Background The use of Do-Not-Resuscitate (DNR) orders has increased but many are placed late in the dying process. This study is to determine the association between the timing of DNR order placement in the intensive care unit (ICU) and nurses' perceptions of patients' distress and quality of death. Methods 200 ICU patients and the nurses (n = 83) who took care of them during their last week of life were enrolled from the medical ICU and cardiac care unit of New York Presbyterian Hospital/Weill Cornell Medicine in Manhattan and the surgical ICU at the Brigham and Women's Hospital in Boston. Nurses were interviewed about their perceptions of the patients' quality of death using validated measures. Patients were divided into 3 groups-no DNR, early DNR, late DNR placement during the patient's final ICU stay. Logistic regression analyses modeled perceived patient quality of life as a function of timing of DNR order placement. Patient's comorbidities, length of ICU stay, and procedures were also included in the model. Results 59 patients (29.5%) had a DNR placed within 48 hours of ICU admission (early DNR), 110 (55%) placed after 48 hours of ICU admission (late DNR), and 31 (15.5%) had no DNR order placed. Compared to patients without DNR orders, those with an early but not late DNR order placement had significantly fewer non-beneficial procedures and lower odds of being rated by nurses as not being at peace (Adjusted Odds Ratio namely AOR = 0.30; [CI = 0.09-0.94]), and experiencing worst possible death (AOR = 0.31; [CI = 0.1-0.94]) before controlling for procedures; and consistent significance in severe suffering (AOR = 0.34; [CI = 0.12-0.96]), and experiencing a severe loss of dignity (AOR = 0.33; [CI = 0.12-0.94]), controlling for non-beneficial procedures. Conclusions Placement of DNR orders within the first 48 hours of the terminal ICU admission was associated with fewer non-beneficial procedures and less perceived suffering and loss of dignity, lower odds of being not at peace and of having the worst possible death.

INTRODUCTION:Non-statin therapy (NST) is used as second-line treatment when statin monotherapy is inadequate or poorly tolerated. OBJECTIVE:To determine the association of NST with plaque composition, alone or in combination with statins, in patients undergoing coronary computed tomography angiography (coronary CTA). METHODS:From the multicenter CONFIRM registry, we analyzed individuals who underwent coronary CTA with known lipid-lowering therapy status and without prior coronary artery disease at baseline. We created a propensity score for being on NST, followed by stepwise multivariate linear regression, adjusting for the propensity score as well as risk factors, to determine the association between NST and the number of coronary artery segments with each plaque type (non-calcified (NCP), partially calcified (PCP) or calcified (CP)) and segment stenosis score (SSS). RESULTS:Of the 27,125 subjects in CONFIRM, 4,945 met the inclusion criteria; 371 (7.5%) took NST. At baseline, patients on NST had more prevalent risk factors and were more likely to be on concomitant cardiac medications. After multivariate and propensity score adjustment, NST was not associated with plaque composition: NCP (0.07 increase, 95% CI: -0.05, 0.20; p = 0.26), PCP (0.10 increase, 95% CI: -0.10, 0.31; p = 0.33), CP (0.18 increase, 95% CI: -0.10, 0.46; p = 0.21) or SSS (0.45 increase, 95% CI: -0.02,0.93; p = 0.06). The absence of an effect of NST on plaque type was not modified by statin use (p for interaction > 0.05 for all). CONCLUSION:In this cross-sectional study, non-statin therapy was not associated with differences in plaque composition as assessed by coronary CTA.

Heart failure represents a clinical syndrome that results from a constellation of disease processes affecting myocardial function. Although recent studies have suggested a declining or stable incidence of heart failure, patients with heart failure continue to have high hospitalization and readmission rates, resulting in a substantial economic and public health burden. We searched PubMed and Google Scholar to identify published literature from 1998 through 2018 using the following keywords: heart failure, readmissions, predictors, prediction models, and interventions. Cited references were also used to identify relevant literature. Developments in the diagnosis and management of patients with heart failure have improved hospitalization and readmission rates in the past few decades. However, heart failure remains the most common cause of hospitalization in persons older than 65 years. As a result, given the enormous clinical and financial burden associated with heart failure readmissions on health care, there has been growing interest in the investigation of mechanisms aimed at improving outcomes and curtailing associated costs of care. Herein, we review the current literature on clinical and socioeconomic predictors of heart failure readmissions, briefly discussing limitations of existing strategies and providing an overview of current technology aimed at reducing hospitalizations.

CONTEXT:Deaths in the intensive care unit (ICU) are increasingly common in the U.S., yet little is known about patients' experiences at the end of life in the ICU. OBJECTIVES:The objective of this study was to determine nurse assessment of symptoms experienced, and care received by ICU patients in their final week, and their associations with nurse-perceived suffering and dignity. METHODS:From September 2015 to March 2017, nurses who cared for 200 ICU patients who died were interviewed about physical and psychosocial dimensions of patients' experiences. Medical chart abstraction was used to document baseline patient characteristics and care. RESULTS:The patient sample was 61% males, 70.2% whites, and on average 66.9 (SD 15.1) years old. Nurses reported that 40.9% of patients suffered severely and 33.1% experienced severe loss of dignity. The most common symptoms perceived to contribute to suffering and loss of dignity included trouble breathing (44.0%), edema (41.9%), and loss of control of limbs (36.1%). Most (n = 9) remained significantly (P < 0.05) associated with suffering, after adjusting for physical pain, including fever/chills, fatigue, and edema. Most patients received vasopressors and mechanical ventilation. Renal replacement therapy was significantly (<0.05) associated with severe suffering (adjusted odds ratio [AOR] 2.53) and loss of dignity (AOR 3.15). Use of feeding tube was associated with severe loss of dignity (AOR 3.12). CONCLUSION:Dying ICU patients are perceived by nurses to experience extreme indignities and suffer beyond physical pain. Attention to symptoms such as dyspnea and edema may improve the quality of death in the ICU.

The letter by Allard et al. discusses concerns regarding the multiple interpretations of dignity as a concept and how multiple interpretations of dignity may influence our study conclusions. First, we would like to clarify that in the development of the nurse assessment used in this study, we used a specific definition of dignity. This definition was provided to each nurse before asking their perceptions of the dignity of the patients for whom they cared in the ICU in the last week of the patient's life. The definition used was as follows: “The state or quality of being worthy of honor or respect,” a common interpretation of the concept of dignity, consistent with the Oxford dictionary.1Dignity | Definition of dignity in US English by Oxford Dictionaries.https://en.oxforddictionaries.com/definition/us/dignityDate accessed: April 9, 2018Google Scholar As Allard et al. note, extrinsic dignity can be externally assessed and lost, whereas intrinsic dignity cannot; thus, our study refers to extrinsic dignity. Placing this adjective in front of the type of dignity the nurse assessed appears to us to be a bit of a distinction without a difference. In other words, adding the term “extrinsic” appears to make little difference to either the value of the assessment or interpretation of our study results. Despite our presentation of a standard definition of dignity to the nurse evaluators in our study, we concede that the perception of what constitutes dignity and a severe loss of dignity may vary with the nurse rater. In general, the point that each nurse may have evaluated dignity differently is not specific to the assessment of dignity, however. Variability is inherent in the assessment of all subjective (and most objective) states (e.g., of another person's suffering, pain, sadness, or happiness). This variability is likely increased in our study because nurses were not reporting on their own experience but instead were reporting their perception of another's experience. For this reason, throughout the article, we clearly stated that our findings were based on nurses' perspectives of suffering and loss of dignity and not patients' own evaluations of their subjective experience. We also acknowledge in the discussion that a main limitation of this study and its conclusions is that only the nurse's perspective is assessed. With careful description of the assessments as nurses' perceptions of the patient's experience in each section of the article, including the title, we believe that we have taken appropriate precaution to prevent readers from misinterpreting our data as patients' own reports. Furthermore, there appears value in nurses' and other proxy reports of dying patients' experiences, particularly in the ICU where many patients have difficulty speaking for themselves.2Cook D. Rocker G. Dying with dignity in the intensive care unit.N Engl J Med. 2014; 370: 2506-2514Crossref PubMed Scopus (193) Google Scholar Nurses' perceptions of the patient's experience have been used in numerous previous studies and found to be helpful to further the understanding of patient care and experience at the end of life.3Hodde N.M. Engelberg R.A. Treece P.D. Steinberg K.P. Curtis J.R. Factors associated with nurse assessment of the quality of dying and death in the intensive care unit.Crit Care Med. 2004; 32: 1648-1653Crossref PubMed Scopus (80) Google Scholar, 4Downey L. Curtis J.R. Lafferty W.E. Herting J.R. Engelberg R.A. The Quality of Dying and Death Questionnaire (QODD): empirical domains and theoretical perspectives.J Pain Symptom Manage. 2010; 39: 9-22Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar, 5Detsky M.E. Harhay M.O. Bayard D.F. et al.Discriminative accuracy of physician and nurse predictions for survival and functional outcomes 6 months after an ICU admission.JAMA. 2017; 317: 2187-2195Crossref PubMed Scopus (95) Google Scholar, 6Sneeuw K.C.A. Sprangers M.A.G. Aaronson N.K. The role of health care providers and significant others in evaluating the quality of life of patients with chronic disease.J Clin Epidemiol. 2002; 55: 1130-1143Abstract Full Text Full Text PDF PubMed Scopus (323) Google Scholar, 7Horton R. Differences in assessment of symptoms and quality of life between patients with advanced cancer and their specialist palliative care nurses in a home care setting.Palliat Med. 2002; 16: 488-494Crossref PubMed Scopus (47) Google Scholar Although the perception of death and dying varies between nurses, physicians, and family members, this variable does not diminish the value of nurses' perspectives. Our study adds to what is known about patients' experience of suffering and dignity at the end of life in the ICU and has the potential to inform future studies of additional perceptions and patient populations. The nurse assessments in this study also identify potential targets for improving the quality of care and experience of patients who died in the ICU, highlighting the contribution of these nurses' perspectives. Dignity or Dignities? When a Concept Has Multiple MeaningsJournal of Pain and Symptom ManagementVol. 56Issue 2PreviewThis letter is intended to offer a reflection on the article by Su et al.,1 which investigates nurses' perceptions of suffering and dignity in patients who die in the intensive care unit (ICU). More specifically, I would like to draw your attention to the lack of an explicit definition of the concept of dignity in this article. This letter is meant to help the readers understand the multiple meanings of the word dignity and highlight the importance of explicitly defining a concept before discussing the findings of a research project. Full-Text PDF Open Archive

RATIONALE:Caring for patients at the end of life is emotionally taxing and may contribute to burnout. Nevertheless, little is known about the factors associated with emotional distress in intensive care unit (ICU) nurses.OBJECTIVES:To identify patient and family factors associated with nurses' emotional distress in caring for dying patients in the ICU.METHODS:One hundred nurses who cared for 200 deceased ICU patients at two large academic medical centers in the Northeast United States were interviewed about patients' psychological and physical symptoms, their reactions to those patient experiences (e.g., emotional distress), and perceived factors contributing to their emotional distress. Logistic regression analyses modeled nurses' emotional distress as a function of patient symptoms and care.RESULTS:Patients' overall quality of death (odds ratio [OR], 3.08; 95% confidence interval [CI], 1.31-7.25), suffering (OR, 2.34; CI, 1.03-5.29), and loss of dignity (OR, 2.95; CI, 1.19-7.29) were significantly associated with nurse emotional distress. Some 40.5% (79 of 195) of nurses identified families' fears of patient death, and 34.4% (67 of 195) identified families' unrealistic expectations as contributing to their own emotional distress.CONCLUSIONS:Patients' emotional distress, physical distress, and perceived quality of death are associated with nurse emotional distress. Unrealistic family expectations for the patient may be a source of nurse emotional distress. Improving patients' quality of death, including enhancing their dignity, reducing their suffering, and promoting acceptance of an impending death among family members may improve the emotional health of nurses.

Since its invention 50 years ago, 3D printing technology has progressed at a rapid pace, with significant impact in both the industrial and commercial world. Stereolithography, selective laser sintering, and fused deposition modeling were among the first widely successful methods of 3D printing, initially used for industrial prototyping. 3D printing technology was soon developed for use in a variety of fields, for large-scale manufacturing, engineering of highly complex parts, and even for personal use. In healthcare in particular, 3D printing facilitates more patient-specific interventions, including surgical planning and implant design. Additionally, 3D bioprinting technology plays an integral role in the advancement of tissue engineering and biomedical research. As 3D printing continues to become more sophisticated, it is likely to have a great influence on healthcare in the future.

Journal of Palliative MedicineVol. 20, No. 10 Letters to the EditorUrinary Incontinence and Quality of Death in the Intensive Care UnitBilal Chughtai, Li Westman, Paul K. Maciejewski, Amanda Su, Lindsay Lief, David Berlin, and Holly G. PrigersonBilal ChughtaiDepartment of Urology, Weill Cornell Medicine-New York Presbyterian Hospital, New York, New York.Search for more papers by this author, Li WestmanDepartment of Epidemiology, University of Nebraska Medical Center College of Public Health, Omaha, Nebraska.Search for more papers by this author, Paul K. MaciejewskiDepartment of Radiology, Weill Cornell Medicine-New York Presbyterian Hospital, New York, New York.Division of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medicine-New York Presbyterian, New York, New York.Center for Research on End of Life Care, Weill Cornell Medicine-New York Presbyterian Hospital, New York, New York.Search for more papers by this author, Amanda SuWeill Cornell Medicine-New York Presbyterian Hospital, New York, New York.Search for more papers by this author, Lindsay LiefDivision of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine-New York Presbyterian Hospital, New York, New York.Search for more papers by this author, David BerlinDivision of Pulmonary and Critical Care Medicine, Department of Medicine, Weill Cornell Medicine-New York Presbyterian Hospital, New York, New York.Search for more papers by this author, and Holly G. PrigersonDivision of Geriatrics and Palliative Medicine, Department of Medicine, Weill Cornell Medicine-New York Presbyterian, New York, New York.Center for Research on End of Life Care, Weill Cornell Medicine-New York Presbyterian Hospital, New York, New York.Search for more papers by this authorPublished Online:1 Oct 2017https://doi.org/10.1089/jpm.2017.0256AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"Urinary Incontinence and Quality of Death in the Intensive Care Unit." Journal of Palliative Medicine, 20(10), pp. 1054–1055FiguresReferencesRelatedDetailsCited byTop Ten Tips Palliative Care Clinicians Should Know About Urological Care Martin H. Umbehr, Adrian Wagg, Muhammad Hamza Habib, Jodi A. Antonelli, Bilal Chughtai, Thomas L. Jang, Alain Kaldany, Biren Saraiya, Ryan D. 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Maciejewski, Amanda Su, Lindsay Lief, David Berlin, and Holly G. Prigerson.Urinary Incontinence and Quality of Death in the Intensive Care Unit.Journal of Palliative Medicine.Oct 2017.1054-1055.http://doi.org/10.1089/jpm.2017.0256Published in Volume: 20 Issue 10: October 1, 2017Online Ahead of Print:June 30, 2017PDF download

Introduction: Statin therapy effectively prevents cardiovascular events. Non-statin lipid-lowering drug therapy (NS-LLDT) is typically used as second-line therapy in patients intolerant to statins....