BACKGROUND: Life-sustaining treatment limitation (LSV) is the medical act of withdrawing or not initiating measures that are considered futile in a patient\'s specific situation. LSV in critically ill patients remains a difficult topic to study, due to the multitude of factors that condition it.
OBJECTIVE: To determine factors related to LSV in ICU in cases of post-ICU in-hospital mortality, as well as factors associated with survival after discharge from ICU.
METHODS: Retrospective longitudinal study.
UNASSIGNED: Intensive care unit of a tertiary hospital.
METHODS: People who died in the hospitalization ward after ICU treatment between January 2014 and December 2019.
METHODS: None. This is an observational study.
METHODS: Age, sex, probability of death, type of admission, LSV in ICU, oncological disease, dependence, invasive mechanical ventilation, emergency hemodialysis, transfusion of blood products, nosocomial infection (NI), pre-ICU, intra-ICU and post-ICU stays.
RESULTS: Of 114 patients who died outside the ICU, 49 had LSV registered in the ICU (42.98%). Age and stay prior to ICU admission were positively associated with LSV (OR 1,03 and 1,08, respectively). Patients without LSV had a higher post-ICU stay, while it was lower for male patients.
CONCLUSIONS: Our results support that LSV established within the ICU can avoid complications commonly associated with unnecessary prolongation of stay, such as NI.

暂无摘要。

UNASSIGNED: \"Futility\" is a common concept and terminology used in healthcare. This article uses a 2021 case to explore the concept and use of \"futility\" by considering its critiques. This article also discusses alternative ways to more clearly communicate concerns about medically harmful or inappropriate and non-beneficial uses of life-sustaining treatments.

Following COVID and the subsequent blood shortage, several investigators evaluated futility cut points in massive transfusion. We hypothesized that early aggressive use of damage-control resuscitation, including whole blood (WB), would demonstrate that these cut points of futility were significantly underestimating potential survival among patients receiving >50 U of blood in the first 4 hours.
Adult trauma patients admitted from November 2017 to October 2021 who received emergency-release blood products in prehospital or emergency department setting were included. Deaths within 30 minutes of arrival were excluded. Total blood products were defined as total red blood cell, plasma, and WB in the field and in the first 4 hours after arrival. Patients were first divided into those receiving ≤50 or >50 U of blood in the first 4 hours. We then evaluated patients by whether they received any WB or received only component therapy. Thirty-day survival was evaluated for all included patients.
A total of 2,299 patients met the inclusion criteria (2,043 in ≤50 U, 256 in >50 U groups). While there were no differences in age or sex, the >50 U group was more likely to sustain penetrating injury (47% vs. 30%, p < 0.05). Patients receiving >50 U of blood had lower field and arrival blood pressure and larger prehospital and emergency department resuscitation volumes ( p < 0.05). Patients in the >50 U group had lower survival than those in the ≤50 cohort (31% vs. 79%; p < 0.05). Patients who received WB (n = 1,291) had 43% increased odds of survival compared with those who received only component therapy (n = 1,008) (1.09-1.87, p = 0.009) and higher 30-day survival at transfusion volumes >50 U.
Patient survival rates in patients receiving >50 U of blood in the first 4 hours of care are as high as 50% to 60%, with survival still at 15% to 25% after 100 U. While responsible blood stewardship is critical, futility should not be declared based on high transfusion volumes alone.
Therapeutic/Care Management; Level III.

Patients with penetrating head trauma that crosses the midline of the brain have a high mortality rate; most die in the prehospital setting or during initial resuscitative efforts. However, surviving patients are often neurologically intact and several factors other than bullet path, including post-resuscitation Glasgow Coma Scale, age, and pupillary abnormalities, must be considered in aggregate when prognosticating patients.
We present a case of an 18-year-old man who presented unresponsive after a single gunshot wound to the head that traversed the bilateral hemispheres. The patient was managed with standard care and without surgical intervention. He was discharged from the hospital neurologically intact 2 weeks after his injury. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients with such apparently devastating injuries are at risk of premature termination of aggressive resuscitative efforts based on clinician bias that these efforts are futile and that patients cannot recover to a neurologically meaningful outcome. Our case reminds clinicians that patients with severe injury patterns with bihemispheric involvement can recover with good outcomes, and that bullet path is only one variable among multiple that must be considered to predict clinical outcome.

This article addresses a common yet rarely discussed aspect of hospital care-a pro-active approach to ethical dilemmas. Potential ethical conflicts often present warning signs to clinicians, analogous to the warning lights on a car\'s dashboard. Using a recent case study, a commonly encountered clinical decision-a conflict about whether to terminally extubate a critically ill patient versus whether to offer a tracheostomy-we describe a pro-active approach to ethical conflicts and outline three learning objectives: (1) the need for a robust understanding of the term \"futility,\" (2) the need for an appreciation the various and often conflicting interpretations of \"improved/improving,\" and (3) the need to understand the challenges of surrogate decision making.

In 2017, the court case over medical treatment of UK infant, Charlie Gard, reached global attention. In this article, I will analyze one of the more distinctive elements of the case. The UK courts concluded that treatment of Charlie Gard was not in his best interests and that it would be permissible to withdraw life-sustaining treatment. However, in addition, the court ruled that Charlie should not be transferred overseas for the treatment that his parents sought, even though specialists in Italy and the US were willing to provide that treatment. Is it ethical to prevent parents from pursuing life-prolonging treatment overseas for their children? If so, when is it ethical to do this? I will outline arguments in defense of obstructing transfer in some situations. I will argue, however, that this is only justified if there is good reason to think that the proposed treatment would cause harm.

OBJECTIVE: To independently assess quality of care among patients who died in hospital and whose next-of-kin submitted a letter of complaint and make comparisons with matched controls. To identify whether use of a treatment escalation limitation plan (TELP) during the terminal illness was a relevant background factor.
METHODS: The study was an investigator-blinded retrospective case-note review of 42 complaints cases and 72 controls matched for age, sex, ward location and time of death.
METHODS: The acute medical and surgical wards of three District General Hospitals administered by NHS Lanarkshire, Scotland.
METHODS: None.
METHODS: None.
METHODS: Quality of care: clinical \'problems\', non-beneficial interventions (NBIs) and harms were evaluated using the Structured Judgment Review Method. Complaints were categorized using the Healthcare Complaints Analysis Tool.
RESULTS: The event frequencies and rate ratios for clinical \'problems\', NBIs and harms were consistently higher in complaint cases compared to controls. The difference was only significant for NBIs (P = 0.05). TELPs were used less frequently in complaint cases compared to controls (23.8 versus 47.2%, P = 0.013). The relationship between TELP use and the three key clinical outcomes was nonsignificant.
CONCLUSIONS: Care delivered to patients at end-of-life whose next-of-kin submitted a complaint was poorer overall than among control patients when assessed independently by blinded reviewers. Regular use of a TELP in acute clinical settings has the potential to influence complaints relating to end-of-life care, but this requires further prospective study.

UNASSIGNED: Withdrawal of treatment is a common practice in critical care settings, perticularly when treatment is considered futile. The case study demonstrates an ethical dilemma, in which Danny is unlikely to make a functional recovery because of multiple organ dysfunction syndromes. Under such a circumstance, withdrawal of treatment will inevitably be considered, although his family refused to do so. Consequently, acritical question must be answered: Who should make the decision?
UNASSIGNED: Danny decided to withdraw the use of life-support, whilst his wife and adult children refused to do so. The ethical dilemma is illustrated by the following question: Who decides the withdrawal of treatment in a critical care setting?
UNASSIGNED: To provide an opotional solution to this case and make the best moral decision, the current study will critically discuss this issue in conjunction with ethical principles, philosophical theories and the values statement of the European and Chinese nurses\' codes of ethics. Additionally, the associated literature relative to this case are analysed before the decision-making.
UNASSIGNED: The best ethical decision is Danny can decide whether to withhold or withdraw life-sustaining treatment. If his family is involved in the discussion, the medical staff should balance the ethical principles when they make the decision and allocate reasonable resources for patients.
UNASSIGNED: In Danny\'s case, health professionals opted to respect his decision to withdraw treatment. The medical staff maintained an effective communication with the family involved, and provided the appropriate intervention to collaborate with other health care professionals to perfect further care.

Recently, the Portuguese Parliament discussed four proposals aimed at allowing some forms of medically assisted death. However, all of them were rejected by the majority. Therefore, doctors who in some way accelerate a patient\'s death risk being convicted of the crime of homicide. Portuguese law provides some legal mechanisms that can exempt a doctor from criminal liability, such as causes excluding the conduct\'s wrongfulness, and causes excluding the doctor\'s culpability. Other elements to take into consideration are a proper interpretation of homicide crimes, thereby excluding conducts without the intent to kill; the relevance of patient consent; and the rejection of medical futility. This article explains how a doctor may not be held criminally accountable for medically assisted death, even in restrictive jurisdictions such as the Portuguese one.