Nighttime intensivist staffing and the timing of death among ICU decedents: a retrospective cohort study. (Carmean)

Reineck LA, Wallace DJ, Barnato AE, Kahn JM. Nighttime intensivist staffing and the timing of death among ICU decedents: a retrospective cohort study. Crit Care. 2013 Oct 3;17(5):R216.

INTRODUCTION: Intensive care units (ICUs) are increasingly adopting 24-hour intensivist physician staffing. Although nighttime intensivist staffing does not consistently reduce mortality, it may affect other outcomes such as the quality of end-of-life care.

METHODS: We conducted a retrospective cohort study of ICU decedents using the 2009–2010 Acute Physiology and Chronic Health Evaluation clinical information system linked to a survey of ICU staffing practices. We restricted the analysis to ICUs with high-intensity daytime staffing, in which the addition of nighttime staffing does not influence mortality. We used multivariable regression to assess the relationship between nighttime intensivist staffing and two separate outcomes potentially related to the quality of end-of-life care: time from ICU admission to death and death at night.

RESULTS: Of 30,456 patients admitted to 27 high-intensity daytime staffed ICUs, 3,553 died in the hospital within 30 days. After adjustment for potential confounders, admission to an ICU with nighttime intensivist staffing was associated with a shorter duration between ICU admission and death (adjusted difference: -2.5 days, 95% CI -3.5 to -1.5, p-value < 0.001) and a decreased odds of nighttime death (adjusted odds ratio: 0.75, 95% CI 0.60 to 0.94, p-value 0.011) compared to admission to an ICU without nighttime intensivist staffing.

CONCLUSIONS: Among ICU decedents, nighttime intensivist staffing is associated with reduced time between ICU admission and death and reduced odds of nighttime death.

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Physician staffing models impact the timing of decisions to limit life support in the ICU. (from CHEST, March 2013 – Wittkamp)

CHEST. 2013;143(3):656-663. doi:10.1378/chest.12-1173.

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BACKGROUND:  A growing trend is the implementation of 24-h attending physician coverage in the ICU. Our aim was to measure the impact of 24-h, in-house, attending intensivist coverage on the quality of end-of-life care and the timing of end-of-life decision-making.

METHODS:  A retrospective cohort study was conducted of all ICU deaths 6 months before and 6 months after the implementation of mandatory 24-h attending intensivist coverage in a medical ICU. Data relevant to end-of-life care per established consensus recommendations were abstracted from the medical record.

RESULTS:  The following changes were observed after implementation of 24-h intensivist coverage: Time from ICU admission to decision to withdraw mechanical ventilation and time to decision to change to do-not-resuscitate code status both were shortened by 2 days (both P = .03). Quality measures, such as increased family presence around time of death (P = .01) also improved. Other findings, which did not reach statistical significance, included the following: Time to family conference was shortened by 2 days (P = .09), time to decision to limit any life support was shortened by 1 day (P = .08), time to death was shortened by 2 days (P = .08), and intubations against patient wishes decreased (from three to none; P = .12).

CONCLUSIONS:  The implementation of mandatory 24-h, in-house, attending intensivist coverage was associated with earlier decision-making across a number of domains related to end-of-life care. Positive trends were noted in quality of end-of-life care as reflected in the presence of family at the time of death.

Decisions to withdraw or withhold life support are routinely made in the ICU when patients, surrogate decision-makers, and the health-care team transition from curative to comfort care.1 The two most important factors influencing such decisions are patient preferences and patient prognosis.2,3 Numerous additional patient-, provider-, and surrogate-related factors impact such decisions and create significant variability in decision-making.4‐6 In an era when up to 20% of all adults die in the ICU and one-third of all health-care dollars in the United States are used in the last year of life, understanding how decisions to limit life support are made and implementing strategies to improve decision-making have been the subjects of continued research.1,7‐10

Additionally, there has been a growing trend and recommendations toward the use of continuous, 24-h, intensivist staffing of ICUs.11 This is typically accomplished by alternating daytime and nighttime intensivist shifts. The impact of adding continuous, attending intensivist coverage in the ICU has been associated with improvement in a number of patient outcomes including decreased hospital length of stay; decreased ICU complication rate; increased staff satisfaction; improvement in a number of evidence-based care processes, such as ventilator bundle compliance; and decreased mortality rates in some care settings.12‐14

In this single-center study, we sought to measure the impact of intensivist staffing models on decisions to limit life support in the ICU. We hypothesized that the continuous (24-h) presence of an attending intensivist would be associated with improved care at the end of life and improved end-of-life decision-making.

The culture of dysthanasia: attempting CPR in terminally ill children. (from Pediatrics, March 2013 – Vats)

Pediatrics. 2013 Mar;131(3):572-80. doi: 10.1542/peds.2012-0393. Epub 2013 Feb 4. PMID: 23382437

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Both dying children and their families are treated with disrespect when the presumption of consent to cardiopulmonary resuscitation (CPR) applies to all hospitalized children, regardless of prognosis and the likely efficacy of CPR. This “opt-out” approach to CPR fails to appreciate the nuances of the special parent-child relationship and the moral and emotional complexity of enlisting parents in decisions to withhold CPR from their children. The therapeutic goal of CPR is not merely to resume spontaneous circulation, but rather it is to provide circulation to vital organs to allow for treatment of the underlying proximal and distal etiologies of cardiopulmonary arrest. When the treating providers agree that attempting CPR is highly unlikely to achieve the therapeutic goal or will merely prolong dying, we should not burden parents with the decision to forgo CPR. Rather, physicians should carry the primary professional and moral responsibility for the decision and use a model of informed assent from parents, allowing for respectful disagreement. As emphasized in the palliative care literature, we recommend a directive and collaborative goal-oriented approach to conversations about limiting resuscitation, in which physicians provide explicit recommendations that are in alignment with the goals and hopes of the family and emphasize the therapeutic indications for CPR. Through this approach, we hope to help parents understand that “doing everything” for their dying child means providing medical therapies that ameliorate suffering and foster the intimacy of the parent-child relationship in the final days of a child’s life, making the dying process more humane.