RESUMEN
BACKGROUND: Surveys have highlighted perceived deficiencies among ICU residents in end-of-life care, symptom control, and confidence in dealing with dying patients. Lack of formal training may contribute to the failure to meet the needs of dying patients and their families. The objective of this study was to evaluate junior intensivists' perceptions of triage and of the quality of the dying process before and after formal academic training. METHODS: Formal training on ethics was implemented as a part of resident training between 2007 and 2012. A cross-sectional survey was performed before (2007) and after (2012) this implementation. This study included 430 junior intensivists who were interviewed during these periods. RESULTS: More responders attended a dedicated training course on ethics and palliative care during 2012 (38.5%) than during 2007 (17.4%; P < .0001). During 2012, respondents reported less discomfort and fewer uncertainties regarding decisions about limiting life-sustaining treatment (17.7% vs 39.1% in 2007; P < .0001) or the triage process (48.5% vs 69.4% in 2007; P < .0001). Factors independently associated with positive perceptions of the dying process were physician's age (OR, 1.19 per year; 95% CI, 1.09-1.25) and male sex (OR, 1.61; 95% CI, 1.05-2.47). Conversely, anxiety about family members' reactions (OR, 0.58; 95% CI, 0.0.37-0.87) and lack of training (OR, 0.29; 95% CI, 0.17-0.50) were associated with negative perceptions of this process. CONCLUSIONS: Formal training dedicated to ethics and palliative care was associated with a more comfortable perception of the dying process. This training may decrease the uncertainty and discomfort of junior intensivists in these situations.
Asunto(s)
Actitud Frente a la Muerte , Cuerpo Médico de Hospitales , Cuidados Paliativos/ética , Cuidado Terminal/ética , Adulto , Estudios Transversales , Femenino , Francia , Humanos , Internado y Residencia/métodos , Masculino , Cuerpo Médico de Hospitales/educación , Cuerpo Médico de Hospitales/psicología , Evaluación de Necesidades , Mejoramiento de la Calidad , Enseñanza/normasRESUMEN
INTRODUCTION: Many potential lung transplants are lost because of hypoxemia during donor management. We hypothesized that the apnea test, necessary to confirm the diagnosis of brain death in potential lung donors, was involved in the decrease in the ratio of partial pressure of arterial O2 to fraction of inspired O2 (PaO2/FiO2) and that a single recruitment maneuver performed just after the apnea test can reverse this alteration. METHODS: In this case-control study, we examined the effectiveness of the recruitment maneuver with a comparison cohort of brain dead patients who did not receive the maneuver. Patients were matched one-to-one on the basis of initial PaO2/FiO2 and on the duration of mechanical ventilation before the apnea test. PaO2/FiO2 was measured before (T1), at the end (T2) and two hours after apnea test (T3). RESULTS: Twenty-seven patients were included in each group. The apnea test was associated with a significant decrease in PaO2/FiO2 from 284 ± 98 to 224 ± 104 mmHg (P < 0.001). The decrease in PaO2/FiO2 between T1 and T3 was significantly lower in the recruitment maneuver group than in the control group (-4 (-68-57) vs -61 (-110--18) mmHg, P = 0.02). The number of potential donors with PaO2/FiO2 > 300 mmHg decreased by 58% (95% CI: 28-85%) in the control group vs 0% (95% CI: 0-34%) in the recruitment maneuver group (P < 0.001). CONCLUSIONS: The apnea test induced a decrease in PaO2/FiO2 in potential lung donors. A single recruitment maneuver performed immediately after the apnea test can reverse this alteration and may prevent the loss of potential lung donors.