Chest ACCP Member Benefits
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Guest Access | Sign In via User Name/Password
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF) Free
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Article Archive
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via ISI Web of Science (51)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Campbell, M. L.
Right arrow Articles by Guzman, J. A.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Campbell, M. L.
Right arrow Articles by Guzman, J. A.
(Chest. 2003;123:266-271.)
© 2003 American College of Chest Physicians

Impact of a Proactive Approach to Improve End-of-Life Care in a Medical ICU*

Margaret L. Campbell, RN, MSN and Jorge A. Guzman, MD

* From the Palliative Care Service, Detroit Receiving Hospital, and the Division of Pulmonary and Critical Care Medicine, Wayne State University, Detroit, MI.

Correspondence to: Jorge A. Guzman, MD, Room 3935, 3 Hudson, Harper University Hospital, 3990 John R, Detroit, MI 48201; e-mail: jguzman{at}intmed.wayne.edu.


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Study objectives: To assess the impact of a proactive case finding approach to end-of-life care for critically ill patients experiencing global cerebral ischemia (GCI) after cardiopulmonary resuscitation and multiple organ system failure (MOSF) in comparison to historical control subjects.

Design: Comparative study of retrospective and prospective cohorts.

Setting: Medical ICU of a university hospital.

Interventions: Patterns of end-of life care for patients with MOSF and GCI obtained through a retrospective chart review were compared to proactive case finding facilitated by the inpatient palliative care service. Interventions included identification of patient’s advance directives or preferences about end-of life care, if any; assistance with discussion of the prognosis and treatment options with patients or their surrogates; and implementation of palliative care strategies when treatment goals changed to a focus on comfort measures.

Results: Although our retrospective data demonstrated a high percentage of do-not-resuscitate decisions for the patients under investigation, a considerable time lag elapsed between identification of the poor prognosis and the establishment of end-of-life treatment goals (4.7 ± 2.4 days and 3.5 ± 0.5 days for patients with MOSF and GCI, respectively [mean ± SE]). The proactive case finding approach decreased hospital length of stay (mean, 20.6 ± 4.1 days vs 15.1 ± 2.5 days and 8.6 ± 1.6 days vs 4.7 ± 0.6 days for MOSF and GCI patients, respectively; p = 0.063 and < 0.001, respectively). More importantly, a proactive palliative care intervention decreased the time between identification of the poor prognosis and the establishment of comfort care goals (7.3 ± 2.9 days vs 2.2 ± 0.8 days and 6.3 ± 1.2 days vs 3.5 ± 0.4 days for MOSF and GCI patients, respectively; p < 0.05 for both), decreased the time dying patients with MOSF remained in the ICU, and reduced the use of nonbeneficial resources, thus reducing the cost of care.

Conclusions: Proactive interventions from a palliative care consultant within this subset of patients decreased the use of nonbeneficial resources and avoided protracted dying.

Key Words: anoxic encephalopathy • critical care • multiple organ system failure • palliative care


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Decisions to forgo life-sustaining treatment are among the most challenging that patients, their surrogates, and clinicians face. Patterns of end-of-life care in ICUs have considerable variability within the United States and Canada.1 2 3 Variability seems to be multifactorial; and, although age, abnormal mental status, malignancy, or cardiac arrest are conditions more frequently associated with do-not-resuscitate (DNR) orders, no clear clinical predictors for having a DNR order have yet been identified.4 5 6

Some argue that the best method to improve ICU care at the end of life is to define the goals of care in advance of ICU admission. However, this strategy is limited by the fact that pre-ICU communications about preferences for cardiopulmonary resuscitation and prolonged mechanical ventilation are uncommon among seriously ill hospitalized adults.7 8 Moreover, even when the patient or surrogate wishes are known, clinicians may not abide by those prestated preferences.9 This strategy further assumes that reliable predictors for successful ICU outcomes exist, when it remains difficult to predict with certainty who will die,10 11 thus highlighting the importance of end-of-life care competence among ICU clinicians.

Although approaches to making improvements in hospital care of the dying have been proposed, the most extensive study to understand the prognosis and preferences for outcomes and risks of treatments (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment [SUPPORT]) presented an unattractive picture of the care of seriously ill or dying persons.12 The SUPPORT trial led their principle investigators to conclude that perhaps more creative interventions and more proactive measures might be needed to improve the quality of end-of-life care for critically ill patients. Positive patient and institutional outcomes through consultation with an inpatient palliative care program and proactive ethics consultation for high-risk ICU populations offer promising approaches to improve decision making and communications and to reduce ICU length of stay (LOS) for dying patients.13 14 15 16 17

To date, most of the literature about end-of-life care in the ICU focuses on the whole ICU population, and little information exists about disease-specific care at the end of life. Conditions such as multiple organ system failure (MOSF) occurs in approximately 14% of the patients admitted to an ICU; and, although the presence of three organs failing simultaneously occurs less frequently, it is nearly always a fatal condition.18 19 However, despite the associated poor prognosis, the majority of these patients are treated aggressively until their death.18 19 Similarly, patients with persistent coma after cardiopulmonary resuscitation are frequently treated aggressively in ICU despite a dim prognosis for functional neurologic recovery.20 21 It would seem that based on the poor prognosis for recovery among these subgroups of patients, a compassionate approach focusing on comfort is more appropriate than protracted, aggressive ICU support. We studied the impact of a proactive case finding approach to end-of life care for hopelessly ill patients experiencing severe global cerebral ischemia (GCI) after cardiopulmonary resuscitation and advanced MOSF in comparison to historical control subjects.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
The Human Investigation Committee of Wayne State University approved the study protocol. The study consisted of two cohorts. A retrospective cohort, which served as a historical control group, obtained by chart analysis of patients with GCI after cardiac arrest or MOSF admitted to the Detroit Receiving Hospital medical ICU (MICU), and a prospective cohort consisting of the same patient populations subjected to proactive palliative care interventions. Since the prospective phase was conducted as a continuous quality improvement project, did not change routine practice, and involved collection of data without compromising patient confidentiality, informed consent was waived by the Human Investigation Committee.

Study Population
GCI: Patients with cerebral ischemia after cardiac arrest with any of the following physical findings 24 h after cardiac arrest were included in the study: coma, absent pupillary and/or corneal reflexes, posturing or absent response to deep painful stimuli, and tonic-clonic seizures or myoclonic jerks attributed to cerebral ischemia. Patients were excluded if they were < 18 years old, were receiving barbiturates or neuromuscular blocking agents, or had clinical criteria for brain death.

MOSF: MOSF was defined according to the classic criteria of Knaus et al,18 and patients were included in the study when they had three or more organ systems simultaneously in failure for >= 3 days.

Study Design
Retrospective Cohort: Patients with GCI were identified by the medical record coding system using the words ICU and cardiac arrest. The medical records were then reviewed, and subjects with GCI meeting inclusion criteria were included in the study. Patients with MOSF were identified by MICU discharge diagnosis-related groups for organ failures. The diagnosis-related group was only used as a filter to identify potential study subjects. Once identified, the charts were reviewed and the medical records of patients discharged from the MICU with three or more organs in failure were selected for subsequent analysis.

Proactive Palliative Care: During the period of July 1, 1999, to June 30, 2000, members of the palliative care service of Detroit Receiving Hospital (M.L.C. and J.A.G.) screened the MICU census daily for any patient meeting the study criteria with the following aims: (1) early involvement of the palliative care service in the process of communicating prognostic news to the family; (2) assistance in identifying patient’s advance directives or preferences for end-of life care, if any; (3) assistance with discussion of the prognosis and treatment options with patients or their surrogates; (4) implementation of palliative care strategies when goals changed to "comfort measures only" (CMO); and (5) provision of consultation and education to the primary team regarding palliative care strategies. The MICU team at Detroit Receiving Hospital is comprised of a faculty intensivist who rotates every 2 weeks, and two fellows in critical care and four residents in internal medicine who rotate every month. A clinical pharmacist, a respiratory therapist, and a clinical dietician are also part of the ICU team. The palliative care service consists of a dedicated nurse practitioner and two rotating physicians (an internist and an intensivist) with interest and training in end-of-life care.13 15

Proactive Interventions
GCI: On the day of MICU admission, patients were identified for study inclusion. As part of routine clinical care for patients after cardiac arrest, an EEG was ordered on the morning of the second day and families or surrogates were informed of the probability of a poor prognosis based on the duration of cardiopulmonary resuscitation and the physical findings.20 21 22 23 24 On the second MICU day, a family meeting was convened and changes in the patient’s medical condition were communicated, and their understanding of the previous discussion was ascertained and clarified as needed. On the third MICU day, the poor prognosis was confirmed with the MICU team based on physical findings and EEG report before that daily family meeting. Based on prognosis, a change of treatment goals to a focus on comfort-oriented care was recommended, and ventilator withdrawal was discussed as an option. On subsequent MICU days, meetings were held if the family was still undecided or unwilling to accept the recommended treatment goals. When treatment goals were changed to CMO, the palliative care service remained involved to facilitate implementation of palliative care interventions, facilitate withdrawal of support if indicated, and to move the patient from the ICU if death was not imminent.

MOSF: Once patients were identified and included in the study, members of the palliative care service were updated by the primary MICU team about the family or surrogate understanding of disease severity and anticipated outcome. Subsequent daily family meetings were held to confirm the poor prognosis and recommend a change in treatment goals to CMO. As with the patients with GCI, if goals changed to CMO the palliative care service remained involved in the patient’s terminal care.

Data Collection
Age, gender, APACHE (acute physiology and chronic health evaluation) II score25 and Therapeutic Intervention Scoring System (TISS)26 values on admission to the MICU were recorded. In addition, TISS points 24 h before and after a change in DNR status, hospital and MICU LOS, frequency and goals of DNR orders, time from admission or development of MOSF to a change in DNR status and from a DNR status to death were recorded. Daily resource use in dollars was calculated from TISS points assigning $300 per point that adjusts to $350 for inflation.27 28 To ensure accuracy of data abstraction, the data collection protocol and data collectors remained the same throughout the study. DNR goals were classified as "withhold" if one or more life-sustaining measures were to be withheld from the patient’s treatment plan, or as CMO if the emphasis of ongoing treatment was the patient’s comfort and/or withdrawal of life support.

Statistical Analysis
Summary values are expressed as percentage, mean ± SE, and median and range. Unpaired Student t test was used when comparing variables between groups, and paired Student t test was used for intragroup comparisons. Fisher exact test was used to compare frequency of DNR orders between groups. Probability values (two-tailed) of < 0.05 were considered statistically significant. Statistical calculations were performed using SPSS for Windows (version 9.0; SPSS; Chicago, IL) software.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
There were 1,972 admissions to the Detroit Receiving Hospital MICU during the period of July 1, 1998, to June 30, 1999. Four hundred four medical records were identified by the medical records searching method previously described. After careful review of the identified charts, 18 patients with CGI and 22 patients with MOSF met inclusion criteria and were included in the retrospective analysis. The proactive cohort consisted of 20 patients with GCI and 21 patients with MOSF enrolled prospectively after screening 1,651 patients admitted to the same MICU during the period of July 1, 1999, to June 30, 2000. Patient age, APACHE II score, and hospital and MICU LOS are shown in Table 1 . Two patients with GCI in the retrospective cohort were discharged from the hospital to a subacute ventilator facility in persistent coma, whereas all patients with GCI enrolled prospectively died in the hospital. In-hospital mortality was 100% for patients with MOSF regardless of study cohort. The proactive end-of life intervention significantly reduced hospital and MICU LOS in the GCI group compared to historical control subjects. During the proactive phase, patients with MOSF had a similar MICU LOS; and, although it did not reach statistical significance, hospital LOS was about 5 days shorter than those patients included in the retrospective analysis.


View this table:
[in this window]
[in a new window]

  		Table 1.. Age, APACHE II, and Hospital and MICU LOS in Both Study Groups*

 
Goals at the time DNR orders were implemented are illustrated in Figure 1 . All patients in the proactive cohort, regardless of diagnostic group, had a DNR order in comparison to 88% of patients with GCI and 91% of patients with MOSF analyzed retrospectively (p < 0.05 for both). Comfort measures were chosen as the DNR goal twice more frequently than a DNR goal to withhold resuscitation during the proactive trial. Most of the patients who had an initial DNR order to withhold resuscitation and other therapies had a subsequent change in the DNR goals to CMO or withdrawal of life-sustaining interventions. For patients who had a change in the goal of the DNR order, the time elapsed between first and second order was comparable in both retrospective and prospective cohorts (3.2 days).



View larger version (21K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 1.. Goals of care for DNR orders. Solid bars = retrospective cohorts; dashed bars = prospective cohorts. Data in parenthesis indicate No. of patients.

 
The timing of changes in treatment goals for both study groups is shown in Table 2 . The time interval between ICU admission and DNR orders was similar in patients with MOSF; however, the time elapsed between development of MOSF and DNR orders was significantly reduced by the proactive palliative care interventions, more so when the change in treatment goals implicated comfort measures. In addition, a 3-day reduction from development of MOSF to death was seen in patients during proactive interventions. The time between ICU admission and DNR order did not reach statistical significance between study cohorts in patients with GCI; however, the lack of difference could simply be due to small sample size. Establishment of CMO as DNR goals occurred nearly 3 days earlier with the palliative care intervention in both study arms.


View this table:
[in this window]
[in a new window]

  		Table 2.. Time Elapsed From Hospital Admission or Development of MOSF Until First Change in Treatment Goals, DNR Orders, and Discharge for Both Groups

 
Change in the use of resources and daily cost of care after establishing DNR goals is illustrated in Table 3 . Composite TISS points before the first DNR order were 26.2 ± 1.5 points and 31.2 ± 1.2 points for patients with GCI and patients with MOSF, respectively. As previously reported29 a DNR order consisting of withholding life-sustaining interventions did not alter intensity of care as evidenced by a subtle decrease in TISS points. However, a significant decrease in TISS points and estimated costs were apparent when treatment goals changed to CMO.


View this table:
[in this window]
[in a new window]

  		Table 3.. Changes in TISS Points ({Delta}TISS) and Estimated Costs After First DNR Order (Withhold vs CMO) Was Established for Both Groups

 
The palliative care service was consulted in only 27% of patients with GCI and 32% of patients with MOSF included in the retrospective cohort. Since patients with a consultation had no statistically significant difference in any of the studied variables with the rest of the control patients who did not have a consultation for either of the two diagnosis, and the proactive approach was not part of the palliative care intervention during the time retrospective data were collected, the group was combined to simplify statistical analysis.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
Outcome measures for evaluating end-of-life care of patients with diagnoses known to have a poor outcome such as GCI after cardiac arrest and persistent MOSF are scarce. In spite of a well-established palliative care practice at our institution,13 14 15 29 30 the program was underutilized by the MICU team, in that the palliative care consultants saw only approximately 30% of the study patients, as demonstrated by the retrospective data analysis. However, our data shows that a dedicated team proactively implementing palliative care consultation in this subgroup of critically ill patients, decreases hospital length of stay, and more importantly, shifts goals of care to comfort much earlier in the disease process.

Even though our sample is relatively small, the incidence of severe MOSF, as defined in our study, is comparable to other reports.18 19 In addition, the similar number of patients enrolled retrospectively and prospectively diminishes the possibility of selection bias, which could otherwise be raised as a limitation in a before/after study. In spite of less available data evaluating the incidence of CGI after cardiac arrest in a general MICU, the comparable number of patients with CGI in both study phases make us believe that the above is true for this subset of patients too.

Although our retrospective data demonstrates that the percentage of designated DNR patients is higher than previously described,31 32 a considerable time lag elapsed between the identification of the patients prognosis and designation of DNR. Furthermore, judging by the type and frequency of DNR orders observed in the retrospective cohort, there was more ease in establishing goals to withhold resuscitation and other interventions than for establishing goals directed at comfort measures only. In spite of a population that has a nearly always fatal outcome, such as patients with severe GCI after cardiopulmonary resuscitation and prolonged MOSF, physicians were likely to consider withdrawing treatment from these patients only later in the course of the illness. Delayed recognition of the poor prognosis by clinicians and/or patient surrogates opposing to recommendations to change treatment goals could potentially explain the above.

A proactive palliative care approach significantly decreased the time between identification of MOSF and the establishment of a DNR order. More importantly, this approach decreased the time hopelessly ill patients spent in the ICU before a change in treatment goals to a focus on comfort was decided, compared to the retrospective group. These findings are different from those reported by the SUPPORT trial.12 Early collaborative interventions after the patient’s prognosis was identified, and involvement throughout the ICU course between the palliative care consultants and intensivists at our institution resulting in timelier decisions about life-sustaining treatment, may explain our positive results.33

Although the study was not powered or intended to show a decrease in ICU resources or costs, judging by TISS scores, reduction in intensive care support did not occur when the DNR goals were to withhold resuscitation. This is in contrast to previously published concerns that DNR orders may lead to a diminished level of care.34 In the retrospective cohort, a reduction in the use of resources (TISS) and costs of care was appreciated when the goals changed to CMO. However, a more substantial and significant reduction was seen with the proactive interventions of the palliative care consultants. This illustrates the usefulness of a palliative care perspective in assisting the ICU staff to recognize which interventions have lost their benefit when the context of care changes to a focus on comfort care only.

Interestingly, the increased presence of a proactive case finding approach not only increased utilization for the study protocol but also contributed to an increase in consultation about other patients with a poor prognosis who were not in the populations being studied. The increased presence in the ICU also contributes to bridging the educational gap of clinicians and sets grounds for incorporating palliative care into the critical care culture and curriculum.

Potential limitations to our study exist. Our sample is relatively small, temporal changes in a before/after study cannot be controlled, and it is a study conducted in a single institution with unique characteristics, such as the existence of an in-hospital palliative care program; therefore, our results may not be generalizable to other institutions.

In summary, our results suggest that a gap between what needs to be known and practiced, and what is currently demonstrated about end-of-life care in the ICU persists. Until this gap is bridged, the interventions of a proactive palliative care consultant will produce measurable improvements in patient care with regard to early identification of a poor prognosis, facilitation of changing treatment goals to comfort measures only, and implementation of palliative care interventions. These improvements result in a reduction in hospital and ICU length of stay, a reduction in the use of nonbeneficial resources with a concomitant savings in the cost of care.


   Footnotes
 
Abbreviations: APACHE = acute physiology and chronic health evaluation; CMO = comfort measures only; DNR = do not resuscitate; GCI = global cerebral ischemia; LOS = length of stay; MICU = medical ICU; MOSF = multiple organ system failure; SUPPORT = Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment; TISS = Therapeutic Intervention Scoring System

Received for publication November 9, 2001. Accepted for publication May 21, 2002.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. McClean, RF, Tarshis, J, Mazer, CD, et al (2000) Death in two Canadian intensive care units: institutional difference and changes over time. Crit Care Med 28,100-103[CrossRef][ISI][Medline]
  2. Prendergast, TJ, Luce, JM Increasing incidence of withholding and withdrawal of life support from the critically ill. Am J Respir Crit Care Med 1997;155,15-20[Abstract]
  3. Prendergast, TJ, Claessens, MT, Luce, J A national survey of end-of-life care for critically ill patients. Am J Respir Crit Care Med 1998;158,1163-1167[Abstract/Free Full Text]
  4. Zimmerman, JE, Knaus, WA, Sharpe, SM, et al The use and implications of do not resuscitate orders in intensive care units. JAMA 1986;255,351-356[Abstract]
  5. Wachter, RM, Luce, JM, Hearst, N, et al Decisions about resuscitation: inequities among patients with different diseases but similar prognoses. Ann Intern Med 1989;111,525-532[ISI][Medline]
  6. Jayes, RL, Zimmerman, JE, Wagner, DP, et al Variations in the use of do-not-resuscitate orders in the ICU. Chest 1996;110,1332-1339[Abstract/Free Full Text]
  7. Hoffman, JC, Wengler, NS, Davis, RB, et al Patient preferences for communication with physicians about end-of-life decisions. Ann Intern Med 1997;127,1-12[Abstract/Free Full Text]
  8. Lo, B, McLeod, G, Saika, G Patient attitudes to discussing life-sustaining treatment. Arch Intern Med 1986;146,1613-1615[CrossRef][ISI][Medline]
  9. Asch, DA, Hansen-Flaschen, J, Lanken, PN Decisions to limit or continue life-sustaining treatment by critical care physicians in the United States: conflicts between physicians’ practices and patients’ wishes. Am J Respir Crit Care Med 1995;151,288-292[Abstract]
  10. Knaus, WA, Wagner, DP, Lynn, J Short-term mortality predictions for critically ill hospitalized adults: science and ethics. Science 1991;254,389-394[Abstract/Free Full Text]
  11. Lynn, J, Teno, JM, Harrell, FEJ Accurate prognostication of death: opportunities and challenges for clinicians. West J Med 1995;163,250-257[ISI][Medline]
  12. SUPPORT Principle Investigators. A controlled trial to improve care for seriously ill hospitalized patients: the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT). JAMA 1995;274,1591-1598[Abstract]
  13. Carlson, RW, Devich, L, Frank, RR Development of a comprehensive supportive care team for the hopelessly ill on a university medical service. JAMA 1988;259,378-383[Abstract]
  14. Field, BE, Devich, LE, Carlson, RW Impact of a comprehensive supportive care team on management of hopelessly ill patients with multiple organ failure. Chest 1989;96,353-356[Abstract/Free Full Text]
  15. Campbell, ML, Frank, RR Experience with an end-of-life practice at a university hospital. Crit Care Med 1997;25,197-202[CrossRef][ISI][Medline]
  16. Dowdy, MD, Robertson, C, Bander, JA A study of proactive ethics consultation for critically and terminally ill patients with extended lengths of stay. Crit Care Med 1998;26,252-259[CrossRef][ISI][Medline]
  17. Schneiderman, LJ, Gilmer, T, Teetzel, HD Impact of ethics consultations in the intensive care setting: a controlled, randomized trial. Crit Care Med 2000;28,3920-3924[CrossRef][ISI][Medline]
  18. Knaus, WA, Draper, EA, Wagner, DP, et al Prognosis in acute organ-system failure. Ann Surg 1985;202,685-693[ISI][Medline]
  19. Zimmerman, JE, Knaus, WA, Wagner, DP, et al A comparison of risks and outcomes for patients with organ system failure: 1982–1990. Crit Care Med 1996;24,1633-1641[CrossRef][ISI][Medline]
  20. Levy, DE, Bates, D, Caronna, JJ, et al Prognosis in nontraumatic coma. Ann Intern Med 1981;94,293-301[CrossRef][ISI][Medline]
  21. Levy, DE, Caronna, JJ, Singer, BH, et al Predicting outcome from hypoxic-ischemic coma. JAMA 1985;253,1420-1426[Abstract]
  22. Rothstein, TL, Thomas, EM, Sumi, SM Predicting outcome in hypoxic-ischemic coma: a prospective clinical and electrophysiologic study. Electroencephalogr Clin Neurophysiol 1991;79,101-107[CrossRef][ISI][Medline]
  23. Shewmon, DA, DeGiorgio, CM Early prognosis in anoxic coma. Neurol Clin 1989;7,823-843[ISI][Medline]
  24. Synek, VM Prognostically important EEG coma patterns in diffuse anoxic and traumatic encephalopathies in adults. J Clin Neurophysiol 1988;5,161-174[ISI][Medline]
  25. Knaus, WA, Draper, EA, Wagner, D, et al APACHE II: a severity of disease classification system. Crit Care Med 1985;13,818-829[ISI][Medline]
  26. Keene, AR, Cullen, DJ Therapeutic intervention scoring system: update 1983. Crit Care Med 1983;11,1-3[ISI][Medline]
  27. Dickie, H, Vedio, A, Dundas, R, et al Relationship between TISS and ICU cost. Intensive Care Med 1998;24,1009-1017[CrossRef][ISI][Medline]
  28. Zimmerman, JE, Shortell, SM, Knaus, WA, et al Value and cost of teaching hospitals: a prospective, multicenter, inception cohort study. Crit Care Med 1993;21,1432-1442[ISI][Medline]
  29. Campbell, ML, Thill-Baharozian, M Impact of the DNR therapeutic plan on patient care requirements. Am J Crit Care 1994;3,202-207[Abstract]
  30. Campbell, ML Program assessment through outcomes analysis: efficacy of a comprehensive supportive care team for end-of-life care. AACN Clin Issues 1996;7,159-167[Medline]
  31. Eliasson, H, Howard, RS, Torrington, KG, et al Do-not-resuscitate decisions in medical ICU: comparing physician and nurse opinions. Chest 1997;111,1106-1111[Abstract/Free Full Text]
  32. Smedira, NG, Evans, BH, Grais, LS, et al Withholding and withdrawal of life support from the critically ill. N Engl J Med 1990;322,309-315[Abstract]
  33. Frank, RR, Campbell, ML The SUPPORT project and improving care to seriously ill patients [letter]. JAMA 1996;275,1228-1229[CrossRef][ISI][Medline]
  34. Sulmasy, DP, Geller, G, Faden, R The quality of mercy-caring for patients with ‘do not resuscitate’ orders. JAMA 1992;267,682-686[Abstract]



This article has been cited by other articles:


Home page
 Arch Intern MedHome page
E. Ferrand, P. Jabre, C. Vincent-Genod, R. Aubry, M. Badet, P. Badia, A. Cariou, F. Ellien, V. Gounant, R. Gil, et al.
Circumstances of Death in Hospitalized Patients and Nurses' Perceptions: French Multicenter Mort-a-l'Hopital Survey
Arch Intern Med, April 28, 2008; 168(8): 867 - 875.
[Abstract] [Full Text] [PDF]

Home page
 ChestHome page
H. Shanawani, M. D. Wenrich, M. R. Tonelli, and J. R. Curtis
Meeting Physicians' Responsibilities in Providing End-of-Life Care
Chest, March 1, 2008; 133(3): 775 - 786.
[Abstract] [Full Text] [PDF]

Home page
 ChestHome page
C. J. Gries, J. R. Curtis, R. J. Wall, and R. A. Engelberg
Family Member Satisfaction With End-of-Life Decision Making in the ICU
Chest, March 1, 2008; 133(3): 704 - 712.
[Abstract] [Full Text] [PDF]

Home page
 ANN INTERN MEDHome page
N. E. Goldstein and D. Fischberg
Update in Palliative Medicine
Ann Intern Med, January 15, 2008; 148(2): 135 - 140.
[Full Text] [PDF]

Home page
 ANN INTERN MEDHome page
K. A. Lorenz, J. Lynn, S. M. Dy, L. R. Shugarman, A. Wilkinson, R. A. Mularski, S. C. Morton, R. G. Hughes, L. K. Hilton, M. Maglione, et al.
Evidence for Improving Palliative Care at the End of Life: A Systematic Review
Ann Intern Med, January 15, 2008; 148(2): 147 - 159.
[Abstract] [Full Text] [PDF]

Home page
 Arch Intern MedHome page
J. E. Nelson, A. F. Mercado, S. L. Camhi, N. Tandon, S. Wallenstein, G. I. August, and R. S. Morrison
Communication About Chronic Critical Illness
Arch Intern Med, December 10, 2007; 167(22): 2509 - 2515.
[Abstract] [Full Text] [PDF]

Home page
 Am J Crit CareHome page
D. A. Gruenberg, W. Shelton, S. L. Rose, A. E. Rutter, S. Socaris, and G. McGee
Factors influencing length of stay in the intensive care unit.
Am. J. Crit. Care., September 1, 2006; 15(5): 502 - 509.
[Abstract] [Full Text] [PDF]

Home page
 Crit Care NurseHome page
M. Thelen
End-of-Life Decision Making in Intensive Care
Crit. Care Nurse, December 1, 2005; 25(6): 28 - 37.
[Full Text] [PDF]

Home page
 Am. J. Respir. Crit. Care Med.Home page
J. R. Curtis, R. A. Engelberg, M. D. Wenrich, S. E. Shannon, P. D. Treece, and G. D. Rubenfeld
Missed Opportunities during Family Conferences about End-of-Life Care in the Intensive Care Unit
Am. J. Respir. Crit. Care Med., April 15, 2005; 171(8): 844 - 849.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF) Free
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Article Archive
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via ISI Web of Science (51)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Campbell, M. L.
Right arrow Articles by Guzman, J. A.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Campbell, M. L.
Right arrow Articles by Guzman, J. A.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS