Objectives:To update the Society of Critical Care Medicine’s guidelines for ICU admission, discharge, and triage, providing a framework for clinical practice, the development of institutional policies, and further research.Design:An appointed Task Force followed a standard, systematic, and evidence-

ICU Admission, Discharge, and Triage Guidelines: A Framework to Enhance Clinical Operations, Development of Institutional Policies, and Further Research.

Background: There is controversy about how to manage requests by patients or surrogates for treatments that clinicians believe should not be administered.Purpose: This multisociety statement provides recommendations to prevent and manage intractable disagreements about the use of such treatments in intensive care units.Methods: The recommendations were developed using an iterative consensus process, including expert committee development and peer review by designated committees of each of the participating professional societies (American Thoracic Society, American Association for Critical Care Nurses, American College of Chest Physicians, European Society for Intensive Care Medicine, and Society of Critical Care).Main Results: The committee recommends: (1) Institutions should implement strategies to prevent intractable treatment conflicts, including proactive communication and early involvement of expert consultants. (2) The term “potentially inappropriate” should be used, rather than futile, to describe...

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An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units.

G-CSF and GM-CSF are used widely to promote the production of granulocytes or APCs. The U.S. Food and Drug Administration approved G-CSF (filgrastim) for the treatment of congenital and acquired neutropenias and for mobilization of peripheral hematopoietic progenitor cells for stem cell transplantation. A polyethylene glycol-modified form of G-CSF is approved for the treatment of neutropenias. Clinically significant neutropenia, rendering an individual immunocompromised, occurs when their number is 20%. GM-CSF (sargramostim) is approved for neutropenia associated with stem cell transplantation. Because of its promotion of APC function, GM-CSF is being evaluated as an immunostimulatory adjuvant in a number of clinical trials. More than 20 million persons have benefited worldwide, and >$5 billion in sales occur annually in the United States.

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G-CSF and GM-CSF in Neutropenia

Purpose To investigate the extent of objective ‘non-beneficial treatments (NBTs)’ (too much) anytime in the last 6 months of life in routine hospital care.

Data sources English language publications in Medline, EMBASE, PubMed, Cochrane library, and the grey literature (January 1995–April 2015).

Study selection All study types assessing objective dimensions of non-beneficial medical or surgical diagnostic, therapeutic or non-palliative procedures administered to older adults at the end of life (EOL).

Data extraction A 13-item quality score estimated independently by two authors.

Results of data synthesis Evidence from 38 studies indicates that on average 33–38% of patients near the EOL received NBTs. Mean prevalence of resuscitation attempts for advanced stage patients was 28% (range 11–90%). Mean death in intensive care unit (ICU) was 42% (range 11–90%); and mean death rate in a hospital ward was 44.5% (range 29–60%). Mean prevalence of active measures including dialysis, radiotherapy, transfusions and life support treatment to terminal patient was 7–77% (mean 30%). Non-beneficial administration of antibiotics, cardiovascular, digestive and endocrine treatments to dying patients occurred in 11–75% (mean 38%). Non-beneficial tests were performed on 33–50% of patients with do-not-resuscitate orders. From meta-analyses, the pooled prevalence of non-beneficial ICU admission was 10% (95% CI 0–33%); for chemotherapy in the last six weeks of life was 33% (95% CI 24–41%).

Conclusion This review has confirmed widespread use of NBTs at the EOL in acute hospitals. While a certain level of NBT is inevitable, its extent, variation and justification need further scrutiny.

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Non-beneficial treatments in hospital at the end of life: a systematic review on extent of the problem

https://www.collegianjournal.com/article/S1322-7696(17)30042-2/pdf

Patient-centred care as an approach to improving health care in Australia

Importance Physicians often perceive as futile intensive care interventions that prolong life without achieving an effect that the patient can appreciate as a benefit. The prevalence and cost of critical care perceived to be futile have not been prospectively quantified. Objective To quantify the prevalence and cost of treatment perceived to be futile in adult critical care. Design, Setting, and Participants To develop a common definition of futile care, we convened a focus group of clinicians who care for critically ill patients. On a daily basis for 3 months, we surveyed critical care specialists in 5 intensive care units (ICUs) at an academic health care system to identify patients whom the physicians believed were receiving futile treatment. Using a multivariate model, we identified patient and clinician characteristics associated with patients perceived to be receiving futile treatment. We estimated the total cost of futile treatment by summing the charges of each day of receiving perceived futile treatment and converting to costs. Main Outcome and Measure Prevalence of patients perceived to be receiving futile treatment. Results During a 3-month period, there were 6916 assessments by 36 critical care specialists of 1136 patients. Of these patients, 904 (80%) were never perceived to be receiving futile treatment, 98 (8.6%) were perceived as receiving probably futile treatment, 123 (11%) were perceived as receiving futile treatment, and 11 (1%) were perceived as receiving futile treatment only on the day they transitioned to palliative care. The patients with futile treatment assessments received 464 days of treatment perceived to be futile in critical care (range, 1-58 days), accounting for 6.7% of all assessed patient days in the 5 ICUs studied. Eighty-four of the 123 patients perceived as receiving futile treatment died before hospital discharge and 20 within 6 months of ICU care (6-month mortality rate of 85%), with survivors remaining in severely compromised health states. The cost of futile treatment in critical care was estimated at $2.6 million. Conclusions and Relevance In 1 health system, treatment in critical care that is perceived to be futile is common and the cost is substantial.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/1735897/ioi130093.pdf

The Frequency and Cost of Treatment Perceived to Be Futile in Critical Care

Pulmonary alveolar proteinosis (PAP) is a rare lung disease characterized by the accumulation of proteinaceous material within the lungs. While typically managed with whole lung lavage (WLL), more recent PAP therapies aimed at reducing granulocyte–macrophage colony stimulating factor autoantibodies (anti-GM-CSF) have reduced symptoms and improved lung function. We present a patient with PAP refractory to WLL, exogenous GM-CSF and rituximab who underwent a novel plasmapheresis protocol as a therapeutic trial. While previously reported regimens have utilized plasmapheresis sessions distributed over months, our patient underwent five consecutive days of plasmapheresis, followed by rituximab. Anti-GM-CSF levels decreased from 24.8 to 2.7 mcg/mL post-plasmapheresis. This reduction of autoantibody correlated with reduction in WLL frequency, increase in diffusing capacity for carbon monoxide, and subjective improvement in dyspnea. Our case suggests that five consecutive days of plasmapharesis results in increased clearance of anti-GM-CSF and may be potentially efficacious in cases of refractory PAP.

A plasmapheresis protocol for refractory pulmonary alveolar proteinosis.

Background: Factors leading to inappropriate critical care, that is treatment that should not be provided because it does not offer the patient meaningful benefit, have not been rigorously characterized. Objective: We explored medical record documentation about patients who received inappropriate critical care and those who received appropriate critical care to examine factors associated with the provision of inappropriate treatment. Design: Medical records were abstracted from 123 patients who were assessed as receiving inappropriate treatment and 66 patients who were assessed as receiving appropriate treatment but died within six months of intensive care unit (ICU) admission. We used mixed methods combining qualitative analysis of medical record documentation with multivariable analysis to examine the relationship between patient and communication factors and the receipt of inappropriate treatment, and present these within a conceptual model. Setting: One academic health system. Results: Medica...

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Understanding Factors Contributing to Inappropriate Critical Care: A Mixed-Methods Analysis of Medical Record Documentation.

A 52-year-old woman underwent bilateral lung transplantation for rheumatoid arthritis–associated interstitial lung disease. Her pretransplant course was notable for immunosuppressive therapy for rheumatoid arthritis with adalimumab, azathioprine, and prednisone. She exhibited extensive pretransplant allosensitization, including 3 low-intensity donorspecific antihuman leukocyte antigen antibodies predicted to react with the allograft, as well as a positive flow cytometric crossmatch at the time of transplant. As a result, her posttransplant induction immunosuppression included rabbit antithymocyte globulin (ATG), plasmapheresis, intravenous (IV) immunoglobulin, and rituximab. Maintenance immunosuppression consisted of tacrolimus, mycophenolate mofetil (MMF), prednisone, and monthly IV immunoglobulin. Antimicrobial

Pulmonary Allograft Versus Host Disease.

BACKGROUND Significant resources have been allocated to decreasing the number of preventable deaths in hospitals, but identifying preventable factors and then leveraging them to effect system-wide change remains challenging. OBJECTIVE To determine the ability of a novel in-person, multidisciplinary "rapid mortality review" process to identify deaths that are preventable and action items that lead to improvements in care. METHODS Rapid mortality review sessions were conducted weekly for patients who died in the medical intensive care unit. Patient data and clinician opinions regarding preventable deaths were discussed and recorded. Bivariate analyses were done to detect associations between case variables and the formation of an action item. RESULTS From 2013 to 2018, 542 patient deaths were reviewed; of those, 36 deaths (7%) were deemed potentially preventable. Facilitators identified issues in 294 cases (54%). A total of 253 action items were identified for 175 cases (32%); 60% of those action items were subsequently completed and led to tangible systemic change in 29 instances (11%). Action items were more likely to be identified for patients who had not been receiving comfort care (P < .001), for patients who had received cardiopulmonary resuscitation (P < .001), when the treatment team (P < .001) or the rapid mortality review facilitator (P < .001) had care-related concerns, and when the patient's death had been preventable (P < .001). CONCLUSIONS Even in settings with low reported rates of preventable deaths, an in-person multidisciplinary mortality review can successfully identify areas where care can be improved, leading to systemic change.

Bryan Garber

Papers

The Frequency and Cost of Treatment Perceived to Be Futile in Critical Care

A plasmapheresis protocol for refractory pulmonary alveolar proteinosis.

Understanding Factors Contributing to Inappropriate Critical Care: A Mixed-Methods Analysis of Medical Record Documentation.

Pulmonary Allograft Versus Host Disease.

Rapid Mortality Review in the Intensive Care Unit: An In-Person, Multidisciplinary Improvement Initiative.