Treatment-Limiting Decisions in Patients with Spontaneous Intracerebral Hemorrhage.

Background and Objectives: Treatment-limiting decisions (TLDs) are employed to actively withhold treatment/invasive interventions from patients in whom clinicians feel they would derive little to no benefit and/or suffer detrimental effects. Data regarding the employment of TLDs in patients with spontaneous intracerebral hemorrhage (ICH) remain sparse. Accordingly, this study sought to investigate both the prevalence of TLDs and factors driving TLDs in patients suffering from spontaneous ICH. Materials and Methods: This was a retrospective study of 249 consecutive patients with ICH treated from 2018−2019 at the Neurovascular Center of the University Hospital Bonn. Reasons deemed critical in the decision-making process with regard to TLD were ultimately extracted/examined via chart review of qualifying patients. Results: A total of 249 patients with ICH were included within the final analyses. During the time period examined, 49 patients (20%) had advanced directives in place, whereas in 53 patients (21%) consultation with relatives or acquaintances was employed before further treatment decisions. Overall, TLD ultimately manifested in 104 patients (42%). TLD was reached within 6 h after admission in 52 patients (50%). Congruent with severity of injury and expected outcomes, TLDs were more likely in patients with signs of cerebral herniation and an ICH score > 3 (p < 0.001). Conclusions: The present study examines details associated with TLDs in patients with spontaneous ICH. These data provide insight into key decisional processes and reinforce the need for further structured investigations in an effort to help guide patients and their families.

[Current view on the issue of insufficient effectiveness of anti-VEGF therapy for age-related macular degeneration]. / Sovremennyi vzglyad na problemu nedostatochnoi effektivnosti antiangiogennoi terapii vozrastnoi makulyarnoi degeneratsii.

Due to the significant medical and social importance of neovascular (wet) age-related macular degeneration (wAMD), increasing the effectiveness of anti-VEGF therapy used to treat this disease is one of the high-priority problems in modern retinology. This article focuses on pathobiological aspects and clinical manifestations of incomplete responses to anti-VEGF therapy of wAMD, considers the proposed ways to improve the terminology and classification of responses to therapy, as well as the assessment of its correctness and effectiveness of the treatment. It also discusses the available ways to optimize anti-VEGF therapy and define the criteria of its termination in cases when the treatment proves to be futile.

Decisiones de no ingreso en las Unidades de Cuidados Intensivos como medida de limitación de los tratamientos de soporte vital: variabilidad geográfica en España / Decisions of refusal intensive Care Units’ admission as a measure of limitation of life support treatments: geographical variability in Spain

A través de un análisis post hoc del estudio ADENI-UCI (estudio multicéntrico, observacional, de co-hortes, prospectivo, con un período de seguimiento de 13 meses, en un total de 62 servicios de MedicinaIntensiva en España; se analizan las diferencias geográficas del motivo de negación de ingreso en UCI comomedida de LTSV. Se incluyeron 2284 pacientes con una edad media de 75,25 (12,45) años. El 59,43% varones.Mediante regresión multinominal ajustada por edad, sexo, APACHE II y SOFA, se evidenció (al elegir lazona norte como referencia) que la edad en la zona sur fue un motivo menos expuesto de forma significati-va (OR: 0.48 (IC95%: 0.35-0.65). p<0,001), que la enfermedad crónica severa era menos valorada en la zona mediterránea (OR: 0.70 (IC95%: 0.56-0.87). p=0,001), mientras que presentaba más peso en la zona centro(OR: 1.78 (IC95%: 1.43-2.23). p<0,001). La limitación funcional previa fue el motivo más esgrimido en regio-nes centro y sur (OR: 1.39, (IC95%: 1.12-1.72). p=0,002; OR: 1.50, (IC95%:1.15-1.94). p=0,002). Fue la futilidaden el tratamiento el motivo que mayores diferencias presentó entre las diversas regiones analizadas (dif:37,2%-68,8%). Por lo tanto, se puede concluir que existen diferencias geográficas en el territorio españolen las decisiones de rechazar el ingreso en una UCI como medida de LTSV, probablemente justificadas pordiferencias organizativas de los servicios de medicina intensiva participantes en el ADENI-UCI.(AU)

From a post hoc analysis of the ADENI-UCI study (multicenter, observational, cohort, prospective study,with a follow-up period of 13 months, in 62 Intensive Medicine Services in Spain. geographical differencesin the reason for denial of income in UCI as a LTSV measure are analyzed. A total of 2284 with an averageage of 75.25 (12.45) years were included. 59.43% male. By means of multinominal regression adjusted byage, sex, APACHE and SOFA, was evident (by choosing the northern for reference) that age in the southwas a less significantly exposed reason (OR: 0.48 (IC95%: 0.35-0.65). p<0.001), that severe chronic diseasewas less valued in the Mediterranean area (OR: 0.7% 0 (IC95%: 0.56-0.87). p-0.001), while it had moreweight in the central area (OR: 1.78 (95% CI: 1.43-2.23). The previous functional limitation was more raisedin central and southern regions (OR: 1.39, (IC95%: 1.12-1.72). p-0.002; OR:1.50, (IC95%:1.15-1.94). 0.002).It was futility in treatment that had the greatest differences between the various regions analysed (dif:37,2% - 68,8%). There are geographical differences in the Spanish territory in decisions to refuse entry intoan ICU as an LTSV measure, probably justified by organizational differences in intensive medicine servicesparticipating in the ADENI-UCI.(AU)

One last round of chemo? Insights from conversations between oncologists and lung cancer patients about prognosis and treatment decisions.

One more chemo or one too many? The increasing use of expensive cancer treatments close to the patient's death is often explained by oncologists' failure to communicate to patients how close to dying they are, implying that patients are often both ill-prepared and over-treated when they die. This article aims at interrogating the politically charged task of prognosticating. Drawing on an ethnographic study of conversations between oncologists and patients with metastatic lung cancer in a Danish oncology clinic, I show that oncologists utilize, rather than avoid, prognostication in their negotiations with patients about treatment withdrawal. The study informs the emerging sociology of prognosis in three ways: First, prognostication is not only about foreseeing and foretelling, but also about shaping the patient's process of dying. Second, oncologists prognosticate differently depending on the level of certainty about the patient's trajectory. To unfold these differences, the article provides a terminology that distinguishes between four 'modes of prognostication', namely hinting, informing, calibrating and organizing. Third, prognosticating can unfold over time through multiple consultations, emphasizing the relevance of adopting methodologies enabling the study of prognosticating over time.

Discrepancies in the use of chemotherapy and artificial nutrition near the end of life for hospitalised patients with metastatic gastric or oesophageal cancer. A countrywide, register-based study.

AIM: To evaluate the frequency and the factors associated with the use of chemotherapy and artificial nutrition near the end of life in hospitalised patients with metastatic oesophageal or gastric cancer. METHODS: Nationwide, register-based study, including all hospitalised adults (≥20 years) who died with metastatic oesophageal or gastric cancer between 2010 and 2013, in France. Chemotherapy and artificial nutrition during the final weeks of life were considered as primary outcomes. RESULTS: A total of 4031 patients with oesophageal cancer and 10,423 patients with gastric cancer were included. While the proportion of patients receiving chemotherapy decreased from 35.9% during the 3rd month before death to 7.9% in the final week (p < 0.001 for trend), the use of artificial nutrition rose from 9.6% to 16.0% of patients. During the last week before death, patients with stomach cancer were more likely to receive chemotherapy (adjusted odds ratio (aOR) = 1.35, 95% CI = 1.17-1.56) but less likely to receive artificial nutrition (aOR = 0.80, 95%CI = 0.73-0.88) than patients with cancer of the oesophagus. The adjusted rates of chemotherapy use during the last week of life varied from 1.6% in rural hospitals to 11.2% in comprehensive cancer centres, while the adjusted probability to receive artificial nutrition varied from 12.1% in private for-profit clinics up to 19.9% in rehabilitation care facilities (p < 0.001). CONCLUSIONS: Our study shows that in hospitalised patients with metastatic oesophageal or gastric cancer, the use of chemotherapy decreases while the use of artificial nutrition increases as death approaches. This raises important questions, as clinical guidelines clearly recommend to limit the use of artificial nutrition in contexts of limited life expectancy.