was seen when it was determined that 15% of the children died within 1 month of their injury, and that 18% of survivors had this fluid buildup for at least 1 month after the injury. Atrophy of the brain was seen in 48% of the children.
Further research needs to be done relating to the development of low attenuation subdural fluid. However, the presence of this type of injury during the first week after the injury should be investigated since it can be misinterpreted for further brain hemorrhage. It can also be helpful in determining whether multiple episodes of brain injury have occurred in suspected child abuse victims.
PALS GUIDELINES SHOWN TO REDUCE SEPTIC SHOCK; MORE EDUCATION NEEDED
Han YY, Carcillo JA, Dragotta MA, et al. Early reversal of pediatric-neonatal septic shock by community physicians is associated with improved outcome. Pediatrics. 2003;112: 793-799.
Children who develop septic shock in community hospitals require immediate care to save their lives. While the best care can be obtained in tertiary care hospitals, time cannot be lost in treating these children at their hospital of origin prior to their transport to another facility. This research investigated whether physicians in community hospitals followed the American College of Critical Care Medicine-developed Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Patients in Septic Shock which are included in the Pediatric Advance Life Support (PALS) guidelines relating to the treatment of septic shock and whether that treatment resulted in better health outcomes for the children.
Children diagnosed with septic shock, defined as infection coupled with decreased tissue perfusion, decreased blood pressure, long capillary refill time, and decreased mental status, were retrospectively assessed for their health outcomes. The data from over 9 years (1993-2001) from community hospital to tertiary care hospital transports were reviewed. It was found that 91 infants and children met the criteria and were included in the study. Approximately one-half (49%) were males and most had positive cultures (71%). Forty percent of the children also had another health condition including neurologic or muscular disease, hematological diseases, or congenital diseases. Children received a PRISM score indicating their chance of mortality. Data showed that 26 children died of their sepsis and that the characteristics of these children did not differ significantly from those who survived.
Analysis of the data showed that only 45% of the community-based physicians strictly followed the PALS guidelines related to fluid therapy to reverse septic shock and that <30% used the drugs recommended in the same guidelines to treat these children. Those children who did receive treatment following the PALS did more likely survive the sepsis. Children who were delayed in receiving treatment also had poorer outcomes than those whose septic shock was treated early.
The researchers noted that the results indicated that community physicians need further education on the PALS guidelines relating to the treatment of septic shock so that more children can be saved by these procedures. Conversely, this research served to give preliminary approval to the guidelines because those children who did receive the recommended treatment were more likely to survive.