Evidence in Intensive Care - ethics and mental health

Systematic reviews and meta-analyses in blue
Other high impact trials in red

Factors influencing consent for organ donation.
BMJ 2009;339:b991

6 modifyable factors identified (greatest 2 in bold italics)

Adequate information during the request
Perceived quality of care.
Understanding of brainstem death.
Timing of the request (separating notification of death from request for donation).
Setting (in private)
Expertise of person making request

NB consent higher when donor coordinator involved in request.
Studies were all observational so related factors might not be causative.
ACRE trial awaited – collaborative requesting.

Perceptions of appropriateness of care.
JAMA 2011

Perception of inappropriate care in 27%.
These did not seem to represent objective assessments but rather reflect aspects of the practice environment and individual beliefs.

Recommendations to limit life support: a national survey of critical care physicians.
Brush et al: Am J Respir Crit Care Med 2012; 186: 633–639.

Shalowitz et al. The accuracy of surrogate decision makers. A systematic review. Arch Intern Med 2006;166: 493-497.
Surrogates do not necessarily know or correctly predict patients wishes.
Kelly B et al. Systematic review: Individuals’ goals for surrogate decision-making. J Am Geriatric Soc 2012;60:884-895
Patients do want their relatives to be involved in end of life decisions

PTSD and depression in relatives of those who die.
Chest 2011;139:795-801
PTDS and depression 6 months later high 14% and 18%.
Increased PTSD when early family conference and when present at death (reasons especially for 1
st unclear).
Less depression when treatment withdrawal (agrees with other research) - more communication with doctors? No sense of failure compared to dying despite everything being done?

Communication of prognosis
Numerical descriptors (10% chance survival) no better than qualitative (very likely to die) no different in terms of surrogates understanding of prognosis.
Surrogates tended to have more optimistic view than that presented by the physician.
This discordance reduced if trusted the doctor.