Characteristics and Prognosis of Patients Who Receive Noninvasive Ventilation and Present Limitation of Life Support Treatment: The LLST-NIVCat Multicenter Cohort Study.

BACKGROUND: Patients who receive noninvasive ventilation (NIV) in the emergency department (ED) sometimes have a limitation of life support treatment (LLST). The characteristics and prognosis in these patients may be worse, however, few studies have been carried out in this respect. OBJECTIVE: Analyze the differences between patients receiving NIV in the ED with LLST (NIV-LLST) or without LLST (NIV-noLLST) and their impact on in-hospital mortality, as well as investigate in-hospital mortality in the NIV-LLST group. METHOD: We performed a secondary analysis of data from the NIVCat registry. This was a prospective, multicenter, analytical cohort study with consecutive inclusion of patients receiving NIV from February to March 2015 in 11 hospital EDs in Spain. Data on the baseline characteristics, the acute episode, and final patient destination were collected. The dependent variable was all-cause in-hospital mortality. RESULTS: We analyzed 152 cases receiving NIV, 66 (43.4%) of whom had NIV-LLTS. Age ≥ 75 years was associated with NIV-LLST. In-hospital mortality was higher in the NIV-LLST group, with an adjusted hazard ratio of 2.50 (95% confidence interval [CI] 1.03-6.06). Patients with NIV-LLST presenting an exacerbation of chronic obstructive pulmonary disease (COPD) presented the lowest mortality, with an odds ratio of 0.27 (95% confidence interval 0.08-0.93), compared with the remaining patients. CONCLUSION: In our cohort of patients receiving NIV in the ED, the presence of LLST is frequent and is associated with high hospital mortality. The NIV-LLST patients with a COPD exacerbation have a better prognosis than NIV-LLST patients with other diseases.

[Perspective of intensive care nursing staff on the limitation of life support treatment]. / Perspectiva de los profesionales de enfermería de unidades de cuidados intensivos sobre la limitación del tratamiento de soporte vital.

OBJECTIVE: To determine the perspective of intensive care nursing staff on the limitation of life support treatment (LLST) in the Intensive Care Units. METHOD: An exploratory qualitative study was carried out by applying the theory of Strauss and Corbin as the analysis tool. Constructivist paradigm. POPULATION: Nursing staff from three Intensive Care Units of Hospital Universitari de Bellvitge. Convenience sampling to reach theoretical saturation of data. Data collection through semi-structured interview recorded prior to informed consent. Rigor and quality criteria (reliability, credibility, transferability), and authenticity criteria: reflexivity. Demographic data was analysed using Excel. RESULTS: A total of 28 interviews were conducted. The mean age of the nurses was 35.6 years, with a mean seniority of 11.46 years of working in ICU. A minority of nurses (21.46%) had received basic training in bioethics. The large majority (85.7%) believe that LLST is not a common practice due to therapeutic cruelty and poor management with it. There is a correlation with the technical concepts; but among the main ethical problems is the decision to apply LLST. Nurses recognise that the decision on applying LLST depends on medical consensus with relatives, and they believe that their opinion is not considered. Their objective is trying to avoid suffering, and assist in providing a dignified death and support to relatives. CONCLUSIONS: There is still a paternalistic pattern between the doctor and patient relationship, where the doctor makes the decision and then agrees with the relatives to apply LLST. Organ failure and poor prognosis are the most important criteria for applying LLST. It is necessary to develop a guide for applying LLST, emphasising the involvement of nurses, patients, and their relatives.

Valoración ética de la craneoplastia con vendaje compresivo como forma de limitación de tratamientos de soporte vital / Valoração ética da cranioplastia com curativo compressivo como forma de limitação de tratamentos de suporte vital / Ethical value of cranioplasty with oppressive binder as a way of limiting life support treatments

Este artículo analiza, desde una postura crítica, la utilización de la craneoplastia de compresión con vendaje como método de limitación de tratamiento de soporte vital (LTSV). Con esta técnica activa, algunos autores han propuesto provocar la muerte encefálica, posibilitando la donación de órganos. Al contrastar este procedimiento con las recomendaciones del documento de consenso sobre el tratamiento al final de la vida del paciente crítico, elaborado por el grupo de bioética de la SEMICYUC, se comprueba que los medios y fines de esta técnica no encajan con las actuaciones propias de la LTSV, que se basan en la retirada de medios de soporte vital o en su no inicio, al considerar dichos medios desproporcionados o extraordinarios en algunos casos, evitando así la obstinación terapéutica. La definición de LTSV permite clarificar los límites en los que, de un modo éticamente correcto y consensuado, las actuaciones al final de la vida se circunscriben a los fines de la medicina, evitando la sospecha de que dichas actuaciones puedan ser malinterpretadas como justificación para una obtención de órganos abusiva. El artículo concluye que la provocación directa de la muerte encefálica mediante la técnica de craneoplastia con vendaje no parece cumplir los criterios propios de la LTSV.

This article analyzes, from a critical perspective, the use of cranioplasty with oppressive binder as a method to limit life support treatment (LLST). Some authors have proposed that this active technique provokes encephalic death, allowing organ donation. Contrasting this procedure with the recommendations of the consent document about treatment of critical patients at the end of life, elaborated by the bioethics group of SEMICYUC, it is shown that the means and ends of this technique do not match with the proper actions of LLST, based on the withdrawal of life support means or in not starting them, considering such means disproportionate or extraordinary in some cases, thus avoiding the therapeutic obstinacy. The definition of LLST allows to clarify the limits in which, in a way ethically fair and with a consensus, the acts at the end of life are included in the medical goals, avoiding the suspicion that these acts may be misinterpreted as justifying an abusive extraction of organs. This article concludes that the direct provocation of encephalic death by the technique of cranioplasty with binder does not appear to fulfill the criteria proper of LLST.

Este artigo analisa, a partir de uma postura crítica, a utilização da cranioplastia de compressão com curativo como método de limitação de tratamento de suporte vital (LTSV). Com esta técnica ativa, alguns autores têm proposto provocar a morte encefálica, possibilitando a doação de órgãos. Ao contrastar este procedimento com as recomendações do documento de consenso sobre o tratamento do final de vida do paciente crítico, elaborado pelo grupo de bioética da SEMICYUC, se comprova que os meios e fins desta técnica não encaixam com as atuações próprias da LTSV, que se baseiam na retirada de meios de suporte vital ou em seu não início, ao considerar os ditos meios desproporcionados ou extraordinários em alguns casos, evitando assim a obstinação terapêutica. A definição de LTSV permite esclarecer os limites nos quais, de um modo eticamente correto e aceito, as atuações ao final da vida se circunscrevem às finalidades da medicina, evitando a suspeita de que ditas atuações podem ser mal interpretadas como justificativa para uma obtenção de órgãos abusiva. O artigo conclui que a provocação direta da morte encefálica mediante a técnica da cranioplastia com curativo não parece cumprir os critérios próprios da LTSV.