Understanding the treatment preferences of seriously ill patients

Long-term mortality and quality of life after prolonged mechanical ventilation

OBJECTIVE

To describe and identify factors associated with mortality rate and quality of life 1 yr after prolonged mechanical ventilation.

DESIGN

Prospective, observational cohort study with patient recruitment over 26 months and follow-up for 1 yr.

SETTING

Intensive care units at a tertiary care university hospital.

PATIENTS

Adult patients receiving prolonged mechanical ventilation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We measured mortality rate and functional status, defined as the inability to perform instrumental activities of daily living (IADLs) 1 yr following prolonged mechanical ventilation. The study enrolled 817 patients. Their median age was 65 yrs, 46% were women, and 44% were alive at 1 yr. Median ages at baseline of 1-yr survivors and nonsurvivors were 53 and 71 yrs, respectively. At the time of admission to the hospital, survivors had fewer comorbidities, lower severity of illness score, and less dependence compared with nonsurvivors. Severity of illness on admission to the intensive care unit and prehospitalization functional status had a significant association with short-term mortality rate, whereas age and comorbidities were related to long-term mortality. Fifty-seven percent of the surviving patients needed caregiver assistance at 1 yr of follow-up. The odds of having IADL dependence at 1-yr among survivors was greater in older patients (odds ratio 1.04 for 1-yr increase in age) and those with IADL dependence before hospitalization (odds ratio 2.27).

CONCLUSIONS

Mortality rate after prolonged mechanical ventilation is high. Long-term mortality rate is associated with older age and poor prehospitalization functional status. Many survivors needed assistance after discharge from the hospital, and more than half still required caregiver assistance at 1 yr. Interventions providing support for caregivers and patients may improve the functional status and quality of life of both groups and thus need to be evaluated.

Improving care for patients dying in the intensive care unit

It is impossible for ICU clinicians to avoid caring for dying patients and their families. For many, this is an extremely rewarding aspect of their clinical practice. There is ample evidence that there is room to improve the care of patients who are near death in the ICU. Despite the considerable holes in our knowledge about optimal care of dying critically ill patients, there is considerable agreement on the general principles of caring for these patients and about how to measure the outcomes of palliative care in the ICU. Practical approaches to improving the quality of end-of-life care exist and should be implemented.

The end of the disease era

The time has come to abandon disease as the focus of medical care. The changed spectrum of health, the complex interplay of biological and nonbiological factors, the aging population, and the interindividual variability in health priorities render medical care that is centered on the diagnosis and treatment of individual diseases at best out of date and at worst harmful. A primary focus on disease may inadvertently lead to undertreatment, overtreatment, or mistreatment. The numerous strategies that have evolved to address the limitations of the disease model, although laudable, are offered only to a select subset of persons and often further fragment care. Clinical decision making for all patients should be predicated on the attainment of individual goals and the identification and treatment of all modifiable biological and nonbiological factors, rather than solely on the diagnosis, treatment, or prevention of individual diseases. Anticipated arguments against a more integrated and individualized approach range from concerns about medicalization of life problems to "this is nothing new" and "resources would be better spent determining the underlying biological mechanisms." The perception that the disease model is "truth" rather than a previously useful model will be a barrier as well. Notwithstanding these barriers, medical care must evolve to meet the health care needs of patients in the 21st century.

Current opinions regarding the importance, diagnosis, and management of delirium in the intensive care unit: A survey of 912 healthcare professionals*

OBJECTIVE

Recently published clinical practice guidelines of the Society of Critical Care Medicine recommend monitoring for the presence of delirium in all mechanically ventilated patients because of the potential for adverse outcomes associated with this comorbidity, yet little is known about healthcare professionals' opinions regarding intensive care unit delirium or how they manage this organ dysfunction. The aim of this survey was to assess the medical community's beliefs and practices regarding delirium in the intensive care unit.

DESIGN

Survey administration was conducted both without a delirium definition (phase 1) and then with a definition of delirium (phase 2).

SETTING

Critical care meetings and continuing medical education/board review courses from October 2001 to July 2002.

PARTICIPANTS

A convenience sample of physicians (n = 753), nurses (n = 113), pharmacists (n = 13), physician assistants (n = 12), respiratory care practitioners (n = 8), and others (n = 13).

INTERVENTIONS

Survey.

MEASUREMENTS AND MAIN RESULTS

Participants completed 912 of the surveys. The majority (68%) of respondents thought that >25% of adult mechanically ventilated patients experience delirium. Delirium was considered a significant or very serious problem in the intensive care unit by 92% of healthcare professionals, yet underdiagnosis was acknowledged by 78%. Only 40% reported routinely screening for delirium, and only 16% indicated using a specific tool for delirium assessment. Delirium was considered important in the outcome of elderly and young patients by 89% and 60% of the respondents, respectively (p <.0001). The most serious complications these professionals associated with delirium were prolonged mechanical ventilation, self-injury, and respiratory difficulties. Delirium was treated with haloperidol by 66% of the respondents, with lorazepam by 12%, and with atypical antipsychotics by <5%. More than 55% administered haloperidol and lorazepam at daily doses of < or =10 mg, but some used >50 mg/day of either medication.

CONCLUSIONS

Most healthcare professionals consider delirium in the intensive care unit a common and serious problem, although few actually monitor for this condition and most admit that it is underdiagnosed. Data from this survey point to a disconnect between the perceived significance of delirium in the intensive care unit and current practices of monitoring and treatment.

Decisions to forgo life-sustaining therapy in ICU patients independently predict hospital death

OBJECTIVE

More than one-half the deaths of patients admitted to intensive care units (ICUs) occur after a decision to forgo life-sustaining therapy (DFLST). Although DFLSTs typically occur in patients with severe comorbidities and intractable acute medical disorders, other factors may influence the likelihood of DFLSTs. The objectives of this study were to describe the factors and mortality associated with DFLSTs and to evaluate the potential independent impact of DFLSTs on hospital mortality.

DESIGN AND SETTING

Prospective multicenter 2-year study in six ICUs in France.

PATIENTS

The 1,698 patients admitted to the participating ICUs during the study period, including 295 (17.4%) with DFLSTs.

MEASUREMENTS AND RESULTS

The impact of DFLSTs on hospital mortality was evaluated using a model that incorporates changes in daily logistic organ dysfunction scores during the first ICU week. Univariate predictors of death included demographic factors (age, gender), comorbidities, reasons for ICU admission, severity scores at ICU admission, and DFLSTs. In a stepwise Cox model five variables independently predicted mortality: good chronic health status (hazard ratio, 0.479), SAPS II score higher than 39 (2.05), chronic liver disease (1.463), daily logistic organ dysfunction score (1.357 per point), and DFLSTs (1.887).

CONCLUSIONS

DFLSTs remain independently associated with death after adjusting on comorbidities and severity at ICU admission and within the first ICU week. This highlights the need for further clarifying the many determinants of DFLSTs and for routinely collecting DFLSTs in studies with survival as the outcome variable of interest.

Waiting for the Platelet Count to Rise: Negotiating Care at the End of Life

Oncologists play a crucial role in enabling patients at the end of life and their families to decide whether the burden of chemotherapy is worth the benefit. Using language that displays their concern for providing ongoing care and that does not mistakenly imply withholding of effective therapies can ease the transition off chemotherapy. Providing accurate, timely prognostic information; exploring patients' hopes, goals, and values; helping them resume meaningful activities; meeting their health care proxies and discussing the advance care plan with them can all enhance the relationship with patients at the end of life and ease fears of abandonment.

Update in palliative medicine and end-of-life care

Palliative medicine includes clinical palliative care, education, and research that focus on the quality of life of patients with advanced disease and their families. The domain of palliative medicine is the relief of suffering: physical, psychological, social, and spiritual. Palliative medicine and care for patients at the end of life and their families include the following key components: compassionate communication; exploration of patient and family values and goals of care; expert attention to relief of suffering; management of pain, depression, delirium, and other symptoms; awareness of the manifestations of grief; and sensitivity to the concerns of bereaved survivors.

Preventing Delirium at the End of Life: Lessons From Recent Research

Preservation of the ability to think clearly, in comfort, is a goal of end-of-life care. Recent research on delirium at the end of life suggests clinical strategies for prevention of cognitive impairment. Clinicians should consider early warnings of mild delirium such as impairment in attention and short-term memory by following the patient's ability to remember 3 words or to attend to digit span before the patient is disoriented. If cognitive impairment is noted, clinicians should pay attention to reversible causes. This article reviews clinical concerns about opiates, benzodiazepines, steroids, hepatic encephalopathy, timely use of neuroleptic medications, and caretaking strategies at home.

Triaging patients to the ICU: a pilot study of factors influencing admission decisions and patient outcomes

OBJECTIVE

To assess the appropriateness of ICU triage decisions. DESIGN. Prospective descriptive single-center study.

SETTING

Ten-bed, medical-surgical ICU in an acute-care 460-bed, tertiary care hospital.

PATIENTS

All patients triaged for admission were entered prospectively.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Age, underlying diseases, admission diagnoses, Mortality Probability Model (MPM0) score, information available to ICU physicians, and mortality were recorded. Of the 334 patients (96% medical), 145 (46.4%) were refused. Reasons for refusal were being too-sick-to-benefit (48, 14%) and too-well-to-benefit (93, 28%). Factors independently associated with refusal were patient location, ICU physician seniority, bed availability, patient age, underlying diseases, and disability. Hospital mortality was 23% and 27% for patients admitted to our ICU and other ICUs, respectively, and 7.5% and 60% for patients too well and too sick to benefit, respectively. In the multivariate Cox model, McCabe = 1 [hazard ratio (HR), 0.44 (95% CI, 0.24-0.77), P=0.001], living at home without help (HR, 0.440, 95% CI, 0.28-0.68, P=0.0003), and immunosuppression (HR, 1.91, 95% CI, 1.09-3.33, P=0.02) were independent predictors of hospital death. Neither later ICU admission nor refusal was associated with cohort survival. MPM0 was not associated with hospital mortality.

CONCLUSIONS

Refusal of ICU admission was related to the ability of the triaging physician to examine the patient, ICU physician seniority, patient age, underlying diseases, self-sufficiency, and number of beds available. Specific training of junior physicians in triaging might bring further improvements. Scores that are more accurate than the MPM0 are needed.

Hypoalbuminemia in acute illness: is there a rationale for intervention? A meta-analysis of cohort studies and controlled trials

OBJECTIVE

To determine whether hypoalbuminemia is an independent risk factor for poor outcome in the acutely ill, and to assess the potential of exogenous albumin administration for improving outcomes in hypoalbuminemic patients.

SUMMARY BACKGROUND DATA

Hypoalbuminemia is associated with poor outcomes in acutely ill patients, but whether this association is causal has remained unclear. Trials investigating albumin therapy to correct hypoalbuminemia have proven inconclusive.

METHODS

A meta-analysis was conducted of 90 cohort studies with 291,433 total patients evaluating hypoalbuminemia as an outcome predictor by multivariate analysis and, separately, of nine prospective controlled trials with 535 total patients on correcting hypoalbuminemia.

RESULTS

Hypoalbuminemia was a potent, dose-dependent independent predictor of poor outcome. Each 10-g/L decline in serum albumin concentration significantly raised the odds of mortality by 137%, morbidity by 89%, prolonged intensive care unit and hospital stay respectively by 28% and 71%, and increased resource utilization by 66%. The association between hypoalbuminemia and poor outcome appeared to be independent of both nutritional status and inflammation. Analysis of dose-dependency in controlled trials of albumin therapy suggested that complication rates may be reduced when the serum albumin level attained during albumin administration exceeds 30 g/L.

CONCLUSIONS

Hypoalbuminemia is strongly associated with poor clinical outcomes. Further well-designed trials are needed to characterize the effects of albumin therapy in hypoalbuminemic patients. In the interim, there is no compelling basis to withhold albumin therapy if it is judged clinically appropriate.

Ethics and decision making in end stage lung disease

Most physicians believe they do more good than harm, and these duties of helping and not harming the patient are rooted in the Hippocratic oath, the good Samaritan tradition, and the Order of the Knight Hospitallers founded in the 11th century to care for pilgrims and those wounded in the Crusades.(1) In recent times the simple principles of beneficence and non-maleficence have been augmented and sometimes challenged by a rising awareness of patient/consumer rights, and the public expectation of greater involvement in medical, social and scientific affairs which affect them. In a publicly funded healthcare system in which rationing (explicit or otherwise) is inevitable, the additional concepts of utility and distributive justice can easily come into conflict with the individual's right to autonomy. Possible treatment options for end stage lung disease include transplantation and long term invasive ventilation which are challenging in resource terms. Other interventions such as pulmonary rehabilitation and palliative care are relatively low cost but not uniformly accessible.

Care without chemotherapy: the role of the palliative care team

So--what will be your answer to the medical student? What should you tell Barbara and her family? That's up to you. But whatever you chose, you can be confident that you will be able to provide for her comfort and help her maximize her quality of life. When you share your most honest estimate of her prognosis and help her reframe her hope, you can increase the chance that she will be able to define and accomplish her last goals, bring closure to her life, and do the work that will minimize the pain of her bereaved family. You are not alone in this work: you can enlist hospice and palliative care teams to help you. With their help, you can promise Barbara the same expert care with or without chemotherapy And then . . . it's up to her.

Looking beyond 28-day all-cause mortality

A growing body of evidence indicates that survivors of intensive care have an impaired quality of life. It is not entirely clear from the available literature whether this impairment is a complication of critical illness or a complication of therapy. There is little evidence to guide physicians to treatments in the intensive care unit that will minimize the effects of critical illness on these sequelae. Although the study by Rublee and colleagues in this issue of Critical Care provides little clinically useful information about the effects of antithrombin III on quality of life, it provides some insight into the challenges that investigators will encounter as we try to incorporate these outcomes into studies of critical illness.