Hello everybody, my dear friends.

Today Iñaki Saralegui share with us the following article recently published in JAMA Internal Medicine: Variability Among US Intensive Care Units 
in Managing the Care of Patients Admitted
 With Preexisting Limits on Life-Sustaining Therapies .

It is a retrospective study that analyzes the data from the IMPACT project, which includes 277.693 patients admitted to 141 ICUs from 105 hospitals in the United States, from 2001 to 2008. Of them 4,8% had some order of limitation on Life-Sustaining Therapies (LLST) prior to the admission in the ICU; the average age of these patients with LLST was superior to the rest and had greater comorbidity and score in predicting mortality. The most common limitation was the order of not attempting CPR (DNR order), subscribed in 77′ 4% patients with LLST prior to their admission.

Almost 25% of patients with prior DNR orders received CPR during their stay in the unit. Patients with prior admission DNR order who died in ICU, 15% received CPR. On the other hand, 40% of patients with prior admission LLST received some kind of treatment of life support, such as vasoactive drugs, mechanical ventilation, renal replacement therapy.

These results show that preferences of ICU patients about medical orders LLST-related are not always taken into account when it´s time of making decisions. This may reflect a paternalistic model and a lack of communication between health providers involved in the care of the patient.

On the other hand it is known that many people write advance wills or advance directive documents without the advice of health care staff, hence the elections reflected in these documents are not based on adequate information to adopt them. In these cases it is possible that they don´t help to improve decision-making.

In addition, numerous studies on the planning of care and treatment in United States (Advance Care Planning) indicate that for people who write documents the most important decision is to appoint a representative. This person will be the valid interlocutor with the responsible doctor. In case that the patient requires an admission in the hospital and even in the ICU, medical decision can deviate in appearance from what is expressed in the document, perhaps by the acceptance of a conditioned treatment (in time and amount of treatment) after receiving enough information for a shared decision.

The LLST as medical decision accepted by the patient or the family, or the rejection of treatments expressed in an advance directive document, should be known by all health staff involved and taken into account to adjust treatment.

In the case that the patient change his/her opinion after receiving medical information, or his/her representative agreed with medical staff a treatment plan that may contradict previously expressed is recommended to explain the decision in the medical history.

In Spain there is a great variability in the implementation of protocols and recommendations on care at the end of life in ICU patients, despite the efforts of dissemination of the Bioethics working group of SEMICYUC.

The integration of palliative care in the field of intensive care medicine is far from being ideal.

With respect to the planning of care and treatment, the goal seems more focused on the number of redacted documents than in the process of communication required to make an informed decision. It doesn’t seem to be interested if its disclosure in chronic patients is actually helping to adapt the care received in the last months of life to the preferences of the ill person.

A long way to walk, as a team, with the patient and their family as a reference. Values, consensus, uncertainty, care.

Words that should encourage us to improve our daily task.

Dr. Iñaki Saralegui (@InakiSaralegui)
Hospital Universitario de Álava.