Background: Hospitalized adults receiving end-of-life care frequently face complex medical decisions that can generate stress and uncertainty for patients and families. Inpatient palliative care consultations aim to support goal-concordant decision-making, improve satisfaction, and reduce potentially non-beneficial interventions, yet their overall effectiveness across hospital settings remains uncertain. Objective: To evaluate the impact of inpatient palliative care consultations on clinical decision-making, satisfaction, psychological outcomes, and healthcare utilization among hospitalized adults. Methods: We performed a systematic review and meta-analysis of randomized controlled trials comparing palliative care consultations to usual care in hospitalized adults. Searches were carried out in MEDLINE, Embase, CINAHL, Cochrane CENTRAL, and PsycINFO to identify relevant studies. Three reviewers independently screened studies and evaluated study quality using the Cochrane RoB 2 tool. The risk of bias for each study will be evaluated, and the overall certainty of evidence will be assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Where applicable, results from multiple studies will be combined using statistical methods that account for variability between studies. We will perform subgroup analyses to examine whether effects varied by hospital setting (ICU vs non-ICU), patient population (cancer vs non-cancer) or whether consultations were default or clinician-initiated. Key outcomes include decisions to withhold or withdraw treatments, patient and family satisfaction, psychological outcomes, ICU and hospital length of stay, and administration of potentially non-beneficial interventions. Results: Searches identified 6,680 unique records. After screening, 250 studies underwent full-text review, with 150 included in the analysis. Included studies examined populations with conditions such as cancer, heart failure, and chronic obstructive pulmonary disease. Conclusions: Inpatient palliative care consultations influence decision-making and care utilization in hospitalized adults. Future research should explore the integration of palliative care across inpatient and outpatient settings, particularly for patients with chronic illnesses transitioning from hospital to ambulatory follow-up.

BACKGROUND:Chronic obstructive pulmonary disease (COPD) contributes substantially to morbidity, mortality, and healthcare costs. For patients with chronic respiratory failure, long-term home non-invasive ventilation (LTHNIV) is an effective therapy, yet existing guidelines offer little direction on the most effective initiation and organization of care. We review current LTH-NIV implementation and management strategies and factors that facilitate or hinder successful treatment. METHODS:A systematic review of studies investigating the organization and implementation of LTHNIV for COPD patients was performed. Studies reporting primary clinical, economic, or organizational data on LTHNIV with home-based care were included, with a particular focus on interventions aiming to improve outcomes or care organization. The findings were synthesized narratively. PROSPERO:CRD42025648464. FINDINGS:From 870 records, 46 studies were included. The majority were from Europe, with fewer studies from Asia and North America. Differences in how LTHNIV is delivered to COPD patients were identified, with variation in initiation settings, stakeholder involvement, and follow-up strategies. Hospital-based initiation remained common, although outpatient and home-based models, often supported by remote titration or telemonitoring, were increasingly used. Follow-up was typically scheduled every 3-6 months across outpatient, inpatient, and home-based modalities. Successful care relied on patient education, technical support, and structured follow-up, supported by remote consultations. These new strategies promise improved patient comfort, adherence, communication, and collection of patient-centred outcomes. Telemonitoring emerged as a promising adjunct, enhancing individualized care, facilitating closer follow-up and early identification of technical or clinical issues. INTERPRETATION:The delivery of LTHNIV remains heterogeneous, even within countries. This variability in care organization and reporting mandates establishing harmonized, patient-centred pathways that integrate telemonitoring and coordinate collaboration among stakeholders, ensuring that patients and their caregivers remain central to the care process.

The organisation and implementation of long-term home noninvasive ventilation treatment for COPD patients across Europe is complex and heterogeneous. Further research and experience sharing is required to optimise and align the patient pathway. https://bit.ly/3M3r566.

Combat and sport require individuals to be ready for successful completion of the task at hand. Cognitive readiness and attention may be impaired for many reasons, including concussion or subconcussive injury, insufficient sleep, fatigue, or any other disruption or deviation of baseline physiology. While rapid readiness screening may identify individuals who are not "ready" for a given task, it is also important to find interventions which can rapidly return an individual to a state of readiness. Although general health practices such as nutrition, physical conditioning, and adequate rest support overall performance, targeted interventions-focused on oculo-vestibular, verbal-cognitive function, and motor control-may accelerate return to readiness. Additional modalities such as structured sleep optimization protocols, controlled stimulant use, and specific supplements may also contribute to rapid restoration. This paper describes an evidence-based framework for developing guidelines that identify, evaluate, and implement rapid readiness restoration strategies across diverse preclinical settings, including military far-forward environments, sports sidelines, and garrison or training contexts.

During COVID-19, most intensive care units (ICUs) in Canada implemented strategies to manage a surge in demand for critical care to avoid turning people away, termed “triage-avoidant strategies.” These strategies, including redeploying non-ICU staff to the ICU to increase patient capacity, and transferring people over long distances to available beds, may have caused negative consequences for patients, healthcare staff, and equity-deserving groups. This study explores the perspectives of equity-deserving groups and organizations on triage-avoidant strategies during COVID-19, examined organization-specific responses, and identified system-level recommendations to improve equity, access, and preparedness. A qualitative descriptive study was conducted between July and December 2023 across five provinces in Canada. Participants, including staff from organizations serving equity-deserving groups, as well as government and healthcare representatives, were recruited through professional networks and snowball sampling. A semi-structured interview guide was used to elicit perspectives, which were then analyzed inductively using thematic analysis. 23 individuals from Ontario (n=12), British Columbia (n=4), Saskatchewan (n=4), Nova Scotia (n=2) and New Brunswick (n=1) participated. 15 participants (65%) identified as persons of colour or among equity-deserving groups; 13 (57%) participants worked within organizations representing decision-makers, clinicians, and/or equity-deserving groups. We identified three themes: 1) Triage-avoidant strategies were perceived to have disproportionately harmful effects on equity-deserving groups and healthcare providers; 2) organizations acted to mitigate effects of triage-avoidant strategies; and 3) various system-level actions could help mitigate the perceived effects of these strategies in future surges in demand. This study contributes to the literature by incorporating perspectives of representatives from diverse organizations and equity-deserving groups on how triage-avoidant strategies disproportionately harmed the populations they serve. Our findings can inform the development/implementation of triage-avoidant strategies that mitigate the perceived harmful effects on decision-makers, clinicians, and equity-deserving groups, while promoting equitable care. Twenty-three individuals from Ontario (n=12), British Columbia (n=4), Saskatchewan (n=4), Nova Scotia (n=2) and New Brunswick (n=1) participated. Fifteen participants (65%) identified as persons of color or from systemically marginalized groups; thirteen (57%) participants worked within organizations representing decision-makers, clinicians, and/or systemically marginalized groups, such as race, illness, disability, socioeconomic factors or health status. We identified three main themes relating to participants’ perspectives of triage-avoidant strategies: Triage-avoidant strategies had disproportionately harmful impacts on systemically marginalized populations and healthcare providers; organizations acted to mitigate effects of triage-avoidant strategies; and, various system-level actions could help mitigate the perceived effects of these strategies in the future. Findings can inform the development and implementation of triage or triage-avoidant strategies that may mitigate the perceived harmful effects of such strategies on decision-makers, clinicians, and/or systemically marginalized groups, and promote equitable care.

In combat and sport, there is an urgent need to identify readiness for performance to decide on removal from and return to activity. Cognitive readiness, including attention, can be impaired for many potentially coexisting reasons, including concussive or subconcussive injury, insufficient sleep/fatigue, and intoxication. Standard tests of concussion, sleep deprivation, and intoxication are often lengthy or require specialized skill or equipment to conduct. The ideal readiness screen should predict readiness or be associated with surrogate measures of readiness, be sensitive to multiple conditions that may impair readiness, and be reliable and rapid. This study outlines the methodology for an evidence-based process to develop multimodal rapid screening tests for readiness that are applicable across a broad range of environments, including military far-forward/sports sideline, garrison, and clinic.

RATIONALE: For staff in adult ICUs, providing family-centered care is an essential skill that affects important outcomes for both patients and families. The COVID-19 pandemic placed unprecedented strain on care of ICU families, and practices for family engagement and support are still adjusting. OBJECTIVES: To review updated evidence for family support in adult ICUs, provide clear recommendations, and spotlight optimal family-centered care practices post-pandemic. PANEL DESIGN: The multiprofessional guideline panel of 28 individuals, including family member partners, applied the processes described in the Society of Critical Care Medicine Standard Operating Procedures Manual to develop and publish evidence-based recommendations in alignment with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Conflict-of-interest policies were strictly followed in all phases of the guidelines, including panel selection, writing, and voting. METHODS: The guidelines consist of four content sections: engagement of families, support of family needs, communication support, and support of ICU clinicians providing family-centered care. We conducted systematic reviews for 15 Population, Intervention, Control, and Outcomes questions, organized among these content sections, to identify the best available evidence. We summarized and assessed the certainty of evidence using the GRADE approach. We used the GRADE evidence-to-decision framework to formulate recommendations as strong or conditional, or as best practice statements where appropriate. The recommendations were approved using an online vote requiring greater than 80% agreement of voting panel members to pass. RESULTS: Our panel issued 17 statements related to optimal family-centered care in adult ICUs, including one strong recommendation, 14 conditional recommendations, and two best practice statements. We reaffirmed the critical importance of liberalized family presence policies as default practice when possible and suggested options for family attendance on rounds and participation in bedside care. We suggested that ICUs provide support for families in the form of educational programs; ICU diaries; and mental health, bereavement, and spiritual support. We suggested the importance of providing structured communication for families and communication training for clinicians but did not recommend for or against any specific clinician-facing tools for family support or decision aids, based on current available evidence. We recommended that adult ICUs implement practices to systematically identify and reduce barriers to equitable critical care delivery for families and suggested that programs designed to support the wellbeing of clinicians responsible for family support be developed. CONCLUSIONS: Our guideline panel achieved consensus regarding recommendations and best practices for family-centered care in adult ICUs.

Importance:Delirium is common after cardiac surgery and associated with adverse outcomes. Intraoperative benzodiazepines may increase postoperative delirium but restricting intraoperative benzodiazepines has not yet been evaluated in a randomized trial. Objective:To determine whether an institutional policy of restricted intraoperative benzodiazepine administration reduced the incidence of postoperative delirium. Design, Setting, and Participants:This pragmatic, multiperiod, patient- and assessor-blinded, cluster randomized crossover trial took place at 20 North American cardiac surgical centers. All adults undergoing open cardiac surgery at participating centers during the trial period were included through a waiver of individual patient consent between November 2019 and December 2022. Intervention:Institutional policies of restrictive vs liberal intraoperative benzodiazepine administration were compared. Hospitals (clusters) were randomized to cross between the restricted and liberal benzodiazepine policies 12 to 18 times over 4-week periods. Main Outcomes and Measures:The primary outcome was the incidence of delirium within 72 hours of surgery as detected in routine clinical care, using either the Confusion Assessment Method-Intensive Care Unit or the Intensive Care Delirium Screening Checklist. Intraoperative awareness by patient report was assessed as an adverse event. Results:During the trial, 19 768 patients (mean [SD] age, 65 [12] years; 14 528 [73.5%] male) underwent cardiac surgery, 9827 during restricted benzodiazepine periods and 9941 during liberal benzodiazepine periods. During restricted periods, clinicians adhered to assigned policy in 8928 patients (90.9%), compared to 9268 patients (93.2%) during liberal periods. Delirium occurred in 1373 patients (14.0%) during restricted periods and 1485 (14.9%) during liberal periods (adjusted odds ratio [aOR], 0.92; 95% CI, 0.84-1.01; P = .07). No patient spontaneously reported intraoperative awareness. Conclusions and Relevance:In intention-to-treat analyses, restricting benzodiazepines during cardiac surgery did not reduce delirium incidence but was also not associated with an increase in the incidence of patient-reported intraoperative awareness. Given that smaller effect sizes cannot be ruled out, restriction of benzodiazepines during cardiac surgery may be considered. Research is required to determine whether restricting intraoperative benzodiazepines at the patient level can reduce the incidence of postoperative delirium. Trial Registration:ClinicalTrials.gov Identifier: NCT03928236.

Importance:The Sequential Organ Failure Assessment (SOFA) score was published in 1996 to describe organ dysfunction in critically ill adult patients in a readily quantifiable and sequential manner. Considerable changes have occurred over the last 3 decades in the use of organ support drugs and devices and in patient outcomes, necessitating revision of the score. Objectives:To develop definitions of organ dysfunction that reflect current understanding and to identify representative variables to generate a revised SOFA score (SOFA-2) of individual organ dysfunction. Evidence Review:A task force of experts in intensive care medicine and epidemiology generated definitions of organ dysfunction, identified relevant variables (physiological and laboratory data specific to the organ system, pharmacological and mechanical organ support), and proposed a 0 to 4-point grading of dysfunction severity through meetings, Delphi processes, and explicit rules, informed by data synthesis, including systematic reviews and meta-analysis. Variables were tested in 2 validation exercises using separate datasets totaling 3.34 million patients within 10 representative databases from diverse geographical and socioeconomic settings to assess distribution and predictive validity (mortality at intensive care unit discharge). Findings:A total of 60 experts participated, with 18 (30%) female participants. Overall, 65 countries were represented, with 33 (51%) from Europe and Central Asia, 13 (20%) from North America; and 8 (12%) from Latin America and the Caribbean. The physiological variables within the 6 organ systems used in the original SOFA score were retained, although some categories were renamed (ie, central nervous system was changed to brain, renal to kidney, coagulation to hemostasis, and hepatic to liver). Revisions of organ support drug and device variables were made to reflect current practice. Alternative variables were added for instances when laboratory data and/or organ support interventions would be inaccessible (eg, in some low-resource settings) or not indicated (eg, ceiling of treatment). Some point cutoff thresholds were modified based on evidence from systematic reviews and data analyses. Scores could not be developed for 2 additional organ systems (gastrointestinal and immune) due to insufficient data, complexity, or lack of content and predictive validity for the variables assessed. Explicit rules were developed to facilitate scoring consistency. Conclusions and Relevance:Through a methodologically robust development process, the SOFA-2 score offers updated definitions to describe organ dysfunction in adult patients requiring critical care and readily quantifiable criteria to grade the degree of dysfunction in individual organ systems. This score considers contemporaneous changes in patient management and outcomes.

RATIONALE:Advances in technology, infection control challenges-as with the COVID-19 pandemic-and evolutions in patient- and family-centered care highlight ideal aspects of ICU design and opportunities for enhancement. OBJECTIVES:To provide evidence-based recommendations for clinicians, administrators, and healthcare architects to optimize design strategies in new or renovation projects. PANEL DESIGN:A guidelines panel of 27 members with experience in ICU design met virtually from the panel's inception in 2019 to 2024. The panel represented clinical professionals, architects, engineers, and clinician methodologists with expertise in developing evidence-based clinical practice guidelines. A formal conflict of interest policy was followed throughout the guidelines-development process. METHODS:Embase, Medline, CINAHL, Central, and Proquest were searched from database inception to September 2023. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to determine certainty in the evidence and to formulate recommendations, suggestions, and practice statements for each Population, Intervention, Control, and Outcomes (PICO) question based on quality of evidence and panel consensus. Recommendations were provided when evidence was actionable; suggestions, when evidence was equivocal; and practice statements when the benefits of the intervention appeared to outweigh the risks, but direct evidence to support the intervention did not exist. RESULTS:The ICU Guidelines panel issued 17 recommendations based on 15 PICO questions relating to ICU architecture and design. The panel strongly recommends high-visibility ICU layouts, windows and natural lighting in all patient rooms to enhance sleep and recovery. The panel suggests integrated staff break/respite spaces, advanced infection prevention features, and flexible surge capacity. Because of insufficient evidence, the panel could not make a recommendation around in-room supplies, decentralized charting, and advanced heating, ventilation, and air conditioning systems. CONCLUSIONS:This ICU design guidelines is intended to provide expert guidance for clinicians, administrators, and healthcare architects considering erecting a new ICU or revising an existing structure.

Introduction Hospitalised patients nearing the end of life (EOL) often face complex treatment decisions, leading to potential conflicts among care teams, patients and families. Palliative care consultations may enhance decision-making processes, improve satisfaction and reduce unnecessary interventions. This systematic review will assess the impact of palliative care consultations on treatment decisions, family and patient satisfaction, and psychological outcomes in hospitalised adults.Methods and analysis We will include randomised controlled trials comparing palliative care consultations to standard care in hospitalised adults. The primary outcomes will include decisions to withhold or withdraw treatments, patient and family satisfaction with EOL decision-making, and psychological outcomes such as anxiety, depression and post-traumatic stress disorder. Secondary outcomes will include intensive care unit (ICU) and hospital length of stay, utilisation of potentially non-beneficial treatments, and the use of institutional policies or legal actions. Databases including MEDLINE, Embase, CINAHL, Cochrane CENTRAL and PsycINFO will be systematically searched from inception to September 2025. Two independent reviewers will screen studies and extract data using Covidence. Meta-analyses will use random-effects models to generate pooled estimates for primary and secondary outcomes. Risk of bias will be assessed using the Cochrane Risk of Bias 2 tool, and evidence certainty will be evaluated using the Grading of Recommendations Assessment, Development and Evaluation approach. Subgroup analyses will explore variations by ICU versus non-ICU settings, cancer versus non-cancer diagnoses and default versus clinician-initiated consultations.Ethics and dissemination Ethical approval is not required for this review. Findings will be disseminated through peer-reviewed publications and conference presentations.PROSPERO registration number CRD420250624190.

Importance:Acute dysfunction of vital organs is the hallmark of critical illness. The Sequential Organ Failure Assessment (SOFA) score, the most widely adopted approach to describe organ dysfunction, has not been updated in 30 years and therefore may not appropriately capture current clinical practice and outcomes. Objectives:To inform the data-driven component of an updated score (SOFA-2) in varied geographical and resource settings (stages 6-8) after expert input via a modified Delphi process (stages 1-5). Design, Setting, and Participants:A federated analysis was performed on data collected from adult patients admitted to 1319 intensive care units (ICUs) in 9 countries (Australia, Austria, Brazil, France, Italy, Japan, Nepal, New Zealand, United States) between 2014 and 2023. Four representative multicenter cohorts containing data from 2 098 356 patients were used for data-driven score development and internal validation. External validation was performed on 6 cohorts containing data from 1 241 114 patients. Main Outcomes and Measures:Content validity for organ dysfunction identified through the modified Delphi process should be reflected by predictive validity using the area under the receiver operating characteristic (AUROC) curve of the score measured on the first ICU day (higher scores indicate worse organ dysfunction). Results:Of 3.34 million patient encounters, 270 108 (8.1%) died in the ICU (range, 4.5% to 20.5% across the 10 cohorts). SOFA-2 modified the 6 organ systems of the original SOFA score (brain, respiratory, cardiovascular, liver, kidney, hemostasis), including new variables and revised thresholds that better describe the organ dysfunction distribution from 0 to 4 points and their associated mortality (SOFA-2 AUROC, 0.79; 95% CI, 0.76-0.81; SOFA-1 AUROC, 0.77; 95% CI, 0.74-0.81). Evaluation of sequential SOFA-2 data from ICU day 1 to day 7 maintained its predictive validity. Insufficient data and lack of content validity precluded incorporation of gastrointestinal and immune dysfunction scores into SOFA-2. Conclusions and Relevance:The SOFA-2 score, updated to include contemporary organ support treatments and new score thresholds, describes organ dysfunction in a large, geographically and socioeconomically diverse population of critically ill adults.

BACKGROUND:The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach is the de facto standard framework for summarising evidence in systematic reviews and developing recommendations in clinical practice guidelines. METHODS:We describe how the GRADE approach is used in clinical practice guidelines, including key points and examples. The intended audience of this overview of GRADE is clinicians and researchers who are, or plan to be, involved in the development or assessment of clinical practice guidelines. RESULTS:We cover guideline endorsement and adaptation; guideline panels and sponsors; conflicts of interest; guideline questions and outcome prioritisation; systematic review creation, updating and re-use; rating the overall certainty of evidence; development of recommendations and implications; and peer review, publication, implementation and updating of guidelines. CONCLUSIONS:This overview aims to help developers, assessors and users of clinical practice guidelines understand how trustworthy, high-quality guidelines are developed using the GRADE approach.