3 research outputs found
Variations in end-of-life practices in intensive care units worldwide (Ethicus-2): a prospective observational study.
BACKGROUND
End-of-life practices vary among intensive care units (ICUs) worldwide. Differences can result in variable use of disproportionate or non-beneficial life-sustaining interventions across diverse world regions. This study investigated global disparities in end-of-life practices.
METHODS
In this prospective, multinational, observational study, consecutive adult ICU patients who died or had a limitation of life-sustaining treatment (withholding or withdrawing life-sustaining therapy and active shortening of the dying process) during a 6-month period between Sept 1, 2015, and Sept 30, 2016, were recruited from 199 ICUs in 36 countries. The primary outcome was the end-of-life practice as defined by the end-of-life categories: withholding or withdrawing life-sustaining therapy, active shortening of the dying process, or failed cardiopulmonary resuscitation (CPR). Patients with brain death were included in a separate predefined end-of-life category. Data collection included patient characteristics, diagnoses, end-of-life decisions and their timing related to admission and discharge, or death, with comparisons across different regions. Patients were studied until death or 2 months from the first limitation decision.
FINDINGS
Of 87 951 patients admitted to ICU, 12 850 (14·6%) were included in the study population. The number of patients categorised into each of the different end-of-life categories were significantly different for each region (p<0·001). Limitation of life-sustaining treatment occurred in 10 401 patients (11·8% of 87 951 ICU admissions and 80·9% of 12 850 in the study population). The most common limitation was withholding life-sustaining treatment (5661 [44·1%]), followed by withdrawing life-sustaining treatment (4680 [36·4%]). More treatment withdrawing was observed in Northern Europe (1217 [52·8%] of 2305) and Australia/New Zealand (247 [45·7%] of 541) than in Latin America (33 [5·8%] of 571) and Africa (21 [13·0%] of 162). Shortening of the dying process was uncommon across all regions (60 [0·5%]). One in five patients with treatment limitations survived hospitalisation. Death due to failed CPR occurred in 1799 (14%) of the study population, and brain death occurred in 650 (5·1%). Failure of CPR occurred less frequently in Northern Europe (85 [3·7%] of 2305), Australia/New Zealand (23 [4·3%] of 541), and North America (78 [8·5%] of 918) than in Africa (106 [65·4%] of 162), Latin America (160 [28·0%] of 571), and Southern Europe (590 [22·5%] of 2622). Factors associated with treatment limitations were region, age, and diagnoses (acute and chronic), and country end-of-life legislation.
INTERPRETATION
Limitation of life-sustaining therapies is common worldwide with regional variability. Withholding treatment is more common than withdrawing treatment. Variations in type, frequency, and timing of end-of-life decisions were observed. Recognising regional differences and the reasons behind these differences might help improve end-of-life care worldwide.
FUNDING
None
Variations in end-of-life practices in intensive care units worldwide (Ethicus-2): a prospective observational study
Background End-of-life practices vary among intensive care units (ICUs)
worldwide. Differences can result in variable use of disproportionate or
non-beneficial life-sustaining interventions across diverse world
regions. This study investigated global disparities in end-of-life
practices. Methods In this prospective, multinational, observational
study, consecutive adult ICU patients who died or had a limitation of
life-sustaining treatment (withholding or withdrawing life-sustaining
therapy and active shortening of the dying process) during a 6-month
period between Sept 1, 2015, and Sept 30, 2016, were recruited from 199
ICUs in 36 countries. The primary outcome was the end-of-life practice
as defined by the end-of-life categories: withholding or withdrawing
life-sustaining therapy, active shortening of the dying process, or
failed cardiopulmonary resuscitation (CPR). Patients with brain death
were included in a separate predefined end-of-life category. Data
collection included patient characteristics, diagnoses, end-of-life
decisions and their timing related to admission and discharge, or death,
with comparisons across different regions. Patients were studied until
death or 2 months from the first limitation decision. Findings Of 87 951
patients admitted to ICU, 12 850 (14middot6%) were included in the
study population. The number of patients categorised into each of the
different end-of-life categories were significantly different for each
region (p<0middot001). Limitation of life-sustaining treatment occurred
in 10 401 patients (11middot8% of 87 951 ICU admissions and 80middot9%
of 12 850 in the study population). The most common limitation was
withholding life-sustaining treatment (5661 [44middot1%]), followed
by withdrawing life-sustaining treatment (4680 [36middot4%]). More
treatment withdrawing was observed in Northern Europe (1217
[52middot8%] of 2305) and Australia/New Zealand (247 [45middot7%]
of 541) than in Latin America (33 [5middot8%] of 571) and Africa (21
[13middot0%] of 162). Shortening of the dying process was uncommon
across all regions (60 [0middot5%]). One in five patients with
treatment limitations survived hospitalisation. Death due to failed CPR
occurred in 1799 (14%) of the study population, and brain death
occurred in 650 (5middot1%). Failure of CPR occurred less frequently in
Northern Europe (85 [3middot7%] of 2305), Australia/New Zealand (23
[4middot3%] of 541), and North America (78 [8middot5%] of 918)
than in Africa (106 [65middot4%] of 162), Latin America (160
[28middot0%] of 571), and Southern Europe (590 [22middot5%] of
2622). Factors associated with treatment limitations were region, age,
and diagnoses (acute and chronic), and country end-of-life legislation.
Interpretation Limitation of life-sustaining therapies is common
worldwide with regional variability. Withholding treatment is more
common than withdrawing treatment. Variations in type, frequency, and
timing of end-of-life decisions were observed. Recognising regional
differences and the reasons behind these differences might help improve
end-of-life care worldwide. Funding None. Copyright (c) 2021 Elsevier
Ltd. All rights reserved
\u3ci\u3eDrosophila\u3c/i\u3e Muller F Elements Maintain a Distinct Set of Genomic Properties Over 40 Million Years of Evolution
The Muller F element (4.2 Mb, ~80 protein-coding genes) is an unusual autosome of Drosophila melanogaster; it is mostly heterochromatic with a low recombination rate. To investigate how these properties impact the evolution of repeats and genes, we manually improved the sequence and annotated the genes on the D. erecta, D. mojavensis, and D. grimshawi F elements and euchromatic domains from the Muller D element. We find that F elements have greater transposon density (25–50%) than euchromatic reference regions (3–11%). Among the F elements, D. grimshawi has the lowest transposon density (particularly DINE-1: 2% vs. 11–27%). F element genes have larger coding spans, more coding exons, larger introns, and lower codon bias. Comparison of the Effective Number of Codons with the Codon Adaptation Index shows that, in contrast to the other species, codon bias in D. grimshawi F element genes can be attributed primarily to selection instead of mutational biases, suggesting that density and types of transposons affect the degree of local heterochromatin formation. F element genes have lower estimated DNA melting temperatures than D element genes, potentially facilitating transcription through heterochromatin. Most F element genes (~90%) have remained on that element, but the F element has smaller syntenic blocks than genome averages (3.4–3.6 vs. 8.4–8.8 genes per block), indicating greater rates of inversion despite lower rates of recombination. Overall, the F element has maintained characteristics that are distinct from other autosomes in the Drosophila lineage, illuminating the constraints imposed by a heterochromatic milieu