Evidence map›Paper›PMID 36007596›Full record

ArticleChest2023

"No Escalation of Treatment" Designations: A Multi-institutional Exploratory Qualitative Study.

Jason N Batten, Jacob A Blythe, Sarah E Wieten, Elizabeth Dzeng, Katherine E Kruse, Miriam P Cotler, Karin Porter-Williamson, Joshua B Kayser, Stephanie M Harman, David Magnus

Abstract readMulticenter Study
PubMed Full text at PMC Publisher
In one paragraph

Article in Chest, 2023. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 2 papers.

0numbers the graph read from it
0cells of the map it votes in
2citing papers in PubMed
–field-weighted citation impact
1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

2 citing papers in PubMed.

  1. Article
  2. Article
4 · The record

Corrections and comments

5 · Who and what money

Authors and funding

10 authors.

Jason N BattenStanford Center for Biomedical Ethics, Stanford University, Stanford, CA; Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA. Electronic address: jbatten@stanford.edu.
Jacob A BlytheStanford Center for Biomedical Ethics, Stanford University, Stanford, CA; Department of Surgery, Massachusetts General Hospital, Boston, MA.
Sarah E WietenStanford Center for Biomedical Ethics, Stanford University, Stanford, CA; Department of Philosophy, Durham University, Durham, England.
Elizabeth DzengDepartment of Medicine, University of California San Francisco, San Francisco, CA.
Katherine E KruseStanford Center for Biomedical Ethics, Stanford University, Stanford, CA; Department of Critical Care, Children's Minnesota, Minneapolis, MN.
Miriam P CotlerDepartment of Health Sciences, California State University Northridge, Northridge, CA.
Karin Porter-WilliamsonDepartment of Internal Medicine, University of Kansas, Lawrence, KS.
Joshua B KayserDepartment of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA; Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA.
Stephanie M HarmanDepartment of Medicine, Stanford University, Stanford, CA.
David MagnusStanford Center for Biomedical Ethics, Stanford University, Stanford, CA.

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

backgroundNo Escalation of Treatment (NoET) designations are used in ICUs internationally to limit treatment for critically ill patients. However, they are the subject of debate in the literature and have not been qualitatively studied. RESEARCH QUESTION: How do physicians understand and perceive NoET designations, especially regarding their usefulness and associated challenges? What mechanisms do hospitals provide to facilitate the use of NoET designations? STUDY DESIGN AND

methodsQualitative study at seven US hospitals, employing semistructured interviews with 30 physicians and review of relevant institutional records (eg, hospital policies, screenshots of ordering menus in the electronic health record).

resultsAt all hospitals, participants reported the use of NoET designations, which were understood to mean that providers should withhold new or higher-intensity interventions ("escalations") but not withdraw ongoing interventions. Three hospitals provided a specific mechanism for designating a patient as NoET (eg, a DNR/Do Not Escalate code status order); at the remaining hospitals, a variety of informal methods (eg, verbal hand-offs) were used. We identified five functions of NoET designations: (1) Defining an intermediate point of treatment limitation, (2) helping physicians navigate prearrest clinical decompensations, (3) helping surrogate decision-makers transition toward comfort care, (4) preventing patient harm from invasive measures, and (5) conserving critical care resources. Across hospitals, participants reported implementation challenges related to the ambiguity in meaning of NoET designations.

interpretationDespite ongoing debate, NoET designations are used in a varied sample of hospitals and are perceived as having multiple functions, suggesting they may fulfill an important need in the care of critically ill patients, especially at the end of life. The use of NoET designations can be improved through the implementation of a formal mechanism that encourages consistency across providers and clarifies the meaning of "escalation" for each patient.

Indexed as

Critical IllnessPhysiciansCritical CareHumansIntensive Care Unitscritical careend-of-life careethicsICUpatient comfortresuscitation orderswithholding treatment

Identifiers

PMID36007596
PMCPMC9993335

What OpenQuestion holds

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Registered trials

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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.