Factors that influence the institution of ceilings of treatment in the Emergency Department
Date First Published:
March 6, 2017
Last Updated:
March 6, 2017
Report by:
Nathan Walzl, Medical Student (University of Glasgow)
Search checked by:
Olivia Villegas, David J Lowe, University of Glasgow
Three-Part Question:
In adult patients who present [with critical illness in the emergency department] what are the [factors that influence] the institution of [ceilings of treatment].
Clinical Scenario:
An 84 year old man presents to your Emergency Department with septic shock. He has a long list of medications, but you learn from his medical notes that he is normally independent at home. You need to decide what level of intervention is in this patient’s best interests. What factors should you consider in order to institute an appropriate ceiling of treatment for this patient?
Search Strategy:
MEDLINE – 1948 to Present with Daily Update
[Terminal Care/ OR End of Life.mp. OR ceilings adj2 care.mp. OR Palliative Care/ OR Treatment adj Limiting.mp. OR Withdrawing treatment.mp. OR Withholding Treatment/ OR Resuscitation/ OR Cardiopulmonary Resuscitation/ OR Resuscitation orders/ OR Advance Directives/ OR Advance Care Planning/] AND [Decision Making/ OR Attitude/ OR Attitude of Health Personnel/ OR Establishing.mp. OR (Practice Guideline as Topic/] AND [Emergency Medicine/ OR Accident and Emergency.mp. OR Emergency Physician.mp. OR Emergency Service, Hospital]
EMBASE – 1974 to 2016 November 29
[End adj2 Life.mp OR Ceilings adj2 Care.mp. OR Palliative Therapy/ OR Treatment adj Limiting.mp. OR Withdrawing adj Treatment.mp. OR Withholding adj Treatment.mp. OR Resuscitation/ OR Advance Directive.mp. OR Living Will/ OR Advance Care Planning.mp.] AND [Decision Making/ OR Health Personnel Attitude/ OR Attitude.mp. OR Establishing.mp. OR Practice Guideline/] AND [Emergency Medicine/ OR Accident and Emergency.mp. OR Emergency Physician/ OR Emergency Health Service/]
[Terminal Care/ OR End of Life.mp. OR ceilings adj2 care.mp. OR Palliative Care/ OR Treatment adj Limiting.mp. OR Withdrawing treatment.mp. OR Withholding Treatment/ OR Resuscitation/ OR Cardiopulmonary Resuscitation/ OR Resuscitation orders/ OR Advance Directives/ OR Advance Care Planning/] AND [Decision Making/ OR Attitude/ OR Attitude of Health Personnel/ OR Establishing.mp. OR (Practice Guideline as Topic/] AND [Emergency Medicine/ OR Accident and Emergency.mp. OR Emergency Physician.mp. OR Emergency Service, Hospital]
EMBASE – 1974 to 2016 November 29
[End adj2 Life.mp OR Ceilings adj2 Care.mp. OR Palliative Therapy/ OR Treatment adj Limiting.mp. OR Withdrawing adj Treatment.mp. OR Withholding adj Treatment.mp. OR Resuscitation/ OR Advance Directive.mp. OR Living Will/ OR Advance Care Planning.mp.] AND [Decision Making/ OR Health Personnel Attitude/ OR Attitude.mp. OR Establishing.mp. OR Practice Guideline/] AND [Emergency Medicine/ OR Accident and Emergency.mp. OR Emergency Physician/ OR Emergency Health Service/]
Search Details:
[Terminal Care/ OR End of Life.mp. OR ceilings adj2 care.mp. OR Palliative Care/ OR Treatment adj Limiting.mp. OR Withdrawing treatment.mp. OR Withholding Treatment/ OR Resuscitation/ OR Cardiopulmonary Resuscitation/ OR Resuscitation orders/ OR Advance Directives/ OR Advance Care Planning/] AND [Decision Making/ OR Attitude/ OR Attitude of Health Personnel/ OR Establishing.mp. OR (Practice Guideline as Topic/] AND [Emergency Medicine/ OR Accident and Emergency.mp. OR Emergency Physician.mp. OR Emergency Service, Hospital]
[End adj2 Life.mp OR Ceilings adj2 Care.mp. OR Palliative Therapy/ OR Treatment adj Limiting.mp. OR Withdrawing adj Treatment.mp. OR Withholding adj Treatment.mp. OR Resuscitation/ OR Advance Directive.mp. OR Living Will/ OR Advance Care Planning.mp.] AND [Decision Making/ OR Health Personnel Attitude/ OR Attitude.mp. OR Establishing.mp. OR Practice Guideline/] AND [Emergency Medicine/ OR Accident and Emergency.mp. OR Emergency Physician/ OR Emergency Health Service/]
[End adj2 Life.mp OR Ceilings adj2 Care.mp. OR Palliative Therapy/ OR Treatment adj Limiting.mp. OR Withdrawing adj Treatment.mp. OR Withholding adj Treatment.mp. OR Resuscitation/ OR Advance Directive.mp. OR Living Will/ OR Advance Care Planning.mp.] AND [Decision Making/ OR Health Personnel Attitude/ OR Attitude.mp. OR Establishing.mp. OR Practice Guideline/] AND [Emergency Medicine/ OR Accident and Emergency.mp. OR Emergency Physician/ OR Emergency Health Service/]
Outcome:
Using MEDLINE the search strategy identified 332 articles, of which 7 were found to be of sufficient quality and relevance to the topic to be included.
Using EMBASE the search strategy identified 1734 articles, of which 1 was found to be of sufficient quality and relevance to the topic to be included.
Using EMBASE the search strategy identified 1734 articles, of which 1 was found to be of sufficient quality and relevance to the topic to be included.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Do-not-resuscitate orders in the emergency department Wrenn, K. Brody, S. L. 1992 United States | 37 consecutive adult patients for whom a DNR order was issued during the author’s shifts in the ED of a hospital in Atlanta over a 10 month period (1987-1988). | Prospective single-centre case series with collection and analysis of patient data. | Analysis of characteristics for patients assigned a DNR order including: patient age, acute and chronic problems, prior DNR orders and capacity. | •tElderly (overall mean age 70) otSubset (32% of patients) were younger (mean age 54) and critically ill with malignancy or AIDS. •tChronic disease & comorbidity (uniformly present) otDementia (46%), decubitus ulcers (41%), malignancy (24%), stroke (19%), chronic renal failure (11%), AIDS (8%), chronic heart disease (8%), chronic neurologic disease (5%), malnutrition (5%), alcoholism (3%). •tAcute disease otSepsis (59%), coma (49%), hypotension (49%), respiratory failure (16%), dehydration (11%), hypothermia (8%), congestive heart failure, stroke, status epilepticus, acute MI, severe anaemia, hyponatraemia (3%) each. •t14% of patients had capacity •t14% of patients had prior DNR orders | Small sample size. Only represents those patients for whom the authors initiated a DNR order, introducing a large potential for bias. This study only looks at DNR orders, a subset of treatment limiting decisions. Does not provide comparison group. |
| Withholding and withdrawing life-support therapy in an Emergency Department: prospective survey Le Conte, Philippe Baron, Denis Trewick, David Touzé, Marie Dominique Longo, Céline Vial, Irshaad Yatim, Danielle Potel, Gille 2004 France | All non-trauma patients (n= 119) for whom a decision to withhold (WH) or withdraw (WD) life-sustaining treatment was taken by senior staff in a French ED between January and September 1998. | Prospective single-centre survey. When making a WH/WD decision, physicians were required to justify it by choosing from 17 pre-defined criteria. Patient characteristics were also recorded. |
Predefined criteria used to justify treatment limiting decision | •tMean of 6±2 criteria chosen per case. ‘Expected quality of life unacceptably poor’ was never chosen alone. otPrincipal acute medical disorder (83%) otIrreversibility of acute disorder in the first 24h (60%) otLevel of care considered maximal (59%) otSeverity of illness using scoring systems (40%) otVegetative state (40%) otPost-morbid expected quality of life unacceptably poor (39%) otUnderlying disease expected to be fatal within 6 months (37%) otAge (24%) otUnderlying chronic debilitating disease (22%) otChoice of patient (8%) | Single centre study, exclusion of trauma patients. Pre-defined list of criteria used to justify treatment limiting decisions limits the range of identifiable factors. |
| Analysis of characteristics for patients in whom a WH/WD decision was made. | •tElderly (mean age 75 years) •tChronic disease (77%) otCause of acute presentation in 56% of patients •tAcute disease otNeurological (38%), cardiovascular (24%), respiratory (17%), digestive (14%), cancer (14%) •tSeverity of illness otPrognosis of underlying disease tFatal within 5 years (35%), fatal within 1 year (40%) otOrgan system failure score of >3 (14%) otMean SAPS score of 14 (indicating expected 30% mortality rate) •tFunctional limitation otNone to moderate (42%), severe (53%) •t73% of patients judged unable to enter the decision making process | ||||
| A five-step protocol for withholding and withdrawing of life support in an emergency department: an observational study Sedillot, N. Holzapfel, L. Jacquet-Francillon, T. Tafaro, N. Eskandanian, A. Eyraud, S. Metton, P. Prost, S. Serre, P. Souton, L. 2008 France | All adult patients admitted to a French general hospital ED in a one year period between 2004-2005 who did not already have a treatment limiting decision in place (98 patients – 1.5% of admission). | Prospective observational study. Pattern of treatment limitation chosen from a five step protocol ranging from no limitation to active withdrawal of life support. | Characteristics of patients in whom a WD/WH decision was made | •tElderly (mean age 82 years). •tChronic disease (95%) otDementia (39%), cardiac insufficiency (34%), cancer (32)%, neurological disease (21%), COPD (6%), chronic renal failure (5%), psychiatric disorders (4%). •tAcute organ failure was observed at admission in 82%. Physicians preferred choose a pattern of treatment limitation (83%) rather than treatment withdrawal as they were not seen as ethically equivalent. | Single centre study. Does not attempt to identify reasons for WD/WH life support. |
| Death in emergency departments: a multicenter cross-sectional survey with analysis of withholding and withdrawing life support Le Conte, Philippe Riochet, David Batard, Eric Volteau, Christelle Giraudeau, Bruno Arnaudet, Idriss Labastire, Laetitia Levraut, Jacques Thys, Frédéric Lauque, Dominique Piva, Claude Schmidt, Jeannot 2010 France | All patients who died in 174 EDs in France and Belgium over two 2-month periods in 2004/2005 were enrolled (n= 2512), 1907 of whom had a treatment WD/WH decision made. | Prospective cross-sectional survey. Physicians were required to justify WD/WH decisions from 9 predefined criteria. Patient characteristics were recorded, including whether a WD/WH decision was made. A logistic regression model for treatment limiting decisions was created. | Predefined criteria used to justify treatment limiting decision | •tMean of 3±3 criteria chosen per case. Neither ‘Expected quality of life unacceptably poor’ nor ‘age’ were ever chosen alone. otPrincipal acute presenting medical disorder (77%) otIrreversibility of acute disorder in the first 24h (54%) otAge (39%) otPrevious functional limitation (38%) otUnderlying chronic disease (35%) otAbsence of improvement following active treatment (26%) otRecovery but expected quality of life unacceptably poor (25%) otUnderlying disease expected to be fatal within 6 months (20%) otLevel of care considered to be maximal (17%). | 37% of patients were transported to the ED by mobile intensive care units staffed by physicians. May limit transferability of findings to other systems. Seasonal variation of study population. Pre-defined list of criteria used to justify treatment limiting decisions limits the range of identifiable factors. |
| Patient factors associated with level of care limitation | •tOld age (71-81 OR 1.6, 81-88 OR 2.51, >88 OR 3.27). •tChronic disease otImmunodeficiency OR 1.9, liver disease OR 2.18, metastatic cancer OR 2.34. •tPrincipal acute presenting disorder otBrain haemorrhage OR 2.62, neurologic OR 1.91, respiratory OR 1.61, cardiovascular OR 0.63, traumatic 0.34. •tSevere functional limitation otKnauss C (OR 3.54) and Knauss D ( OR 5.84) •t92% of patients unable to enter decision making process. | ||||
| Ethical arguments for limiting life support | Futility of care (57.6%), age (35.6%), physical pain (18.9%), psychological pain (11.1%), DNR order issued by patient or transmitted by relative (6.3%). | ||||
| Physicians' impression on the elders' functionality influences decision making for emergency care Rodriguez-Molinero, A. Lopez-Dieguez, M. Tabuenca, A. I. de la Cruz, J. J. Banegas, J. R. 2010 Spain | 101 randomly selected elderly patients (>80 or 65-79 with ≥ 2 comorbid conditions) admitted to the ED, and their respective physicians. Selected patients did not need intensive care treatment at the time of the study, which took place in 2003 over 5 months in 4 Spanish hospitals. | Cross-sectional study. Reasons underpinning WH/WD decisions were recorded via open-ended questionnaires. Patient cognitive/functional status was recorded. | Physician-reported factors taken into account during decision making | •tPrior functional status (69%), •tAge (42%), •tPatient’s pathologic background (30%), •tCurrent disease (18%), •tPrior mental status (10%), •tSubjective assessment of quality of life (4%), •t Family or patient preferences (2%), •tSocial status (2%) •tMoral considerations (1%). | Based on hypothetical events. Small sample size. Only ‘elderly’ population included. Large proportion of participating physicians were trainees. |
| Patient factors associated with decisions to administer intensive treatment (CPR, ICU/CCU referral) | •tFunctional status as perceived by physician ot (CPR administration OR 1.97, ICU/CCU referral OR 4.09/4.32) •tCognitive function as perceived by physician ot(ICU referral OR 15.38) •tAge ot(ICU/CCU referral OR 0.86/0.76). | ||||
| Treatment-limiting decisions, comorbidities, and mortality in the emergency departments: a cross-sectional elderly population-based study de Decker, L. Beauchet, O. Gouraud-Tanguy, A. Berrut, G. Annweiler, C. Le Conte, P. 2012 France | Data from LeConte et al. (2010) used. Exclusion criteria were age <65. N=2095 | Prospective cross-sectional survey. Post-hoc analysis of medical notes to calculate the Charlson Comorbidity Index (CCI)’s association with treatment WH/WD decisions. A logistic regression model for treatment limiting decisions was created. | Patient factors associated with a treatment limiting decision. | •tComorbidities ot CCI ≥5 (OR 25.56), •tAge ot ≥ 85 (OR 20.00) •tHaematological disease ot (OR 6.92). •tFactors found to be protective from treatment limiting decisions otLiving in an institution (OR 0.15), having respiratory disease (OR 0.17), neurologic causes of organ failure (OR 0.2) | All included patients died in the ED introducing the potential for bias. CCI was a post-hoc calculation. |
| Emergency clinicians' attitudes and decisions in patient scenarios involving advance directives Wong, R. E. Weiland, T. J. Jelinek, G. A. 2012 Australia | 388 surveys distributed to fellows (190) and trainees (176) by the Australasian College for Emergency Medicine in 2010 with 13% response rate. | Online survey eliciting level of treatment decisions in 3 hypothetical clinical scenarios before and after the introduction of an Advance Directive (AD). Participants also identified the factor that most influenced their treatment decision. | Study is based on hypothetical scenarios. Response rate is low (13%) so study may be subject to non-response bias. | ||
| Who Am I to Decide Whether This Person Is to Die Today? Physicians' Life-or-Death Decisions for Elderly Critically Ill Patients at the Emergency Department-ICU Interface: A Qualitative Study Fassier, T. Valour, E. Colin, C. Danet, F. 2016 France | 15 ED physicians and 9 ICU physicians interviewed over a one year period in 2010 in France. Data was collected across 8 units in 2 hospitals | Qualitative study. Non-participant observations identified physicians making end-of-life decisions. They were subsequently interviewed and thematic analysis was carried out. | Patient factors | •tAge otPhysiologic age preserved/altered otOld age thresholds (<70, 70 to 80-85, >85) •tInformation on patient’s EOL preference otPresence/absence of information or advance directives •tFamily-related factors otPresence/absence of family, conflicts | May have limited transferability of results outside France due to legal/ethical/healthcare system differences, potentially leaving influential factors unexplored in interviews. |
| Physician factors | •tExperience and training in EOL decision making •tPhysician’s positive/negative age-related stereotypes of elderly •tPhysician’s familial experience of ageing | ||||
| Time/resource factors | •tHeterogeneous terminology and unclear acronyms in patient notes. •tUnit-related factors otED vs step-down vs short-stay units •tTiming-related factors otTime available, handoffs, night/weekend shifts, leadership changes |
Author Commentary:
8 papers aiming to identify factors that influence ceiling of treatment decisions in the ED were included in this review. There was considerable variation in the terminology used to define the patient group including ceilings of treatment, treatment limiting and ceilings of care. The heterogeneity in study type and results perhaps reflecting this variation of both definition and methodology but also the nature of this challenging clinical issue. Observational studies identified factors that can be broadly categorised into patient-related factors (of which the most recurring were age, chronic disease and severe functional disability) and disease-related factors (of which the most recurring were severity of acute disorder, incurable disease and absence of improvement following a period of active treatment). Qualitative methods elucidated a number of factors which reflect the complexity of end of life decisions, including physician, timing and resource related factors.
Bottom Line:
It is difficult to pinpoint the factors that influence the institution of ceilings of care in the ED, but they can be loosely subdivided into patient, disease, physician, unit and timing factors. How these factors are combined, their weighting and influence on the decision to institute ceilings of care is variable. The decision to institute a ceiling of care is complex and the clinician should be cognizant of these factors and their associated biases.
Although challenging, the formulation of a set criteria of patient/disease related factors could act as a guide for physicians making end of life decisions in the ED.
Although challenging, the formulation of a set criteria of patient/disease related factors could act as a guide for physicians making end of life decisions in the ED.
References:
- Wrenn, K. Brody, S. L.. Do-not-resuscitate orders in the emergency department
- Le Conte, Philippe Baron, Denis Trewick, David Touzé, Marie Dominique Longo, Céline Vial, Irshaad Yatim, Danielle Potel, Gille. Withholding and withdrawing life-support therapy in an Emergency Department: prospective survey
- Sedillot, N. Holzapfel, L. Jacquet-Francillon, T. Tafaro, N. Eskandanian, A. Eyraud, S. Metton, P. Prost, S. Serre, P. Souton, L.. A five-step protocol for withholding and withdrawing of life support in an emergency department: an observational study
- Le Conte, Philippe Riochet, David Batard, Eric Volteau, Christelle Giraudeau, Bruno Arnaudet, Idriss Labastire, Laetitia Levraut, Jacques Thys, Frédéric Lauque, Dominique Piva, Claude Schmidt, Jeannot. Death in emergency departments: a multicenter cross-sectional survey with analysis of withholding and withdrawing life support
- Rodriguez-Molinero, A. Lopez-Dieguez, M. Tabuenca, A. I. de la Cruz, J. J. Banegas, J. R.. Physicians' impression on the elders' functionality influences decision making for emergency care
- de Decker, L. Beauchet, O. Gouraud-Tanguy, A. Berrut, G. Annweiler, C. Le Conte, P.. Treatment-limiting decisions, comorbidities, and mortality in the emergency departments: a cross-sectional elderly population-based study
- Wong, R. E. Weiland, T. J. Jelinek, G. A.. Emergency clinicians' attitudes and decisions in patient scenarios involving advance directives
- Fassier, T. Valour, E. Colin, C. Danet, F.. Who Am I to Decide Whether This Person Is to Die Today? Physicians' Life-or-Death Decisions for Elderly Critically Ill Patients at the Emergency Department-ICU Interface: A Qualitative Study