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End-of-life care in the intensive care unit: Remarks on the Italian situation
Journal of Critical Care xxx (2016) xxx–xxx
Contents lists available at ScienceDirect
Journal of Critical Care journal homepage: www.jccjournal.org
End-of-life care in the intensive care unit: Remarks on the Italian situation To the Editor, Following your call for comments [1], we would like to underline a few points about the interesting WFSICCM Task Force (WFSICCM-TF) report on end-of-life (EoL) care in the intensive care unit (ICU) [2]. The document provides an exhaustive summary of the statements produced by national and international intensive care societies about EoL care in the ICU and, in this sense, it could be considered a useful tool for ethical training of intensivists. It is also remarkable that the WFSICCM-TF shares the statement included in the SCCM EoL care recommendations [3]: not every statement of a scientific paper can be based on evidence. We hope that this way of thinking represents a further step toward the publication of documents that cannot be based on grading of evidence, as it happens in the case of ethical and legal issues. This novel approach to clinical practice combines values and preferences of the patients and their families with evidence-based medicine in light of a “personalized,” patientcentered rather than doctor-centered or protocols-based medicine [4-6]. In our opinion, however, a comparison among different positions emerging from the documents examined, as well as original suggestions on shared care pathways at the EoL in the ICU, is lacking in the report. This may be considered a weakness, even more remarkable considering that modern intensive care medicine requires strong intercultural competence [7], to respect the specific attitudes of the different cultures and religions that are found in our multicultural and multiethnic societies. In regard to the Italian contribution to the task force, some important issues emerge. It is relevant to note that neither the Italian Society of Anesthesia and Intensive Care Medicine (SIAARTI) nor the SIAARTI Study Group on Bioethics (SIAARTI-SGB) was asked to appoint representatives to participate in the WFSICCM-TF, and it seems that none of the documents produced by our scientific society were considered [8-12]. Regarding the Italian situation, we need to underline that the content of paragraph 7 Section 5 (International Variations) is not supported neither by the current Italian legislative framework nor by the results of 2 large Italian studies about the EoL in the Italian ICUs [13,14]. The findings of the 2 studies show that the involvement of the families in EoL decisions in Italian ICUs was hardly restricted (only information or no involvement at all), and the patient's expressed wishes were generally ignored. Lastly, in Section 6 (Research Initiatives), in regard to the “surprise question” and the WFSICCM-TF recommendation “to conduct studies of this simple yet effective exercise for patients in the ICU,” we emphasize that the surprise question is included in a shared position paper, endorsed by 11 Italian scientific societies, as a first step of an algorithm for evaluating whether to start intensive or palliative care for patients with end-stage chronic organ failure [10].
Giuseppe Gristina, MD Marco Vergano, MD⁎ Luigi Riccioni, MD Italian Society of Anesthesia and Intensive Care Medicine, Study Group on Bioethics, Rome, Italy ⁎Corresponding author. E-mail address: [email protected]
http://dx.doi.org/10.1016/j.jcrc.2016.08.012
References [1] Lumb PD. Preface. J Crit Care 2016;34:vi. http://dx.doi.org/10.1016/S08839441(16)30099-5. [2] Myburgh J, Abillama F, Chiumello D, Dobb G, Jacobe S, Kleinpell R, et al. End-of-life care in the intensive care unit: report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine. J Crit Care 2016;34:125–30. http://dx.doi.org/10.1016/j.jcrc.2016.04.017. [3] Truog RD, Campbell ML, Curtis JR, Haas CE, Luce JM, Rubenfeld GD, 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. http:// dx.doi.org/10.1097/CCM.0B013E3181659096. [4] Greenhalgh T. Evidence based medicine: a movement in crisis? With context and professional expertise so that individual patients get optimal treatment, 3725; 2014 1–7. http://dx.doi.org/10.1136/bmj.g3725. [5] Vincent JL. The future of critical care medicine: integration and personalization. Crit Care Med 2016;44:386–9. http://dx.doi.org/10.1097/CCM.0000000000001530. [6] Sackett DL. Evidence-based medicine. Semin Perinatol 1997;21:3–5. [7] Bein T. Understanding intercultural competence in intensive care medicine. Int Care Med 2016. http://dx.doi.org/10.1007/s00134-016-4432-2. [8] SIAARTI—Italian Society of Anaesthesia Analgesia Resuscitation and Intensive Care Ad-Hoc Study Group. SIAARTI guidelines for admission to and discharge from intensive care units and for the limitation of treatment in intensive care. Minerva Anestesiol 2003;69:101–18. [9] SIAARTI—Italian Society of Anaesthesia Analgesia Resuscitation and Intensive Care Bioethical Board. End-of-life care and the intensivist: SIAARTI recommendations on the management of the dying patient. Minerva Anestesiol 2006;72:927–63. [10] Gristina GR, Orsi L, Carlucci A, Causarano IR, Formica M, Romanò M, et al. Parte I. Il percorso clinico e assistenziale nelle insufficienze croniche d'organo “end-stage”. Documento di consenso per una pianificazione condivisa delle scelte di cura; 2014. p. 9–24. http://dx.doi.org/10.1701/1398.15554. [11] SIAARTI—Italian Society of Anaesthesia Analgesia Resuscitation and Intensive Care Bioethical Board. Guiding principles for the development of legislation regulating the doctor-patient relationship and end-of-life decisions; 2015 1–5[Available at: http://bit.ly/29uhIc4 Last accessed July 2016]. [12] Antonelli M, Gristina GR. Guiding principles for the development of legislation regulating the doctor-patient effort by believers and non-believers. Minerva Anestesiol 2016;82:143–6. [13] Giannini A, Pessina A, Tacchi EM. End-of-life decisions in intensive care units: attitudes of physicians in an Italian urban setting; 2003 1902–10. http://dx.doi. org/10.1007/s00134-003-1919-4. [14] Bertolini G, Boffelli S, Malacarne P, Peta M, Marchesi M, Barbisan C, et al. End-of-life decision-making and quality of ICU performance: an observational study in 84 Italian units. Intensive Care Med 2010;36:1495–504. http://dx.doi.org/10.1007/ s00134-010-1910-9.
0883-9441/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Gristina G, et al, End-of-life care in the intensive care unit: Remarks on the Italian situation, J Crit Care (2016), http:// dx.doi.org/10.1016/j.jcrc.2016.08.012
Contents lists available at ScienceDirect
Journal of Critical Care journal homepage: www.jccjournal.org
End-of-life care in the intensive care unit: Remarks on the Italian situation To the Editor, Following your call for comments [1], we would like to underline a few points about the interesting WFSICCM Task Force (WFSICCM-TF) report on end-of-life (EoL) care in the intensive care unit (ICU) [2]. The document provides an exhaustive summary of the statements produced by national and international intensive care societies about EoL care in the ICU and, in this sense, it could be considered a useful tool for ethical training of intensivists. It is also remarkable that the WFSICCM-TF shares the statement included in the SCCM EoL care recommendations [3]: not every statement of a scientific paper can be based on evidence. We hope that this way of thinking represents a further step toward the publication of documents that cannot be based on grading of evidence, as it happens in the case of ethical and legal issues. This novel approach to clinical practice combines values and preferences of the patients and their families with evidence-based medicine in light of a “personalized,” patientcentered rather than doctor-centered or protocols-based medicine [4-6]. In our opinion, however, a comparison among different positions emerging from the documents examined, as well as original suggestions on shared care pathways at the EoL in the ICU, is lacking in the report. This may be considered a weakness, even more remarkable considering that modern intensive care medicine requires strong intercultural competence [7], to respect the specific attitudes of the different cultures and religions that are found in our multicultural and multiethnic societies. In regard to the Italian contribution to the task force, some important issues emerge. It is relevant to note that neither the Italian Society of Anesthesia and Intensive Care Medicine (SIAARTI) nor the SIAARTI Study Group on Bioethics (SIAARTI-SGB) was asked to appoint representatives to participate in the WFSICCM-TF, and it seems that none of the documents produced by our scientific society were considered [8-12]. Regarding the Italian situation, we need to underline that the content of paragraph 7 Section 5 (International Variations) is not supported neither by the current Italian legislative framework nor by the results of 2 large Italian studies about the EoL in the Italian ICUs [13,14]. The findings of the 2 studies show that the involvement of the families in EoL decisions in Italian ICUs was hardly restricted (only information or no involvement at all), and the patient's expressed wishes were generally ignored. Lastly, in Section 6 (Research Initiatives), in regard to the “surprise question” and the WFSICCM-TF recommendation “to conduct studies of this simple yet effective exercise for patients in the ICU,” we emphasize that the surprise question is included in a shared position paper, endorsed by 11 Italian scientific societies, as a first step of an algorithm for evaluating whether to start intensive or palliative care for patients with end-stage chronic organ failure [10].
Giuseppe Gristina, MD Marco Vergano, MD⁎ Luigi Riccioni, MD Italian Society of Anesthesia and Intensive Care Medicine, Study Group on Bioethics, Rome, Italy ⁎Corresponding author. E-mail address: [email protected]
http://dx.doi.org/10.1016/j.jcrc.2016.08.012
References [1] Lumb PD. Preface. J Crit Care 2016;34:vi. http://dx.doi.org/10.1016/S08839441(16)30099-5. [2] Myburgh J, Abillama F, Chiumello D, Dobb G, Jacobe S, Kleinpell R, et al. End-of-life care in the intensive care unit: report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine. J Crit Care 2016;34:125–30. http://dx.doi.org/10.1016/j.jcrc.2016.04.017. [3] Truog RD, Campbell ML, Curtis JR, Haas CE, Luce JM, Rubenfeld GD, 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. http:// dx.doi.org/10.1097/CCM.0B013E3181659096. [4] Greenhalgh T. Evidence based medicine: a movement in crisis? With context and professional expertise so that individual patients get optimal treatment, 3725; 2014 1–7. http://dx.doi.org/10.1136/bmj.g3725. [5] Vincent JL. The future of critical care medicine: integration and personalization. Crit Care Med 2016;44:386–9. http://dx.doi.org/10.1097/CCM.0000000000001530. [6] Sackett DL. Evidence-based medicine. Semin Perinatol 1997;21:3–5. [7] Bein T. Understanding intercultural competence in intensive care medicine. Int Care Med 2016. http://dx.doi.org/10.1007/s00134-016-4432-2. [8] SIAARTI—Italian Society of Anaesthesia Analgesia Resuscitation and Intensive Care Ad-Hoc Study Group. SIAARTI guidelines for admission to and discharge from intensive care units and for the limitation of treatment in intensive care. Minerva Anestesiol 2003;69:101–18. [9] SIAARTI—Italian Society of Anaesthesia Analgesia Resuscitation and Intensive Care Bioethical Board. End-of-life care and the intensivist: SIAARTI recommendations on the management of the dying patient. Minerva Anestesiol 2006;72:927–63. [10] Gristina GR, Orsi L, Carlucci A, Causarano IR, Formica M, Romanò M, et al. Parte I. Il percorso clinico e assistenziale nelle insufficienze croniche d'organo “end-stage”. Documento di consenso per una pianificazione condivisa delle scelte di cura; 2014. p. 9–24. http://dx.doi.org/10.1701/1398.15554. [11] SIAARTI—Italian Society of Anaesthesia Analgesia Resuscitation and Intensive Care Bioethical Board. Guiding principles for the development of legislation regulating the doctor-patient relationship and end-of-life decisions; 2015 1–5[Available at: http://bit.ly/29uhIc4 Last accessed July 2016]. [12] Antonelli M, Gristina GR. Guiding principles for the development of legislation regulating the doctor-patient effort by believers and non-believers. Minerva Anestesiol 2016;82:143–6. [13] Giannini A, Pessina A, Tacchi EM. End-of-life decisions in intensive care units: attitudes of physicians in an Italian urban setting; 2003 1902–10. http://dx.doi. org/10.1007/s00134-003-1919-4. [14] Bertolini G, Boffelli S, Malacarne P, Peta M, Marchesi M, Barbisan C, et al. End-of-life decision-making and quality of ICU performance: an observational study in 84 Italian units. Intensive Care Med 2010;36:1495–504. http://dx.doi.org/10.1007/ s00134-010-1910-9.
0883-9441/© 2016 Elsevier Inc. All rights reserved.
Please cite this article as: Gristina G, et al, End-of-life care in the intensive care unit: Remarks on the Italian situation, J Crit Care (2016), http:// dx.doi.org/10.1016/j.jcrc.2016.08.012