Acute and Critical Care

Original Article

Ethics
The Current Status of Medical Decision-Making for Dying Patients in a Medical Intensive Care Unit: A Single-Center Study: Kyunghwa Shin, Jeong Ha Mok, Sang Hee Lee, Eun Jung Kim, Na Ri Seok, Sun Suk Ryu, Myoung Nam Ha, Kwangha Lee; Korean J Crit Care Med. 2014;29(3):160-165. Published online August 31, 2014; DOI: https://doi.org/10.4266/kjccm.2014.29.3.160

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BACKGROUND
Many terminally ill patients die while receiving life-sustaining treatment. Recently, the discussion of life-sustaining treatment in intensive care units (ICUs) has increased. This study is aimed to evaluate the current status of medical decision-making for dying patients.
METHODS
The medical records of patients who had died in the medical ICU from March 2011 to February 2012 were reviewed retrospectively.
RESULTS
Eighty-nine patients were enrolled. Their mean age was 65.8 +/- 13.3 years and 73.0% were male. The most common diagnosis was acute respiratory failure, and the most common comorbidity was hemato-oncologic malignancy. Withdrawing or withholding life-sustaining treatment including do-not-resuscitate (DNR) orders was discussed for 64 (71.9%) patients. In almost all cases, the discussion involved a physician and the patient's family. No patient wrote advance directives themselves before ICU admission. Of the patients for whom withdrawing or withholding life-sustaining treatment was discussed, the decisions were recorded in formal consent documents in 36 (56.3%) cases, while 28 (43.7%) cases involved verbal consent. In patients granting verbal consent, death within one day of the consent was more common than in those with formal document consent (85.7% vs. 61.1%, p < 0.05). The most common demand was a DNR order. Patients died 2.7 +/- 1.0 days after the decision for removal of life-sustaining treatment.
CONCLUSIONS
The decision-making for life-sustaining treatment of dying patients in the ICU very often involves conflict. There is a general need to heighten our sensitivity on the objective decision-making based on patient autonomy.

Citations

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Agreement between Family Members and the Physician’s View in the ICU Environment: Personal Experience as a Factor Influencing Attitudes towards Corresponding Hypothetical Situations
Paraskevi Stamou, Dimitrios Tsartsalis, Georgios Papathanakos, Elena Dragioti, Mary Gouva, Vasilios Koulouras
Healthcare.2023; 11(3): 345. CrossRef
Family's Perception of Proxy Decision Making to Authorize Do Not Resuscitate Order of Elderly Patients in Long Term Care Facility: A Q-Methodological Study
Hyeon Jin Cho, Jiyeon Kang
Journal of Korean Academy of Nursing.2021; 51(1): 15. CrossRef
Decision-making regarding withdrawal of life-sustaining treatment and the role of intensivists in the intensive care unit: a single-center study
Seo In Lee, Kyung Sook Hong, Jin Park, Young-Joo Lee
Acute and Critical Care.2020; 35(3): 179. CrossRef
Factors Associated With Quality of Death in Korean ICUs As Perceived by Medical Staff: A Multicenter Cross-Sectional Survey
Jun Yeun Cho, Ju-Hee Park, Junghyun Kim, Jinwoo Lee, Jong Sun Park, Young-Jae Cho, Ho Il Yoon, Sang-Min Lee, Jae-Ho Lee, Choon-Taek Lee, Yeon Joo Lee
Critical Care Medicine.2019; 47(9): 1208. CrossRef
Transcultural Adaptation and Validation of Quality of Dying and Death Questionnaire in Medical Intensive Care Units in South Korea
Jun Yeun Cho, Jinwoo Lee, Sang-Min Lee, Ju-Hee Park, Junghyun Kim, Youlim Kim, Sang Hoon Lee, Jong Sun Park, Young-Jae Cho, Ho Il Yoon, Jae Ho Lee, Choon-Taek Lee, Yeon Joo Lee
Acute and Critical Care.2018; 33(2): 95. CrossRef

Case Reports

Hematology/Obstetric
Acute Myeloid Leukemia in Suspected Sepsis after Caesarean Section: Myoung Hwa Kim, Sung Won Na, Shin Ok Koh, Eun Jung Kim, Hye Jin Yoon, Yong Jae Lee, Hee Young Cho; Korean J Crit Care Med. 2014;29(2):99-104. Published online May 31, 2014; DOI: https://doi.org/10.4266/kjccm.2014.29.2.99

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Abstract PDF: The incidence of acute leukemia during pregnancy is extremely rare, and often it is not easy to differentiate it from other diseases associated with pregnancy such as sepsis or hemorrhage. Pregnancy itself is not known to affect the natural course of leukemia; however, complications of leukemia like anemia, infections, and coagulopathy can adversely influence both the fetus and the mother. In this case, a pregnant patient misdiagnosed with septic shock and severe leukocytosis was correctly diagnosed with acute myeloid leukemia after surgical delivery.

Cardiology/Pulmonary
One Hundred Seven Days of ECMO as a Bridge to Lung Transplantation: The Longest Duration Among Elderly Patients: Eun Jung Kim, Hyo Chae Paik, Moo Suk Park, Myung Hwa Kim, Shin Ok Koh, You Jin Lee, Sungwon Na; Korean J Crit Care Med. 2014;29(1):48-51. Published online February 28, 2014; DOI: https://doi.org/10.4266/kjccm.2014.29.1.48

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Abstract PDF

Extracorporeal membrane oxygenation (ECMO) is a means for supporting adequate gas exchange in patients with severe respiratory failure and is the only therapeutic option for ventilation-refractory patients awaiting lung transplantation. Moreover, defining the patients likely to benefit from ECMO as a bridge to transplantation has recently become a point of interest. Here, we report a case of prolonged ECMO support to a patient awaiting lung transplantation. A 66-year-old woman was diagnosed with acute interstitial pneumonia and was placed on veno-venous (VV) ECMO due to unsatisfactory gas exchange despite maximal ventilator care. She underwent bilateral lung transplantation after 99 days of ECMO and was successfully weaned from it on the 107th ECMO day. This is the longest period of ECMO support to be reported among elderly patients.

Citations

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Long-Term Venovenous Connection for Extracorporeal Carbon Dioxide Removal (ECCO2R)–Numerical Investigation of the Connection to the Common Iliac Veins
N. B. Steuer, K. Hugenroth, T. Beck, J. Spillner, R. Kopp, S. Reinartz, T. Schmitz-Rode, U. Steinseifer, G. Wagner, J. Arens
Cardiovascular Engineering and Technology.2020; 11(4): 362. CrossRef
One hundred forty six days on extracorporeal membrane oxygenation (ECMO): Our longest ECMO run
Ahmad Said Abdalmohsen Ali, Mohamed Yosri, Mohamed Abouelwafa, Mahmoud Saad, Kareem Zaki, Shady Mashhour, Husam Salah, Tarek Mohsen, Amaany Abozeid, Mohamed Khaled, Akram Abdelbary, Alia Abdelfattah
The Egyptian Journal of Critical Care Medicine.2018; 6(3): 113. CrossRef
Recovery from Acute Respiratory Distress Syndrome with Long-Run Extracorporeal Membrane Oxygenation
Jin Jeon, Jin Won Huh, Chae-Man Lim, Younsuck Koh, Sang-Bum Hong
Korean Journal of Critical Care Medicine.2014; 29(3): 212. CrossRef

Skin Necrosis after High Dose Vasopressor Infusion in Septic Shock: Two Case Reports: Ah Reum Cho, Jeung Il Kim, Eun Jung Kim, Seung Min Son; Korean J Crit Care Med. 2012;27(3):182-186.; DOI: https://doi.org/10.4266/kjccm.2012.27.3.182

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Abstract PDF

Survival sepsis campaign recommends that vasopressor therapy is required to maintain mean arterial pressure (MAP) > or = 65 mmHg. However, the absolute maximum dose of vasopressor is difficult to determine. Herein, we report 2 cases of severe skin necrosis after high dose vasopressor infusion to maintain the recommended MAP in septic shock. In our first case, norepinephrine 1.0-2.0 microg/kg/min and vasopressin 0.03-0.1 U/min were infused for 5 days; in the second case, dopamine 10-20 microg/kg/min and norepinephrine 0.25-2.5 microg/kg/min were infused for 7 days. Severe ischemic skin lesions, which required amputations, developed in both cases. The clinical appearance of the skin lesions in the 2 cases was different because of the unique distribution of target receptors for different vasopressors. Thus, when high dose vasopressors are required to achieve recommended MAP, extra vigilance is required. Further studies for dose adjustment are needed.

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