Patients and their families often value the avoidance of invasive or overly aggressive life-sustaining measures when they are at the end of life. However, many dying patients receive aggressive life-sustaining therapies, in part due to clinicians’ failures to elicit patients’ preferences and to provide recommendations.
Downar J, et al. Nonbeneficial treatment Canada: definitions, causes, and potential solutions from the perspective of healthcare practitioners*. Crit Care Med. 2015 Feb;43(2):270-81. PMID: 25377017.
Myburgh J, 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 Aug;34:125-30. PMID: 27288625.Share on Facebook Share on Twitter
Maintaining critically ill patients in an immobile or minimally mobile state during care may potentiate muscle loss and deconditioning. Excessive and/or prolonged use of sedatives is associated with worse outcomes, including increased delirium, excessive use of diagnostic imaging for coma, increased number of tracheostomies, greater duration of mechanical ventilation and ICU length-of-stay.
Burry L, et al. Daily sedation interruption versus no daily sedation interruption for critically ill adult patients requiring invasive mechanical ventilation. Cochrane Database Syst Rev. 2014 Jul 9;(7):CD009176. PMID: 25005604.
Schweickert WD, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009 May 30;373(9678):1874-82. PMID: 19446324.Share on Facebook Share on Twitter
Screening for readiness for liberation from mechanical ventilation with spontaneous breathing trials allows clinicians earlier recognition of patients that may be liberated from mechanical ventilation.
Girard TD, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet. 2008 Jan 12;371(9607):126-34. PMID: 18191684.Share on Facebook Share on Twitter
Chest radiographs (“X-rays”, CXRs) are not indicated for routine assessment of critically-ill patients except when indicated for specific procedures (e.g., endotracheal tube, naso- or orogastric tube, central vein catheter, pulmonary artery catheter, or other procedure requiring verification after insertion), or to provide information for a specific question related to a change in patient’s clinical condition, and if the information will likely impact a specific decision related to diagnosis or treatment.
Ganapathy A, et al. Routine chest x-rays in intensive care units: a systematic review and meta-analysis. Crit Care. 2012 Dec 12;16(2):R68. PMID: 22541022.Share on Facebook Share on Twitter
Unnecessary transfusion of red blood cells (RBCs) is more harmful than helpful, and wastes a limited resource, which should be reserved for patients with proven indications. Transfusing RBCs at a threshold higher than 70 g/L does not improve survival in ICU patients, and is associated with more complications and higher costs. This has been extensively studied and a restrictive transfusion strategy results in similar or lower mortality compared with higher thresholds, and other complications, including stroke and infections, may also be reduced.
Carson JL, et al. Clinical Practice Guidelines From the AABB: Red Blood Cell Transfusion Thresholds and Storage. JAMA. 2016 Nov 15;316(19):2025-2035. PMID: 27732721.Share on Facebook Share on Twitter