5. Reluctance about end-of-life discussions
specific reasons to avoid
end-of-life discussion
most frequently observed
in Taiwan：
‘‘bad things happen after
you say them out loud’’
‘‘a bad life is better than
a good death’’
Medicine (Baltimore). 2015 Sep;94(39):e1573.
6. Role of family members
壞消息要先讓長輩
知道
所有家屬在最後一
刻出現是重要的
盡孝道
Medicine (Baltimore). 2015 Sep;94(39):e1573.
19. A TLT is an agreement between clinicians and a patient/family
to use certain medical therapies over a defined period
to see if the patient improves or deteriorates
according to agreed-on clinical outcomes
JAMA. 2011;306(13):1483–1484.
20. 5. Define potential actions at the end of the TLT
4. Suggest a time frame for reevaluation
3. Identify objective markers of improvement or deterioration
2. Clarify the patient’s goals and priorities
1. Define clinical problem and prognosis
TLTs：5 key sequential elements
JAMA. 2011;306(13):1483–1484.
22. JAMA Oncol. 2016 Jan;2(1):76-83.
The model was validated in 3 independent cohorts with 349, 158, and 117 participants
from quaternary care academic hospitals.
INTERVENTIONS
Time-unlimited vs time-limited trials of intensive care.
23. poor-prognosis solid tumors：
trials of ICU care lasting
1 to 4 days may be sufficient
hematologic malignant
neoplasms or less severe illness：
seem to benefit from
longer trials（10-12 days）
of intensive care.
JAMA Oncol. 2016 Jan;2(1):76-83.
27. J Am Coll Surg. 2010 Jan;210(1):17-22.
residents were given a special communication seminar at the beginning of
the rotation.
The seminar emphasized a shift from individual flawless performance to a
relational coordination model consisting of
frequent timely and accurate communication
mutual problem-solving
shared goals
mutual respect
溝通好照顧就好
34. “Early DNR”
– patients who had a DNR directive earlier than their last admission
EDNR patients died
‧ less frequently in the ICU
‧ less frequent mechanical ventilation
‧ more frequent non-invasive MV
‧ shorter length of hospital stay
International journal of chronic obstructive pulmonary disease, 13, 2447–2454.
35. J Pain Symptom Manage 2019; 58: 968-976.
Nearly 70% of DNR directives for COPD patients are
established during their terminal hospitalization
EDNR：
• less likely to be admitted to ICU
• lower total medical expenditures
• less likely to undergo invasive mechanical ventilator
36. 5 Strategies for Improvement
1. Reduce Inappropriate ICU Admissions
2. Reevaluate Goals of Care During the ICU Stay
3. Improve Shared Decision Making With Patients and Families
4. Improve Consensus Building Among the Entire Clinical Team
5. Make ICUs More Humane
