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Palliative/End of Life Care in the ICU

Society Statements & Guidelines

Truog RD, Campbell ML, Curtis JR, et al. Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College of Critical Care Medicine. Crit Care Med 2008; 36:953-63. Provides an overview of ethical issues as well as a compassionate approach to practical aspects of end-of-life care.

PMID: 18431285

Lanken PN, Terry PB, DeLisser HM, et al. An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses. Am J Respir Crit Care Med 2008;177:912-27. Overlap with above ACCM statement but offers additional worthwhile discussion of hospice eligibility and on timing and settings for palliative care.

PMID: 18390964

Bosslet, GT, Pope T, Rubenfeld GD, et al. An official ATS/AACN/ACCP/ESICM/SCCM policy statement: Responding to requests for potentially inappropriate treatments in intensive care units. Am J Respir Crit Care Med 2015; 191:1318-1330. This consensus statement differentiates between the terms, “futile”, and, “potentially inappropriate”, reserving the former for when “surrogates request interventions that simply cannot accomplish their intended physiologic goal.” They also recommend implementing proactive strategies to prevent conflict at the institutional level, while engaging the public to implement change at the health policy and legislative level.

PMID: 25978438

End of Life Discussions with Patients and Families

Clinical Trials

White DB, Angus DC, Shields AM et al. A randomized trial of a family-support intervention in intensive care units. N Engl J Med. 2018; 378:2365-2375. Cluster-randomized trial involving the surrogates of 1,400 patients with a high risk of death compared a nurse-led multicomponent family-support intervention to usual care. The intervention did not significantly affect the surrogates' burden of psychological symptoms, but did improve surrogates' ratings of the quality of communication and patient- and family-centeredness of care. Of note, the length of ICU stay was 0.7 days shorter in the intervention group (p = .045) but 6-month mortality did not differ, suggesting the intervention did not lead to premature transition to comfort care.

PMID: 29791247

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Carson S, Cox C, Wallenstein S, et al. Effect of palliative care–led meetings for families of patients with chronic critical illness: a randomized clinical trial. JAMA. 2016; 316:51-62. This trial of usual care (ICU-led family meetings + brochure) vs Palliative Care-led conferences + brochure for patients with chronic critical illness and their families found no difference in family anxiety or depression. The Palliative Care intervention group may have increased risk of PTSD. The authors conclude that routine palliative care consult is not indicated, but remains important for select cases.

PMID: 27380343

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Detsky ME, Harhay MO, Bayard DF, et al. Discriminative accuracy of physician and nurse predictions for survival and functional outcomes 6 months after an ICU admission. JAMA. 2017; 317: 2187-2195. Prospective cohort study of 303 critically ill patients in which the discriminative accuracy of intensive care unit physicians and nurses in predicting 6-month patient mortality and morbidity was examined. As might be expected, when providers had low confidence in their decision, prognostic accuracy was poor. However, when confidence was high (particularly if both nurses and intensivists agreed), the prognostic accuracy was quite good.  These findings can be useful for framing goals of care discussions.

PMID: 28528347

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Practical Guidance

Scheunemann LP, Arnold RM, White DB. The facilitated values history: helping surrogates make authentic decisions for incapacitated patients with advanced illness. Am J Respir Crit Care Med. 2012;186:480-6 This article offers a practical framework for how best to assist surrogate decision-makers with the challenge of determining, and applying, patients’ values to medical decision-making in this population.

PMID: 22822020

Billings JA, Block SD. The end-of-life family meeting in intensive care part III: A guide for structured discussions. J Palliat Med 2011; 14:1058-64. Offers an explicit step-by-step blueprint for approaching family conferences while recognizing the need for flexibility depending on family and patient circumstances. Provides sample language useful for navigating difficult aspects of decision-making.

PMID: 21910613

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Pleural Diseases

Pleural effusion

Light RW, MacGregor MI, Luchsinger PC, et al. Pleural effusions: the diagnostic separation of transudates and exudates. Ann Intern Med 1972;77:507-13. This paper is the basis for using pleural fluid LDH and protein to classify effusions as transudative or exudative.

PMID: 4642731

Lentz RJ, Lerner AD, Pannu JK, et al. Routine monitoring with pleural manometry during therapeutic large-volume thoracentesis to prevent pleural-pressure-related complications: a multicentre, single-blind randomised controlled trial. Lancet Respir Med. 2019; 7:447-455. This study randomized 124 patients with free-flowing effusions with estimated volume > 500 ml (63% with malignant effusion) to thoracentesis drainage based on symptoms alone vs. symptoms plus pleural manometry. There was no significant difference in chest discomfort, volume of fluid drained, proportion of patients with complete lung expansion, or clinically significant complications. Of note, the mean volume of fluid drained was 1,100 ml (SD 500 ml) and patients with known re-expandable lung, such as those with a large hepatic hydrothorax, were excluded.

PMID: 30772283


Pleural infection

Rahman NM, Maskell NA, West A et al. Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med. 2011;365:518-26. Randomized double blinded trial of 210 patients found an 8% greater reduction in the proportion of the hemithorax occupied by pleural fluid on chest radiograph with tissue plasminogen activator (TPA) and DNAse administered intrapleurally compared to placebo. TPA and DNAse used in isolation did not differ from placebo. Patients receiving placebo were more likely to be referred to surgery than the TPA-DNAse group, but the rate of surgical intervention and mortality did not differ.

PMID: 21830966

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Maskell NA, Davies CW, Nunn AJ et al. UK controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med 2005;352:865-74. This study of 454 patients randomly assigned to streptokinase or placebo is noteworthy for contradicting previous small studies supporting the use of lytics in complicated parapneumonic effusion. The study found no difference in mortality, need for surgery, radiographic outcome, or length of hospital stay.

PMID: 15745977

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Malignant pleural effusion

Feller-Kopman DJ, Reddy CB, DeCamp MM et al. Management of malignant pleural effusions. An Official ATS/STS/STR Clinical Practice Guideline. Am J Respir Crit Care Med. 2018; 198:839-849.

PMID: 30272503

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Thomas R, Fysh ETH, Smith NA, et al. Effect of an indwelling pleural catheter vs talc pleurodesis on hospitalization days in patients with malignant pleural effusion: The AMPLE randomized clinical trial. JAMA. 2017; 318:1903-1912. Trial of 146 patients with symptomatic malignant pleural effusion randomized to either indwelling pleural catheters (IPC) or talc pleurodesis and followed for up to 12 months. The IPC group spent significantly fewer days in hospital than the pleurodesis group (10.0 vs 12.0; P = .03) but without significant differences in improvements in breathlessness or quality of life.

PMID: 29164255

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Bhatnagar R, Piotrowska H, Laskawiec-Szkonter M, et al. Effect of thoracoscopic talc poudrage vs talc slurry via chest tube on pleurodesis failure rate among patients with malignant pleural effusions: a randomized clinical trial. JAMA 2020; 323:60-69. Open label clinical trial randomized 330 patients with malignant pleural effusion to receive talc poudrage during thoracoscopy versus bedside chest tube insertion followed by talc slurry. At 90 days, pleurodesis failure occurred in 22% of talc poudrage group versus 24% in talc slurry group (p=0.74).

PMID: 31804680

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Spontaneous pneumothorax

MacDuff A, Arnold A, Harvey J for the British Thoracic Society Pleural Disease Guideline Group. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax 2010;65(Suppl 2):ii18-ii31


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Hallifax RJ, McKeown E, Sivakumar P, et al. Ambulatory management of primary spontaneous pneumothorax: an open-label, randomised controlled trial. Lancet. 2020; 396:39-49. This study randomized 236 patients with primary spontaneous pneumothorax to either placement of an 8F catheter attached to a one-way valve followed by discharge if there was insufficient lung re-expansion vs. management based on BTS guidelines above. Enrollment criteria included pneumothorax > 2 cm from chest wall at the level of the hilum and/or significant symptoms. Although 12% of the ambulatory group subsequently required admission for a serious adverse event, this group overall had a lower median number of hospital days (0 days [IQR 0 – 3] vs. 4 days [IQR 0 -8]; p<0.0001).

PMID 32622394

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Brown SGA, Ball EL, Perrin K, et al. Conservative versus interventional treatment for spontaneous pneumothorax. N Engl J Med. 2020; 382:405-415. This trial randomized 316 patients with primary spontaneous pneumothorax > 32% of the hemithorax and without severe distress to conservative vs. interventional management. Conservative management entailed discharge if symptoms, pneumothorax size, and room air oxygen saturations were stable after 4 hours of observation. The intervention group received a small-bore catheter and were admitted unless the tube could be removed after 4 hours based on full lung re-expansion and absence of an air leak. In the conservative group, 85% did not require an intervention and, if excluding the 19% of patients lost to follow-up, conservative was non-inferior to interventional management (94.4% vs. 98.5% complete reexpansion at 8 weeks, respectively, p = 0.02). 

PMID: 31995689