End of life in the intensive care unit: should French law be adapted?

BACKGROUND: Longstanding concerns regarding end of life in the ICU led in France to the publication of guidelines, updated in 2009, that take into account the insights provided by a recent law (Leonetti's law) regarding patients' rights. After the French President asked a specific expert to review end of life issues, the French Intensive Care Society (SRLF) surveyed their members (doctors and paramedics) about various aspects of end of life in the ICU. METHODS: SRLF members were invited to respond to a questionnaire, sent by Email, designed to assess their knowledge of Leonetti's law and to determine how many caregivers would agree with the authorization of lethal drug administration in selected end of life situations. RESULTS: Questionnaires returned by 616 (23%) of 2,700 members were analyzed. Most members (82.5%) reported that they had a good knowledge of Leonetti's law, which most (88%) said they have often applied. One third of respondents had received 'assisted death' requests from patients and more than 50% from patients' relatives. One quarter of respondents had experienced the wish to give lethal drugs to end of life patients. Assuming that palliative care in the ICU is well-managed, 25.7% of the respondents would approve a law authorizing euthanasia, while 26.5% would not. Answers were influenced by the fear of a possible risk of abuse. Doctors and nurses answered differently. CONCLUSION: ICU caregivers appear to be well acquainted with Leonetti's law. Nevertheless, in selected clinical situations with suitable palliative care, one quarter of respondents were in favor of a law authorizing administration of lethal drugs to patients.

Contribution of the ethics committee of the French Intensive Care Society to describing a scenario for implementing organ donation after Maastricht type III cardiocirculatory death in France.

French law allows organ donation after death due to cardiocirculatory arrest. In the Maastricht classification, type III non-heart-beating donors are those who experience cardiocirculatory arrest after the withdrawal of life-sustaining treatments. French authorities in charge of regulating organ donation (Agence de la Biomédecine, ABM) are considering organ collection from Maastricht type III donors. We describe a scenario for Maastricht type III organ donation that fully complies with the ethical norms governing care to dying patients. That organ donation may occur after death should have no impact on the care given to the patient and family. The dead-donor rule must be followed scrupulously: the organ retrieval procedure must neither cause nor hasten death. The decision to withdraw life-sustaining treatments, withdrawal modalities, and care provided to the patient and family must adhere strictly to the requirements set forth in patient-rights legislation (the 2005 Léonetti law in France) and should not be influenced in any way by the possibility of organ donation. A major ethical issue regarding the family is how best to transition from discussing treatment-withdrawal decisions to discussing possible organ retrieval for donation should the patient die rapidly after treatment withdrawal. Close cooperation between the healthcare team and the organ retrieval team is crucial to minimize the distress of family members during this transition. Modalities for implementing Maastricht type III organ donation are discussed here, including the best location for withdrawing life-sustaining treatments (operating room or intensive care unit).

Abciximab treatment modalities for thromboembolic events related to aneurysm coiling.

BACKGROUND: Thromboembolic complications are the most common cause of periprocedural morbidity associated with the endovascular treatment of intracranial aneurysms with detachable coils. OBJECTIVE: To estimate the safety and efficacy of using combined intra-arterial and intravenous abciximab to treat thrombi complicating endovascular cerebral aneurysm coil embolization. METHODS: In a retrospective analysis of 390 aneurysmal coiling procedures, we identified 39 patients (10.0%) with thromboembolic events related to the procedure. As the first line of treatment in 23 of these patients, abciximab was administered intra-arterially as a bolus followed by intravenous infusion over a 12-hour period. Eleven of the 23 patients were treated for ruptured aneurysms, 9 for unruptured aneurysms, and 3 for aneurysmal recanalization. Flow restoration and neurological outcome were evaluated. RESULTS: Amelioration as measured by the Thrombolysis in Myocardial Infarction flow grade score was achieved in 17 of 23 patients (73.9%), and no change was observed in 6 of 23 patients (26.1%). Complete recanalization was achieved in 13 patients (56.5%). A greater response to abciximab was noted for thrombi at the coil-parent artery interface, and a lesser response was noted for distal thrombi. No hemorrhagic complications were noted for any of the patients, whereas 11 patients (47.8%) showed ischemic lesions. A modified Rankin Scale score of 2 or less was achieved in 17 of 23 patients (73.9%), whereas 6 of 23 patients (26.1%) had a modified Rankin Scale score of more than 2. CONCLUSION: Combined intra-arterial/intravenous administration of abciximab is safe and effective for treating thromboembolic complications that occur during aneurysmal coil embolization with no hemorrhagic complications.

Randomized, double-blind, placebo-controlled, pilot trial of high-dose methylprednisolone in aneurysmal subarachnoid hemorrhage.

OBJECT: The object of this study was to determine the efficacy of methylprednisolone in reducing symptomatic vasospasm and poor outcomes after subarachnoid hemorrhage (SAH). METHODS: Ninety-five patients with proven SAH were recruited into a double-blind, placebo-controlled, randomized trial. Starting within 6 hours after angiographic diagnosis of aneurysm rupture, placebo or methylprednisolone, 16 mg/kg, was administered intravenously every day for 3 days to 46 and 49 patients, respectively. Deterioration, defined as development of a focal sign or decrease of more than 1 point on the Glasgow Coma Scale for more than 6 hours, was investigated by using clinical criteria and transcranial Doppler ultrasonography, cerebral angiography, or CT when appropriate. The end points were incidence of symptomatic vasospasm (delayed ischemic neurological deficits associated with angiographic arterial narrowing or accelerated flow on Doppler ultrasonography, or both) and outcome 1 year after entry into the study according to a simplified Rankin scale (Functional Outcome Scale [FOS]) in living patients and the Glasgow Outcome Scale in all patients included. RESULTS: All episodes of deterioration and all living patients with a 1-year outcome were assessed by a review committee. In patients treated with methylprednisolone, the incidence of symptomatic vasospasm was 26.5% compared with 26.0% in those given placebo. Poor outcomes according to FOS were significantly reduced in the Methylprednisolone Group at 1 year of follow-up; the risk difference was 19.3% (95% CI 0.5-37.9%). The outcome was poor in 15% (6/40) of patients in the Methylprednisolone Group versus 34% (13/38) in the Placebo Group. CONCLUSIONS: A safe and simple treatment with methylprednisolone did not reduce the incidence of symptomatic vasospasm but improved ability and functional outcome at 1 year after SAH.