(Press-News.org) PHILADELPHIA—The decision to limit life support in patients in the intensive care unit (ICU) appears to be significantly influenced by physician practices and/or the culture of the hospital, suggests new findings from researchers at the Perelman School of Medicine at the University of Pennsylvania presented at the American Thoracic Society International Conference on May 21.
A retrospective analysis of over 269,000 ICU patients from the Project IMPACT database revealed a substantial variation in decisions to forgo life-sustaining therapies rates among 153 ICUs in the United States—which suggests many factors unrelated to the patient or family may be affecting such decisions, particularly for patients who are unable to participate in decision making.
"Patient factors such as severity of illness, age, race, and functional status explain a significant amount of the variability in decisions to forgo life-sustaining therapies, but it is likely that ICU culture and physician practices also play a major role," said Caroline M. Quill, MD, a fellow in the department of Pulmonary, Allergy, and Critical Care at Penn Medicine. "My sense is because patients in the ICU are often unable to participate in decision-making, the influence of providers and the ICU culture may be even greater than the patient or family preference."
One in five Americans die during or shortly after an ICU stay, with many them dying following a decision to forgo life support. Though these decisions are common, the influences on these decisions are not well understood.
Limitations on care include do-not-resuscitate orders, withholding or withdrawing mechanical ventilation, withholding CPR, or an order for comfort measures or hospice care.
In order to study better understand these influences, the researchers wanted to quantify the variation among ICUs after adjusting for patient factors—gender, condition, age, and race, for example. The thought is that if a host of patient characteristics can be identified that reliably predict who will and who will not have a decision to forgo life-sustaining therapy, then after adjustment for such characteristics among large samples of ICU patients, rates should be relatively consistent among ICUs.
Here, that was not the case. Overall, 11.7 percent of patients had a decision to forgo life-sustaining therapies among 153 ICUs in the US between 2001 and 2009. Of those, 58.8 percent died in the ICU and 41.2 percent survived to ICU discharge. After researchers adjusted for patient factors in their model, the study still revealed a six-fold variation among ICUs in the probability of a decision to forgo life-sustaining therapy. This suggests that the ICU to which a given patient is admitted influences his or her odds of having a DFLST, regardless of personal or clinical characteristics.
The team also looked at which patient characteristics are associated with these decisions. Older patients, women, and patients with more functional limitations at the time of admission to an ICU were more likely to limit life support, the researchers found. Conversely, black race and other non-white races were less likely to make the decisions to forgo life-sustaining therapies.
"This high variability among ICUs highlights an opportunity to improve upon 'patient-centeredness' in end of life decisions," said Dr. Quill. "Knowing how certain physicians reach and convey prognostic judgments, and how an ICU culture, their organizational factors, like nighttime staffing, influences these decision may help us devise targeted interventions to improve the quality of end-of-life care."
INFORMATION:
Sarah J. Ratcliffe, PhD, Michael O. Harhay, MPH and Scott D. Halpern, MD, PhD are co-authors on the study.
END
This news release is available in French.
Children who are exposed to secondhand smoke in early childhood are more likely to grow up to physically aggressive and antisocial, regardless of whether they were exposed during pregnancy or their parents have a history of being antisocial, according to Linda Pagani and Caroline Fitzpatrick of the University of Montreal and its affiliated CHU Sainte-Justine hospital. No study to date has controlled for these factors. "Secondhand smoke is in fact more dangerous that inhaled smoke, and 40% of children worldwide are exposed ...
Declines in the biodiversity of pollinating insects and wild plants have slowed in recent years, according to a new study.
Researchers led by the University of Leeds and the Naturalis Biodiversity Centre in the Netherlands found evidence of dramatic reductions in the diversity of species in Britain, Belgium and the Netherlands between the 1950s and 1980s.
But the picture brightened markedly after 1990, with a slowdown in local and national biodiversity losses among bees, hoverflies and wild plants.
Professor Bill Kunin, Professor of Ecology at the University of ...
DURHAM, N.C. -- Having the biggest playlist doesn't make a male songbird the brainiest of the bunch, a new study shows.
"For songbirds, singing a lot of songs indicates a bird is smart, but that signal is not necessarily indicative of intelligence for everything," said Duke biologist Steve Nowicki.
In a series of problem-solving tests with the birds, he and his colleagues found that the male song sparrows that sang the most songs learned to solve food-finding puzzles more slowly than the birds singing fewer songs. The results are the first to show that a larger song ...
The researchers say that in a group of 10,000 young people, they would expect 39 cancers to occur during the next 10 years, but if they all had one CT scan, up to six extra cancers would occur.
CT (computed tomography) scans have great medical benefits, but their increasing use since the 1980s has raised some concerns about possible cancer risks, particularly following exposures in childhood. Most previous studies have estimated risks indirectly, and some radiation experts have questioned the validity of these estimates.
There is currently much uncertainty and as ...
The higher death rate associated with mental illness has been extensively documented, but most of the attention has focused on the elevated risk of suicide, whereas most of the risk can be attributed to physical illness such as cardiovascular and respiratory diseases and cancer (80% of deaths). The higher death rate is also normally reported in terms of mortality rates but other measures can be used such as potential years of life lost, average age at death and life expectancy. Life expectancy is also a useful alternative as it can reflect changes in rates across ages. ...
He calls on the UK's Scientific Advisory Committee on Nutrition and the Department of Health "to act swiftly" to tackle the rising obesity crisis and increasing prevalence of type 2 diabetes.
In 2003 the World Health Organization stated that "added sugars" should contribute no more than 10% of total energy intake. This was in line with the UK government's Committee on Medical Aspects of Food and Nutrition Policy (COMA) recommendations.
This nutritional advice has formed the basis of UK food labelling since 2003 and subsequently influenced European legislation, but Dr ...
They show that up to 50% of all heart attack cases are missed using just one data source.
These findings may be relevant to other common conditions, such as stroke, and support the wider use of linked multiple record sources by clinicians, policy makers and researchers, say the authors.
Electronic health records are increasingly used to measure health outcomes, and for research, but records from one part of the health service (e.g. primary care) may not capture health events occurring in other parts of the health system (e.g. hospital care).
So a team of researchers ...
ANN ARBOR, Mich. – Children with obstructive sleep apnea who had a common surgery to remove their tonsils and adenoids showed notable improvements in behavior, quality of life and other symptoms compared to those treated with "watchful waiting" and supportive care, according to a new study.
However, surprisingly, there was no difference between both groups in the primary study outcome, attention and executive functioning, as measured by formal neuropsychological tests. The research was published online today in the New England Journal of Medicine, in conjunction with ...
Children with sleep apnea syndrome who have their tonsils and adenoids removed sleep better, are less restless and impulsive, and report a generally better quality of life, finds a new study funded by the National Institutes of Health. However, the study found cognitive abilities did not improve compared with children who did not have surgery, and researchers say the findings don't mean surgery is an automatic first choice.
The findings of the Childhood Adenotonsillectomy Trial (CHAT) will be presented May 21 at the American Thoracic Society 2013 meeting in Philadelphia. ...
Overweight and obese patients are significantly more likely than their normal-weight counterparts to repeatedly switch primary care doctors, a practice that disrupts continuity of care and leads to more emergency room visits, new Johns Hopkins research suggests.
The practice of "doctor shopping" among overweight patients may be a result of negative experiences with the health care system, whether that be off-putting comments by office staff, unsolicited weight loss advice by providers, or improperly sized medical equipment and office furniture, says Kimberly A. Gudzune, ...
