Article Text

PDF

Ethics consultations reduced hospital, ICU, and ventilation days in patients who died before hospital discharge in the ICU
  1. Tina Jones, RN, MNSc, DNurs
  1. University of Adelaide
 Adelaide, South Australia, Australia
    • ethics consultation
    • intensive care
    • patient care planning

    
 
 Q Does offering an ethics consultation reduce non-beneficial life sustaining treatments or hospital days more than usual care for patients in the intensive care unit (ICU) who subsequently die before hospital discharge?

    METHODS

    GraphicDesign:

    randomised controlled trial.

    GraphicAllocation:

    concealed.

    GraphicBlinding:

    blinded {patients and data collectors}*.

    GraphicFollow up period:

    until death before hospital discharge.

    GraphicSetting:

    ICUs of 7 hospitals in the US.

    GraphicPatients:

    551 adult ICU patients (mean age 68 y, 54% men) in whom imminent or manifest value laden conflicts that could lead to incompatible courses of treatment were identified. Conflicts occurred within or between the healthcare team and family and friends (eg, whether to pursue aggressive life sustaining treatment or comfort care, whether treatments were regarded as futile by ⩾1 member of the team, and which treatments were in the patients’ best interest in the absence of a qualified decision maker).

    GraphicInterventions:

    278 patients were allocated to be offered an ethics consultation within 24 hours of randomisation. Consultation consisted of a consultation request; assessment of request; ethical diagnosis; recommendations of next steps, such as improving communication by sharing information, dealing with emotional discomfort and grieving, and correcting misunderstandings; documentation of the consultation in the patient’s medical record; follow up by the ethics consultant to provide ongoing support to the process; evaluation; and record keeping to enhance future learning and quality improvement. 273 patients were allocated to usual care (family meetings or other conferences as judged to be appropriate by the healthcare team).

    GraphicOutcomes:

    hospital days, ICU days, and non-beneficial life sustaining treatments.

    GraphicPatient follow up:

    of 546 patients (99%) included in the follow up, a subgroup of 329 patients (60%) who died before hospital discharge.

    MAIN RESULTS

    Analysis was by intention to treat. 67 patients (24%) in the treatment group did not receive an ethics consultation, and 77 patients (28%) in the usual care group received an ethics consultation. The groups did not differ for mortality rate. Among patients who died before hospital discharge, those who received ethics consultations had fewer hospital, ICU, and ventilation days than those who received usual care (table). The groups did not differ for outcomes among patients who survived to hospital discharge (p>0.5).

    Ethics consultations v usual care for patients in the intensive care unit (ICU) who died before hospital discharge*

    CONCLUSION

    Ethics consultations reduced hospital, intensive care unit, and life sustaining ventilation days for patients in the intensive care unit who died before hospital discharge.

    Commentary

    This well executed, large, multisite randomised controlled trial (RCT) by Schneiderman et al compared the offer of ethics consultations with usual care (family meetings or other conferences as judged to be appropriate by the healthcare team). This study builds on previous research from a single centre RCT by the same authors, which also found that ethics consultations reduced hospital, ICU, and life sustaining ventilation days without increasing mortality.1 Schneiderman et al did not use a standardised protocol for the intervention because the participating hospitals had pre-existing ethics consultation services. Although broad guidelines were presented, it remains unclear what effect ethics consultations might have in hospitals with start-up services. It is clear, however, that even in hospitals with established ethics support, the routine offer of an ethics consultation can still reduce futile interventions in situations where conflict over treatment is likely.

    The findings of this study are important for nurses who work in critical care settings where withdrawal of life sustaining treatment is common and subject to value laden conflict between health professionals, patients, and patient surrogates. Ethics consultations in the ICU are not routine services in many countries, and given that ethical principles are cultural artefacts, further research in healthcare settings outside of the US would be appropriate. However, the findings of Schneiderman et al suggest that opportunities for moral conversations about treatment should certainly be considered. The positive views expressed by nurses, physicians, and patient surrogates who found ethics consultations helpful suggests that this service could be embraced by those who are faced with ethical dilemmas in critical care.

    References

    Statistics from Altmetric.com

    
 
 Q Does offering an ethics consultation reduce non-beneficial life sustaining treatments or hospital days more than usual care for patients in the intensive care unit (ICU) who subsequently die before hospital discharge?

    METHODS

    Embedded ImageDesign:

    randomised controlled trial.

    Embedded ImageAllocation:

    concealed.

    Embedded ImageBlinding:

    blinded {patients and data collectors}*.

    Embedded ImageFollow up period:

    until death before hospital discharge.

    Embedded ImageSetting:

    ICUs of 7 hospitals in the US.

    Embedded ImagePatients:

    551 adult ICU patients (mean age 68 y, 54% men) in whom imminent or manifest value laden conflicts that could lead to incompatible courses of treatment were identified. Conflicts occurred within or between the healthcare team and family and friends (eg, whether to pursue aggressive life sustaining treatment or comfort care, whether treatments were regarded as futile by ⩾1 member of the team, and which treatments were in the patients’ best interest in the absence of a qualified decision maker).

    Embedded ImageInterventions:

    278 patients were allocated to be offered an ethics consultation within 24 hours of randomisation. Consultation consisted of a consultation request; assessment of request; ethical diagnosis; recommendations of next steps, such as improving communication by sharing information, dealing with emotional discomfort and grieving, and correcting misunderstandings; documentation of the consultation in the patient’s medical record; follow up by the ethics consultant to provide ongoing support to the process; evaluation; and record keeping to enhance future learning and quality improvement. 273 patients were allocated to usual care (family meetings or other conferences as judged to be appropriate by the healthcare team).

    Embedded ImageOutcomes:

    hospital days, ICU days, and non-beneficial life sustaining treatments.

    Embedded ImagePatient follow up:

    of 546 patients (99%) included in the follow up, a subgroup of 329 patients (60%) who died before hospital discharge.

    MAIN RESULTS

    Analysis was by intention to treat. 67 patients (24%) in the treatment group did not receive an ethics consultation, and 77 patients (28%) in the usual care group received an ethics consultation. The groups did not differ for mortality rate. Among patients who died before hospital discharge, those who received ethics consultations had fewer hospital, ICU, and ventilation days than those who received usual care (table). The groups did not differ for outcomes among patients who survived to hospital discharge (p>0.5).

    Ethics consultations v usual care for patients in the intensive care unit (ICU) who died before hospital discharge*

    CONCLUSION

    Ethics consultations reduced hospital, intensive care unit, and life sustaining ventilation days for patients in the intensive care unit who died before hospital discharge.

    Commentary

    This well executed, large, multisite randomised controlled trial (RCT) by Schneiderman et al compared the offer of ethics consultations with usual care (family meetings or other conferences as judged to be appropriate by the healthcare team). This study builds on previous research from a single centre RCT by the same authors, which also found that ethics consultations reduced hospital, ICU, and life sustaining ventilation days without increasing mortality.1 Schneiderman et al did not use a standardised protocol for the intervention because the participating hospitals had pre-existing ethics consultation services. Although broad guidelines were presented, it remains unclear what effect ethics consultations might have in hospitals with start-up services. It is clear, however, that even in hospitals with established ethics support, the routine offer of an ethics consultation can still reduce futile interventions in situations where conflict over treatment is likely.

    The findings of this study are important for nurses who work in critical care settings where withdrawal of life sustaining treatment is common and subject to value laden conflict between health professionals, patients, and patient surrogates. Ethics consultations in the ICU are not routine services in many countries, and given that ethical principles are cultural artefacts, further research in healthcare settings outside of the US would be appropriate. However, the findings of Schneiderman et al suggest that opportunities for moral conversations about treatment should certainly be considered. The positive views expressed by nurses, physicians, and patient surrogates who found ethics consultations helpful suggests that this service could be embraced by those who are faced with ethical dilemmas in critical care.

    References

    View Abstract

    Footnotes

    • * Information provided by author.

    • For correspondence: Dr L J Schneiderman, Department of Family and Preventive Medicine, University of California, San Diego, La Jolla, CA, USA. ljsucsd.edu

    • Source of funding: Agency for Healthcare Research and Quality.

    • * A modified version of this abstract appears in ACP Journal Club.

    Request permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.