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Andersen SK, Yang Y, Kross EK, Haas B, Geagea A, May TL, Hart J, Bagshaw SM, Dzeng E, Fischhoff B, White DB. Achieving Goals of Care Decisions in Chronic Critical Illness: A Multi-Institutional Qualitative Study. Chest 2024; 166:107-117. [PMID: 38365177 PMCID: PMC11251076 DOI: 10.1016/j.chest.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 01/29/2024] [Accepted: 02/11/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Physicians, patients, and families alike perceive a need to improve how goals of care (GOC) decisions occur in chronic critical illness (CCI), but little is currently known about this decision-making process. RESEARCH QUESTION How do intensivists from various health systems facilitate decision-making about GOC for patients with CCI? What are barriers to, and facilitators of, this decision-making process? STUDY DESIGN AND METHODS We conducted semistructured interviews with a purposeful sample of intensivists from the United States and Canada using a mental models approach adapted from decision science. We analyzed transcripts inductively using qualitative description. RESULTS We interviewed 29 intensivists from six institutions. Participants across all sites described GOC decision-making in CCI as a complex, longitudinal, and iterative process that involved substantial preparatory work, numerous stakeholders, and multiple family meetings. Intensivists required considerable time to collect information on prior events and conversations, and to arrive at a prognostic consensus with other involved physicians prior to meeting with families. Many intensivists stressed the importance of scheduling multiple family meetings to build trust and relationships prior to explicitly discussing GOC. Physician-identified barriers to GOC decision-making included 1-week staffing models, limited time and cognitive bandwidth, difficulty eliciting patient values, and interpersonal challenges with care team members or families. Potential facilitators included scheduled family meetings at regular intervals, greater interprofessional involvement in decisions, and consistent messaging from care team members. INTERPRETATION Intensivists described a complex time- and labor-intensive group process to achieve GOC decision-making in CCI. System-level interventions that improve how information is shared between physicians and decrease logistical and relational barriers to timely and consistent communication are key to improving GOC decision-making in CCI.
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Affiliation(s)
- Sarah K Andersen
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada.
| | - Yanran Yang
- Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA; Global Health Research Center, Duke Kunshan University, Jiangsu, China
| | - Erin K Kross
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, WA; Cambia Palliative Care Center of Excellence at UW Medicine, Seattle, WA
| | - Barbara Haas
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Anna Geagea
- Division of Critical Care Medicine, Department of Medicine, North York General Hospital, Toronto, ON, Canada
| | - Teresa L May
- Department of Pulmonary and Critical Care, Maine Medical Center, Portland, ME
| | - Joanna Hart
- Palliative and Advanced Illness Research Center, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
| | - Elizabeth Dzeng
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Baruch Fischhoff
- Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA
| | - Douglas B White
- Program on Ethics and Decision Making, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Bushroe KM, Crisp KD, Politi MC, Brennan SK, Housten AJ. Evaluating caregiver-clinician communication for tracheostomy placement in the neonatal intensive care unit: a qualitative inquiry. J Perinatol 2024; 44:963-969. [PMID: 37833495 PMCID: PMC11014892 DOI: 10.1038/s41372-023-01793-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 09/07/2023] [Accepted: 09/26/2023] [Indexed: 10/15/2023]
Abstract
OBJECTIVE Identify stakeholders' tracheostomy decision-making information priorities in the Neonatal Intensive Care Unit (NICU). STUDY DESIGN English-speaking caregivers and clinicians who participated in NICU tracheostomy discussions between January 2017 and December 2021 were eligible. They reviewed a pediatric tracheostomy communication guide prior to meeting. Interviews focused on tracheostomy decision-making experiences, communication preferences, and guide perceptions. Interviews were recorded, transcribed, and analyzed using iterative inductive/deductive coding to inform thematic analysis. RESULTS Ten caregivers and nine clinicians were interviewed. Caregivers were surprised by the severity of their child's diagnosis and the intensive home care required, but proceeded with tracheostomy because it was the only chance for survival. All recommended that tracheostomy information be introduced early and in phases. Inadequate communication limited caregivers' understanding of post-surgical care and discharge requirements. All felt a guide could standardize communication. CONCLUSIONS Caregivers seek detailed information regarding expectations after tracheostomy placement in the NICU and at home.
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Affiliation(s)
- Kylie M Bushroe
- Department of Pediatrics, Division of Newborn Medicine, St. Louis Children's Hospital and Washington University in St. Louis School of Medicine, St. Louis, MO, USA.
| | - Kelly D Crisp
- College of Health and Human Sciences, Northern Illinois University, DeKalb, IL, USA
- Department of Surgery, Division of Public Health Sciences, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Mary C Politi
- Department of Surgery, Division of Public Health Sciences, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Steven K Brennan
- Department of Pediatrics, Division of Allergy and Pulmonary Medicine, St. Louis Children's Hospital and Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Ashley J Housten
- Department of Surgery, Division of Public Health Sciences, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
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Zhao L, Xu WK, Wang Y, Lu WY, Wu Y, Hu R. Development and clinical empirical validation of the chronic critical illness prognosis prediction model. Technol Health Care 2024; 32:977-987. [PMID: 37545280 DOI: 10.3233/thc-230359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
BACKGROUND The evolution of critical care medicine and nursing has aided and enabled the rescue of a large number of patients from numerous life-threatening diseases. However, in many cases, patient health may not be quickly restored, and the long-term prognosis may not be optimistic. OBJECTIVES In this study, we aimed to develop and validate a prediction model for accurate, precise, and objective identification of the severity of chronic critical illness (CCI) in patients. METHODS We used a retrospective case-control and prospective cohort study with no interventions. Patients diagnosed with CCI admitted to the ICU of a large metropolitan public hospital were selected. In the case-control study, 344 patients (case: 172; control:172) were enrolled to develop the prognosis prediction model of chronic critical illness (PPCCI Model); 88 patients (case:44; control: 44) in a prospective cohort study, served as the validation cohort. The discrimination of the model was measured using the area under the curve (AUC) of the receiver operating characteristic curve (ROC). RESULTS Age, prolonged mechanical ventilation (PMV), sepsis or other severe infections, Glasgow Coma Scale (GCS), mean artery pressure (MAP), heart rate (HR), respiratory rate (RR), oxygenation index (OI), and active bleeding were the nine predictors included in the model. In both cohorts, the PPCCI model outperformed the Acute Physiology And Chronic Health Evaluation II (APACHE II), Modified Early Warning Score (MEWS), and Sequential Organ Failure Assessment (SOFA) in identifying deceased patients with CCI (development cohort: AUC, 0.934; 95%CI, 0.908-0.960; validation cohort: AUC, 0.965; 95% CI, 0.931-0.999). CONCLUSION The PPCCI model can provide ICU medical staff with a standardized measurement tool for assessing the condition of patients with CCI, enabling them to allocate ward monitoring resources rationally and communicate with family members.
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Affiliation(s)
- Li Zhao
- School of Nursing, Fujian Medical University, Fuzhou, Fujian, China
- Intensive Care Unit, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Wen-Kui Xu
- School of Nursing, Fujian Medical University, Fuzhou, Fujian, China
| | - Ying Wang
- School of Nursing, Fujian Medical University, Fuzhou, Fujian, China
| | - Wei-Yan Lu
- Department of Orthopaedic Trauma, Foot and Ankle Surgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Yong Wu
- Department of Hematology, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Rong Hu
- School of Nursing, Fujian Medical University, Fuzhou, Fujian, China
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Schwartz NH, Teed DN, Glover CM, Basapur S, Blodgett C, Giesing C, Lawm G, Podzimek G, Reeter R, Schorfheide L, Swiderski S, Greenberg JA. Clinician-initiated written communication for families of patients at a long-term acute care hospital. PEC INNOVATION 2023; 3:100179. [PMID: 38213760 PMCID: PMC10782111 DOI: 10.1016/j.pecinn.2023.100179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 06/07/2023] [Accepted: 06/12/2023] [Indexed: 01/13/2024]
Abstract
Objective To assess the experience of families and clinicians at a long term acute care hospital (LTACH) after implementing a written communication intervention. Methods Written communication templates were developed for six clinical disciplines. LTACH clinicians used templates to describe the condition of 30 mechanically ventilated patients at up to three time points. Completed templates were the basis for written summaries that were sent to families. Impressions of the intervention among families (n = 21) and clinicians (n = 17) were assessed using a descriptive correlational design. Interviews were analyzed using thematic content analysis. Results We identified four themes during interviews with families: Written summaries 1) facilitated communication with LTACH staff, 2) reduced stress related to COVID-19 visitor restrictions, 3) facilitated understanding of the patient condition, prognosis, and goals and 4) facilitated communication among family members. Although clinicians understood why families would appreciate written material, they did not feel that the intervention addressed their main challenge - overly optimistic expectations for patient recovery among families. Conclusion Written communication positively affected the experience of families of LTACH patients, but was less useful for clinicians. Innovation Use of written patient care updates helps LTACH clinicians initiate communication with families.
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Affiliation(s)
| | - Don N. Teed
- West Suburban Medical Center, Oak Park, United States
| | - Crystal M. Glover
- Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, United States
- Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, United States
- Department of Neurological Sciences, Rush University Medical Center, Chicago, United States
| | - Santosh Basapur
- Department of Family and Preventive Medicine, Rush University Medical Center, Chicago, United States
| | | | | | - Gerald Lawm
- RML Specialty Hospital, Chicago, United States
| | | | | | | | | | - Jared A. Greenberg
- Department of Internal Medicine, Rush University Medical Center, Chicago, United States
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Kruser JM, Sharma K, Holl JL, Nohadani O. Identifying Patterns of Medical Intervention in Acute Respiratory Failure: A Retrospective Observational Study. Crit Care Explor 2023; 5:e0984. [PMID: 37868025 PMCID: PMC10589534 DOI: 10.1097/cce.0000000000000984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023] Open
Abstract
IMPORTANCE Characterizing medical interventions delivered to ICU patients over time and their relationship to outcomes can help set expectations and inform decisions made by patients, clinicians, and health systems. OBJECTIVES To determine whether distinct and clinically relevant pathways of medical intervention can be identified among adult ICU patients with acute respiratory failure. DESIGN SETTING AND PARTICIPANTS Retrospective observational study using all-payer administrative claims data from 2012 to 2014. Patients were identified from the Healthcare Cost and Utilization Project State Inpatient Databases from Maryland, Massachusetts, Nevada, and Washington. MAIN OUTCOMES AND MEASURES Patterns of cumulative medical intervention delivery, over time, using temporal k-means clustering of interventions delivered up to hospital days 0, 5, 10, 20, and up to discharge. RESULTS A total of 12,175 admissions were identified and divided into training (75%; n = 9,130) and validation sets (25%; n = 3,045). Without applying a priori classification and using only medical interventions to cluster, we identified three distinct pathways of intervention accounting for 93.5% of training set admissions. We found 45.9% of admissions followed a "cardiac" intervention pathway (e.g., cardiac catheterization, cardioversion); 36.7% followed a "general" pathway (e.g., diagnostic interventions); and 17.4% followed a "prolonged" pathway (e.g., tracheostomy, gastrostomy). Prolonged pathway admissions had longer median hospital length of stay (13 d; interquartile range [IQR], 7.5-18.5 d) compared with cardiac (5; IQR, 2.5-7.5) and general (5; IQR, 3-7). In-hospital death occurred in 24.6% of prolonged pathway admissions compared with 17.9% of cardiac and 6.9% of general. Findings were confirmed in the validation set. CONCLUSIONS AND RELEVANCE Most ICU admissions for acute respiratory failure follow one of three clinically relevant pathways of medical intervention which are associated with hospitalization outcomes. This study helps define the longitudinal nature of critical care delivery, which can inform efforts to predict patient outcomes, communicate with patients and their families, and organize critical care resources.
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Affiliation(s)
- Jacqueline M Kruser
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Kartikey Sharma
- Zuse Institute, Department of AI in Society, Science, and Technology, Berlin, Germany
| | - Jane L Holl
- Department of Neurology, University of Chicago, Chicago, IL
| | - Omid Nohadani
- Benefits Science Technologies, Artificial Intelligence and Data Science, Boston, MA
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Boegle K, Bassi M, Comanducci A, Kuehlmeyer K, Oehl P, Raiser T, Rosenfelder M, Sitt JD, Valota C, Willacker L, Bender A, Grill E. Informal Caregivers of Patients with Disorders of Consciousness: a Qualitative Study of Communication Experiences and Information Needs with Physicians. NEUROETHICS-NETH 2022; 15:24. [PMID: 35912377 PMCID: PMC9307713 DOI: 10.1007/s12152-022-09503-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 07/11/2022] [Indexed: 10/27/2022]
Abstract
AbstractDue to improvements in medicine, the figures of patients with disorders of consciousness (DoC) are increasing. Diagnostics of DoC and prognostication of rehabilitation outcome is challenging but necessary to evaluate recovery potential and to decide on treatment options. Such decisions should be made by doctors and patients’ surrogates based on medico-ethical principles. Meeting information needs and communicating effectively with caregivers as the patients´ most common surrogate-decision makers is crucial, and challenging when novel tech-nologies are introduced. This qualitative study aims to explore information needs of informal DoC caregivers, how they manage the obtained information and their perceptions and experiences with caregiver-physician communication in facilities that implemented innovative neurodiagnostics studies. In 2021, we conducted semi-structured interviews with nine caregivers of clinically stable DoC patients in two rehabilitation centers in Italy and Germany. Participants were selected based on consecutive purposeful sampling. Caregivers were recruited at the facilities after written informed consent. All interviews were recorded, transcribed verbatim and translated. For analysis, we used reflexive thematic analysis according to Braun & Clarke (2006). Caregivers experienced the conversations emotionally, generally based on the value of the information provided. They reported to seek positive information, comfort and empathy with-in the communication of results of examinations. They needed detailed information to gain a deep understanding and a clear picture of their loved-one’s condition. The results suggest a mismatch between the perspectives of caregivers and the perspectives of medical profession-als, and stress the need for more elaborate approaches to the communication of results of neu-rodiagnostics studies.
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Liang HY, Lee MD, Lin KC, Lin LH, Yu S. Determinants of the health care service choices of long-term mechanical ventilation patients: Applying andersen’s behavioral model. PLoS One 2022; 17:e0274303. [PMID: 36084012 PMCID: PMC9462724 DOI: 10.1371/journal.pone.0274303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 08/25/2022] [Indexed: 11/18/2022] Open
Abstract
Aims
The number of ventilator-dependent patients is rapidly increasing globally. As a result, long-term mechanical ventilation (LTMV) patients face the choice of receiving health care in respiratory care wards (RCWs) rather than at home. In this study, we applied Andersen’s behavioral theoretical model (ABM) to investigate the determinants of the health care service decisions of patients receiving LTMV.
Methods
A cross-sectional research design and cluster random sampling were used to select 365 participants from nine RCWs and eight home care facilities in northern Taiwan. Data were collected in face-to-face interviews using a structured questionnaire.
Results
Of the predisposing factors, advanced age and an education level of at least junior high school influenced the choice to use RCW services. Being married, living with extended family, and medium or higher socioeconomic status were associated with the decision to use home care services. Of the enabling factors, patients with more caregivers, those whose family caregivers held strong beliefs about providing care, and those who perceived greater social support from health care providers were more likely to choose home care services. Of the need factors examined, poor cognitive function and higher dependence on assistance for activities of daily living (ADL) increased the probability of patients choosing RCW services. Hierarchical logistic regression analysis indicated that our final model accounted for 44.8% of the observed variance in health care service choice.
Conclusions
ABM enables an improved understanding of the health care service choices of LTMV patients. Our findings also highlight the importance of rigorously assessing patient needs and helping patients choose the most appropriate health care service.
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Affiliation(s)
- Hui-Yu Liang
- School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Ming-Der Lee
- Department of Long-Term Care, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Kuan-Chia Lin
- Community Research Center, Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Lieh-Hann Lin
- Department of Emergency Medicine, Lo-Hsu Medical Foundation Lotung Poh-Ai Hospital, Yilan, Taiwan
| | - Shu Yu
- School of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan
- * E-mail:
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Abstract
While medical advancements have led to improved survival of extremely premature infants, children remain at risk for brain injury and neurodevelopmental impairment. Brain imaging can offer insight into an infant's acute and long-term outcome; however, counseling parents about the results and implications of brain imaging remains challenging. The purpose of this article is to review the current literature and describe the challenges associated with counseling families of premature infants on neuroimaging findings. We propose a framework to guide clinicians in counseling parents about brain imaging results, informed by best practices in other disciplines: (FIGURE): 1) Formulate a plan 2) Identify parental needs and values 3) Give information 4) Acknowledge Uncertainty 5) Recognize and Respond to emotions 6) Discuss Expectations and Establish follow-up.
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Affiliation(s)
- Sarah M Bernstein
- Department of Pediatrics, Duke University Medical Center, Durham, NC, United States
| | | | - Monica E Lemmon
- Departments of Pediatrics and Population Health Sciences, Duke University Medical Center, Duke-Margolis Center for Health Policy, DUMC 3936, Durham, NC 27710, United States.
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Dammann M, Staudacher S, Simon M, Jeitziner MM. Insights into the challenges faced by chronically critically ill patients, their families and healthcare providers: An interpretive description. Intensive Crit Care Nurs 2021; 68:103135. [PMID: 34736830 DOI: 10.1016/j.iccn.2021.103135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 08/03/2021] [Accepted: 08/15/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To describe and understand the challenges of patients with chronic critical illness (CCI), their families and healthcare providers during the disease trajectory. METHODOLOGY/DESIGN This qualitative study follows Thorne's methodology of interpretive description and was guided by the ethnographic method of observation and participation. Five cases, each comprising one patient with chronic critical illness their family members and several healthcare providers, were followed from the intensive care unit of a university hospital in Switzerland across different settings. In total, five patients with chronic critical illness, 12 family members and 92 healthcare providers (nurses, nursing students, care assistants, physiotherapists and occupational therapists and physicians) were observed. FINDINGS Regardless of the medical diagnoses and disease trajectories of the patients with chronic critical illness, all cases faced three main challenges: 1. Dealing with the unpredictability of the disease trajectory beyond the underlying disease. 2. Coping with the complexity of care. 3. Perceiving communication challenges despite all involved parties' dependency on it. CONCLUSION Unpredictability is not only a unique characteristic of the prolonged disease trajectory of patients with chronic critical illness, but also one of the main challenges of the participants. Therefore, the way unpredictability is handled is dependent on changes in the complexity of care and communication, highlighting the need for participation, information, empathy, clarity and honesty among all participants.
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Affiliation(s)
- Maria Dammann
- Department of Nephrology, University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland; Institute of Nursing Science (INS), Department of Public Health (DPH), Faculty of Medicine, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland.
| | - Sandra Staudacher
- Institute of Nursing Science (INS), Department of Public Health (DPH), Faculty of Medicine, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland.
| | - Michael Simon
- Institute of Nursing Science (INS), Department of Public Health (DPH), Faculty of Medicine, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland; Nursing Research Unit, Department of Nursing, University Hospital Bern (Inselspital), Freiburgstrasse 4, 3010 Bern, Switzerland.
| | - Marie-Madlen Jeitziner
- Institute of Nursing Science (INS), Department of Public Health (DPH), Faculty of Medicine, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland; Department of Intensive Care Medicine, University Hospital Bern (Inselspital), University of Bern, Freiburgstrasse 4, 3010 Bern, Switzerland.
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Tracheostomy Decision-making Communication among Patients Receiving Prolonged Mechanical Ventilation. Ann Am Thorac Soc 2021; 18:848-856. [PMID: 33351720 DOI: 10.1513/annalsats.202009-1217oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rationale: Patients receiving prolonged mechanical ventilation experience high morbidity and mortality, poor quality of life, and significant caregiving and financial burden. It is unclear what is discussed with patients and families during the tracheostomy decision-making process.Objectives: The aim of this study was to identify themes of communication related to tracheostomy decision-making in patients receiving prolonged mechanical ventilation and to explore patient and clinical factors associated with more discussion of these themes.Methods: We conducted a mixed-methods study involving adult patients in medical or cardiac intensive care units who received continuous mechanical ventilation for ≥7 days and were considered for tracheostomy placement during the same admission. We performed a consensus-driven review of documented family meeting conversations to identify characteristics and themes related to tracheostomy decision-making. A multivariate analysis was performed to investigate patient and clinical factors associated with the discussion of one or more of the identified themes.Results: Of the 241 patients included, 191 (79.2%) had at least one documented conversation regarding tracheostomy decision-making, and 148 (61.4%) required further discussions before reaching a decision. We identified the following four themes related to tracheostomy decision-making: patient's previously expressed preferences, patient's baseline condition and functional status, long-term complications, and long-term prognosis. Of the documented conversations, 45.3% addressed none of the identified themes. Patients who did not undergo tracheostomy placement were more likely to have documented discussion of one or more themes compared with those who did (74.6% vs. 41.6%). In multivariate analysis, age ≥75, female sex, significant preadmission functional dependence, home oxygen requirement, and involvement of palliative care were associated with more documented discussion of one or more themes.Conclusions: Our findings suggest inadequate information exchange regarding patient preferences and long-term prognosis during tracheostomy decision-making, especially among patients who went on to pursue tracheostomy. There is a critical need to promote effective shared decision-making to better align tracheostomy intervention with patient values and to prevent unwanted health states at the end of life.
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Geense WW, de Graaf M, Vermeulen H, van der Hoeven J, Zegers M, van den Boogaard M. Reduced quality of life in ICU survivors - the story behind the numbers: A mixed methods study. J Crit Care 2021; 65:36-41. [PMID: 34082253 DOI: 10.1016/j.jcrc.2021.05.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/19/2021] [Accepted: 05/04/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE To gain insight into the daily functioning of ICU survivors who reported a reduced quality of life (QoL) one year after ICU admission. MATERIALS AND METHODS A two-phase mixed method study design. QoL was assessed using the SF-36 questionnaire before admission and after one year (Phase 1). Participants reporting a reduced QoL were invited for an in-depth interview (Phase 2). Interview data were coded thematically using the PROMIS framework. RESULTS Of the 797 participants, 173 (22%) reported a reduced QoL, of which 19 purposively selected patients were interviewed. In line with their questionnaire scores, most participants described their QoL as reduced. They suffered from physical, mental and/or cognitive problems, impacting their daily life, restricting hobbies, work, and social activities. A new balance in life, including relationships, had to be found. Some interviewees experienced no changes in their QoL; they were grateful for being alive, set new life priorities, and were able to accept their life with its limitations. CONCLUSIONS Reduction in QoL is due to physical, mental, and cognitive health problems, restricting participants what they want to do. However, QoL was not only affected by the critical illness, but also by factors including independency, comorbidity, and life events. Registration: NCT03246334 (clinical trials.gov).
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Affiliation(s)
- Wytske W Geense
- Radboud university medical center, Radboud Institute for Health Sciences, Department of Intensive Care Medicine, Nijmegen, the Netherlands
| | - Mirjam de Graaf
- Radboud university medical center, Radboud Institute for Health Sciences, Department of Intensive Care Medicine, Nijmegen, the Netherlands
| | - Hester Vermeulen
- Radboud university medical center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare, Nijmegen, the Netherlands; HAN University of Applied Science, Faculty of Health and Social Studies, Nijmegen, the Netherlands
| | - Johannes van der Hoeven
- Radboud university medical center, Radboud Institute for Health Sciences, Department of Intensive Care Medicine, Nijmegen, the Netherlands
| | - Marieke Zegers
- Radboud university medical center, Radboud Institute for Health Sciences, Department of Intensive Care Medicine, Nijmegen, the Netherlands
| | - Mark van den Boogaard
- Radboud university medical center, Radboud Institute for Health Sciences, Department of Intensive Care Medicine, Nijmegen, the Netherlands.
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BAYKAL D, ÇAVUŞOĞLU A, ÖZTÜRK ERDEN S. Hasta Ailesinin, Nöroloji Yoğun Bakım Hemşireleriyle İletişiminin Araştırılması. İSTANBUL GELIŞIM ÜNIVERSITESI SAĞLIK BILIMLERI DERGISI 2021. [DOI: 10.38079/igusabder.870481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Howard F, Crowe S, Beck S, Haljan G. Attending to Methodological Challenges in Qualitative Research to Foster Participation of Individuals with Chronic Critical Illness and Communication Impairments. Glob Qual Nurs Res 2021; 8:23333936211000044. [PMID: 33954226 PMCID: PMC8058801 DOI: 10.1177/23333936211000044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 02/11/2021] [Accepted: 02/15/2021] [Indexed: 11/16/2022] Open
Abstract
Individuals with chronic critical illness experience multiple complex physiological disturbances including ongoing respiratory failure, requiring prolonged mechanical ventilation, and thus communication impairments. In conducting a qualitative interpretive description study, we sought to ensure that individuals with chronic critical illness themselves were included as participants. Our commitment to recruiting these individuals to the study and ensuring their data meaningfully informed the analysis and findings required us to reconsider and challenge some of the traditional notions of high-quality qualitative research and develop appropriate practical strategies. These strategies included: (1) centering participant abilities and preferences, (2) adopting a flexible approach to conducting interviews, (3) engaging in a therapeutic relationship, and (4) valuing "thin" data. In this article, we extend existing literature describing the complexities of conducting research with individuals with communication impairments and strategies to consider in the hopes of informing future research with other populations historically excluded from study participation.
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Affiliation(s)
| | - Sarah Crowe
- The University of British Columbia, Vancouver, Canada.,Fraser Health, Surrey, BC, Canada
| | - Scott Beck
- The University of British Columbia, Vancouver, Canada
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Yan H, Deldin PJ, Kukora SK, Arslanian-Engoren C, Pituch K, Zikmund-Fisher BJ. Using Narratives to Correct Forecasting Errors in Pediatric Tracheostomy Decision Making. Med Decis Making 2021; 41:305-316. [PMID: 33559518 DOI: 10.1177/0272989x21990693] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE Parents who face goals-of-care tracheostomy decisions may lack an understanding of challenges affecting their child's and family's long-term quality of life (QOL) to accurately forecast possible outcomes for decision making. We sought to examine whether and how parents' narratives of the child's and family's long-term QOL influence parental tracheostomy decisions and forecasting. METHOD We recruited US adult Amazon Mechanical Turk participants (N = 1966) who self-reported having a child (<6 y old) or planning a pregnancy within 5 y. Participants read a vignette about making a tracheostomy decision for their hypothetical neurologically impaired baby. They were randomized to 1 of the following 4 conditions: 1) Baby QOL narratives, 2) Family QOL narratives, 3) Baby QOL + Family QOL narratives, and 4) control: no narratives. They then made a decision about whether or not to pursue tracheostomy, forecasted their concerns about the baby's and family's QOL, reported their values and social norm beliefs about tracheostomy, comfort care, and parental medical decision making, and completed individual differences scales and demographics. RESULTS Controlling for individual characteristics, participants in the Baby QOL and Baby QOL + Family QOL conditions were less likely to choose tracheostomy as compared with the control (odds ratio [OR] = 0.38 and 0.25, respectively, P < 0.001). Fewer participants in the Family QOL condition chose tracheostomy compared with the control, but this difference was not statistically significant (OR = 0.70, P = 0.11). Moreover, narratives increased pessimistic forecasting, which was associated with less interest in tracheostomy. CONCLUSION Narratives clarifying long-term implications of pursuing tracheostomy have the potential to influence forecasting and decisions. Narrative-based interventions may be valuable in other situations in which forecasting errors are common.
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Affiliation(s)
- Haoyang Yan
- Department of Psychology, University of Michigan, Ann Arbor, MI, USA
| | - Patricia J Deldin
- Department of Psychology, University of Michigan, Ann Arbor, MI, USA
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Stephanie K Kukora
- C.S. Mott Children's Hospital and Department of Pediatrics, Michigan Medicine, Ann Arbor, MI, USA
| | - Cynthia Arslanian-Engoren
- Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | - Kenneth Pituch
- C.S. Mott Children's Hospital and Department of Pediatrics, Michigan Medicine, Ann Arbor, MI, USA
| | - Brian J Zikmund-Fisher
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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15
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Grandjean C, Ullmann P, Marston M, Maitre MC, Perez MH, Ramelet AS. Sources of Stress, Family Functioning, and Needs of Families With a Chronic Critically Ill Child: A Qualitative Study. Front Pediatr 2021; 9:740598. [PMID: 34805041 PMCID: PMC8600118 DOI: 10.3389/fped.2021.740598] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 10/04/2021] [Indexed: 11/26/2022] Open
Abstract
PICU hospitalization is particularly stressful for families. When it is prolonged and the prognostic is uncertain, it can significantly and negatively affect the whole family. To date, little is known on how families with a chronic critically ill (CCI) child are affected. This national study explored the specific PICU-related sources of stress, family functioning and needs of families of CCI patients during a PICU hospitalization. This descriptive qualitative study was conducted in the eight pediatric intensive care units in Switzerland. Thirty-one families with a child meeting the CCI criteria participated in semi-structured interviews. Interviews, including mothers only (n = 12), fathers only (n = 8), or mother and father dyads (n = 11), were conducted in German, French, or English by two trained researchers/clinical nurses specialists. Interviews were recorded, transcribed verbatim, and analyzed using deductive and inductive content analyses. Five overarching themes emerged: (1) high emotional intensity, (2) PICU-related sources of stress, (3) evolving family needs, (4) multi-faceted family functioning, and (5) implemented coping strategies. Our study highlighted the importance of caring for families with CCI children. Parents reported high negative emotional responses that affect their family functioning. Families experience was highly dependent on how HCPs were able to meet the parental needs, provide emotional support, reinforce parental empowerment, and allow high quality of care coordination.
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Affiliation(s)
- Chantal Grandjean
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Pediatric Intensive Care Unit, Department Woman-Mother-Child, Department Woman-Mother-Child, Lausanne, Switzerland
| | - Pascale Ullmann
- School of Healthcare, University of Applied Sciences and Arts, Fribourg, Switzerland
| | - Mark Marston
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Pediatric Intensive Care Unit, Department Woman-Mother-Child, Department Woman-Mother-Child, Lausanne, Switzerland.,University Children's Hospital Basel, Basel, Switzerland
| | - Marie-Christine Maitre
- Pediatric Intensive Care Unit, Department Woman-Mother-Child, Department Woman-Mother-Child, Lausanne, Switzerland
| | - Marie-Hélène Perez
- Pediatric Intensive Care Unit, Department Woman-Mother-Child, Department Woman-Mother-Child, Lausanne, Switzerland
| | - Anne-Sylvie Ramelet
- Institute of Higher Education and Research in Healthcare, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Pediatric Intensive Care Unit, Department Woman-Mother-Child, Department Woman-Mother-Child, Lausanne, Switzerland
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16
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Aiding end-of-life medical decision-making: A Cardinal Issue Perspective. Palliat Support Care 2020; 18:1-3. [PMID: 31775941 DOI: 10.1017/s1478951519000981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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17
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Dale CM, Carbone S, Istanboulian L, Fraser I, Cameron JI, Herridge MS, Rose L. Support needs and health-related quality of life of family caregivers of patients requiring prolonged mechanical ventilation and admission to a specialised weaning centre: A qualitative longitudinal interview study. Intensive Crit Care Nurs 2020; 58:102808. [PMID: 32115334 DOI: 10.1016/j.iccn.2020.102808] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 12/02/2019] [Accepted: 01/22/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Family caregivers of patients requiring prolonged mechanical ventilation may experience physical and psychological morbidity associated with a protracted intensive care unit experience. Our aim was to explore potentially modifiable support needs and care processes of importance to family caregivers of patients requiring prolonged mechanical ventilation and transition from the intensive care unit to a specialised weaning centre. RESEARCH METHODOLOGY/DESIGN A longitudinal qualitative descriptive interview study. Data was analysed using directed content analysis. SETTING A 6-bed specialised weaning centre in Toronto, Canada. FINDINGS Eighteen family caregivers completed interviews at weaning centre admission (100%), and at two-weeks (40%) and three-months after discharge (22%) contributing 29 interviews. Caregivers were primarily women (61%) and spouses (50%). Caregivers perceived inadequate informational, emotional, training, and appraisal support by health care providers limiting understanding of prolonged ventilation, participation in care and decision-making, and readiness for weaning centre transition. Participants reported long-term physical and psychological health changes including alterations to sleep, energy, nutrition and body weight. CONCLUSIONS Deficits in informational, emotional, training, and appraisal support of family caregivers of prolonged mechanical ventilation patients may increase caregiver burden and contribute to poor health outcomes. Strategies for providing support and maintaining family caregiver health-related quality of life are needed.
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Affiliation(s)
- Craig M Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Canada; Sunnybrook Health Sciences Centre, Toronto, Canada.
| | - Sarah Carbone
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Canada
| | | | - Ian Fraser
- Division of Respirology, Department of Medicine, Michael Garron Hospital & University of Toronto, Toronto, Canada
| | - Jill I Cameron
- Department of Occupational Science & Occupational Therapy, University of Toronto, Canada
| | - Margaret S Herridge
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Canada; Toronto General Hospital Research Institute, Canada
| | - Louise Rose
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Canada; Division of Respirology, Department of Medicine, Michael Garron Hospital & University of Toronto, Toronto, Canada; Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College, London, United Kingdom
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18
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Minton C, Batten L, Huntington A. A qualitative multicase study of the trajectories of prolonged critical illness: Patient, family, and healthcare professionals' experiences. Aust Crit Care 2019; 33:463-468. [PMID: 31786072 DOI: 10.1016/j.aucc.2019.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 10/21/2019] [Accepted: 10/21/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Contemporary intensive care enables many critically ill patients to survive their initial illness; however, a small group of patients require a protracted stay in the intensive care unit (ICU), experiencing many complications throughout their illness. It is only when we understand the total illness experience from patients' and families' perspectives, as well as the complexity of care for healthcare professionals, that we can fully engage in developing services and promoting evidence-based practice to improve broad health outcomes and experiences for all groups. OBJECTIVE The objective of this study was to explore the trajectories of a prolonged critical illness in an ICU from the experiences of the patient, their family, and the healthcare professionals who provide care. METHODS This was a longitudinal, qualitative, multicase study of six cases from four New Zealand ICUs. Theoretical underpinnings were informed by the Chronic Illness Trajectory Framework. Each case consisted of the patient, their family members, and nurses and other healthcare professionals who provided care. Data collection methods included observations, conversations, interviews, and document review. Data were analysed using thematic analysis and trajectory mapping. RESULTS Regardless of the patient's admitting diagnosis, the trajectory of a prolonged critical illness is made up of common phases, determined by the patient's physiological condition. However, all subphases represented different psychosocial needs. The patients' debilitated state made them susceptible to complications and added to the complexity of their trajectory. The family's trajectory was informed by the patient's trajectory, and uncertainty dominated throughout. Each phase of the illness presented different challenges for healthcare professionals as they cared for this complex group of patients. CONCLUSION The study highlights the distinct phases of a prolonged critical illness. Knowledge of these phases provides the ground work for improving care, not only for patients but also for their family and the healthcare professionals who provided care.
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Affiliation(s)
- Claire Minton
- School of Nursing, Massey University, Palmerston North, New Zealand.
| | - Lesley Batten
- College of Health, Massey University, Palmerston North, New Zealand
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Polito A, Combescure C, Levy-Jamet Y, Rimensberger P. Long-stay patients in pediatric intensive care unit: Diagnostic-specific definition and predictors. PLoS One 2019; 14:e0223369. [PMID: 31577836 PMCID: PMC6774522 DOI: 10.1371/journal.pone.0223369] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 09/19/2019] [Indexed: 11/30/2022] Open
Abstract
Aims To stipulate a new definition for long-stay patients (LSPs) in pediatric intensive care unit (PICU). We defined LSPs as the 10% of patients with the longest PICU length-of-stay (LOS) for each age and diagnostic group. To assess whether the thresholds (days of PICU stay) for the definition of LSPs in PICU significantly differ among diagnostic and age categories. To determine whether independent associations exist between patients’ characteristics at admission and LSPs diagnosis in pre-specified diagnostic and age groups. Methods This was a multicenter retrospective cohort study including all PICUs in Switzerland. Multivariable regression analysis was used to seek for association between patients’ variables at admission and LSPs Results We included 22,284 patients with a median (IQR) age of 12 (1–84) months. Significantly different thresholds across diagnostic and age subgroups are identified. Readmission to PICU, higher PIM2 and NEMS (a score used to quantify nursing workload at intensive care unit level) at admission were associated with higher likelihood of becoming LSPs. Conclusions Our results showed a significantly different definitions of LSPs for specific diagnoses and age categories. Readmission to PICU and higher acuity at admission are associated with longer PICU length-of-stay in the majority of diagnostic groups. A more personalized definition of LSPs in children based on actual patients’ characteristics should probably be used in an effort to optimize care and reduce costs.
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Affiliation(s)
- Angelo Polito
- Pediatric and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital of Geneva, Geneva, Switzerland
- * E-mail:
| | - Christophe Combescure
- Division of Clinical Epidemiology, Faculty of Medicine, University of Geneva, and Geneva University Hospitals, Geneva, Switzerland
| | - Yann Levy-Jamet
- Pediatric and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital of Geneva, Geneva, Switzerland
| | - Peter Rimensberger
- Pediatric and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital of Geneva, Geneva, Switzerland
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20
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Greenberg JA, Gerhart J, Horst JN, Chen E, Hunter RL, O'Mahony S, Yeow ME, Fosler L, LaGorio LA, Meksraityte E, Weiss TT, Nowak K, Geddes J, Lambe SS, Fenton K, Shah RC. A Multidisciplinary Team-Based Approach to Improve Communication With Surrogates of Patients With Chronic Critical Illness. Am J Hosp Palliat Care 2019; 37:214-221. [PMID: 31526015 DOI: 10.1177/1049909119876606] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Clinicians need to deliver prognostic information to surrogates of nondecisional, critically ill patients so that surrogates can make informed medical decisions that reflect the patient's values. Our objective was to implement a new approach for communicating with surrogates of patients with chronic critical illness. METHODS Surrogate decision makers of patients who were difficult to liberate from mechanical ventilation were prospectively enrolled. Surrogates met with different members of the intensive care unit treatment team for sequential 15-minute appointments to receive patient-specific assessments and education on chronic critical illness. The feasibility and acceptability of this approach were determined. A 24-question comprehension instrument was developed to assess a participant's understanding that a family member was displaying features of chronic critical illness. Each question was scored from 1 to 5, with larger scores indicating greater comprehension. RESULTS Over a 15-week period, educational sessions for 9 mechanically ventilated patients were conducted. On average, 2 surrogates per patient (range: 1-4) and 6 members of the interdisciplinary team (range: 4-6) were at each meeting. Surrogates and clinicians had very positive impressions of the communication intervention. The average preintervention comprehension score was 85 of 120 (standard deviation [SD]: 8, range: 71-101). The postintervention comprehension score was greater by 5 points on average (SD: 9, range: -11 to +20 points, P = .04). CONCLUSIONS Surrogates of critically ill patients approved of this novel communication approach and had a greater understanding of the patient's medical condition after the intervention.
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Affiliation(s)
- Jared A Greenberg
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Rush University Medical Center, Chicago, IL, USA
| | - James Gerhart
- Department of Psychology, Central Michigan University, Mount Pleasant, MI, USA
| | - Jacqueline N Horst
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Elaine Chen
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Rush University Medical Center, Chicago, IL, USA.,Section of Palliative Medicine, Department of Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Rebecca L Hunter
- Division of Bone Marrow Transplant & Cellular Therapy, Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Sean O'Mahony
- Section of Palliative Medicine, Department of Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Mei-Ean Yeow
- Center for Palliative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Laura Fosler
- Section of Palliative Medicine, Department of Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Lisa A LaGorio
- Department of Communication Disorders and Sciences, Rush University Medical Center, Chicago, IL, USA
| | - Edita Meksraityte
- Department of Respiratory Care, Edward Hines, Jr. VA Hospital, Hines, IL, USA
| | - Tyler T Weiss
- Department of Respiratory Care, Rush University Medical Center, Chicago, IL, USA
| | - Kristen Nowak
- Department of Clinical Nutrition, Rush University Medical Center, Chicago, IL, USA
| | - Jacqueline Geddes
- Department of Physical Therapy, Rush University Medical Center, Chicago, IL, USA
| | - Stacy S Lambe
- Department of Physical Therapy, Rush University Medical Center, Chicago, IL, USA
| | - Kara Fenton
- Department of Occupational Therapy, University of Illinois at Chicago, IL, USA
| | - Raj C Shah
- Department of Family Medicine and the Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, IL, USA
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21
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Rückholdt M, Tofler GH, Randall S, Buckley T. Coping by family members of critically ill hospitalised patients: An integrative review. Int J Nurs Stud 2019; 97:40-54. [PMID: 31132688 DOI: 10.1016/j.ijnurstu.2019.04.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 04/28/2019] [Accepted: 04/28/2019] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To provide a comprehensive integrative review of research literature on 1) the coping strategies that are reported by adult family members following admission of their adult loved ones to the intensive care unit (ICU), 2) identify which coping strategies are associated with psychological response during this stressful experience, and 3) the factors that are associated with coping strategies. DATA SOURCES Electronic databases: MEDLINE, PubMed, CINAHL, PsycINFO, and EMBASE; reference lists of journal publications. REVIEW METHODS A total of 643 citations or abstracts were initially screened for content relevance, 15 were included in the integrative review, including 7 quantitative, 3 qualitative and 5 mixed methods studies. Included studies were all conducted in the hospital intensive care unit. RESULTS Coping approaches such as self-distraction appear to be associated with lower psychological distress, and avoidant coping and denial associated with increased psychological distress including traumatic stress symptoms. Factors including social support, gender, age, relationship with the patient, decision maker role, and prior ICU experience can influence coping by family members. Uncertainty of the patient's prognosis and recovery heightens the intensity of the emotional response experienced by family members. Such family members appear at increased risk for experiencing depressive symptoms. CONCLUSIONS From the studies reviewed, it is unclear if coping approaches employed by family members mediate psychological responses such as anxiety and depressive symptoms, or whether coping is a response to psychological stress experienced following hospitalisation of their relative. Future research should focus on the relationship between coping and psychological, physiological and health related behaviours in family members following ICU admission that might contribute towards transient increased health risk during this time. Additionally, future research should explore potential interventions to modify coping and promote family well-being following hospitalisation.
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Affiliation(s)
- Monica Rückholdt
- University of Sydney, Australia; Hornsby Ku-Ring-Gai Hospital, Sydney, Australia.
| | - Geoffrey H Tofler
- University of Sydney, Australia; Royal North Shore Hospital, Sydney, Australia
| | - Sue Randall
- Royal North Shore Hospital, Sydney, Australia
| | - Thomas Buckley
- University of Sydney, Australia; Royal North Shore Hospital, Sydney, Australia
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22
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Pignatiello GA, Hickman RL. Correlates of Cognitive Load in Surrogate Decision Makers of the Critically III. West J Nurs Res 2019; 41:650-666. [PMID: 30366508 PMCID: PMC6467818 DOI: 10.1177/0193945918807898] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Surrogate decision makers (SDMs) of the critically ill experience intense emotions and transient states of decision fatigue. These factors may increase the cognitive load experienced by electronic decision aids. This cross-sectional study explored the associations of emotion regulation (expressive suppression and cognitive reappraisal) and decision fatigue with cognitive load (intrinsic and extraneous) among a sample of 97 SDMs of the critically ill. After completing subjective measures of emotion regulation and decision fatigue, participants were exposed to an electronic decision aid and completed a subjective measurement of cognitive load. Multiple regression analyses indicated that decision fatigue predicted intrinsic cognitive load and expressive suppression predicted extraneous cognitive load. Emotion regulation and decision fatigue represent modifiable determinants of cognitive load among SDMs exposed to electronic decision aids.
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Patient and Family Centered Actionable Processes of Care and Performance Measures for Persistent and Chronic Critical Illness: A Systematic Review. Crit Care Explor 2019; 1:e0005. [PMID: 32166252 PMCID: PMC7063874 DOI: 10.1097/cce.0000000000000005] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Supplemental Digital Content is available in the text. To identify actionable processes of care, quality indicators, or performance measures and their evidence base relevant to patients with persistent or chronic critical illness and their family members including themes relating to patient/family experience.
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Minton C, Batten L, Huntington A. A multicase study of prolonged critical illness in the intensive care unit: Families' experiences. Intensive Crit Care Nurs 2018; 50:21-27. [PMID: 30297150 DOI: 10.1016/j.iccn.2018.08.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 08/13/2018] [Accepted: 08/22/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND It is widely acknowledged a critical illness is a stressful life event for not only the patient but also their family members; when an illness becomes prolonged, the impact is profound. It is suggested that as medical technologies advance, the number of days patients stay in an intensive care unit will increase. Therefore, it is important nurses understand how families experience a prolonged critical illness of their family member in an intensive care unit. OBJECTIVE To explore the trajectory of a prolonged critical illness in the intensive care unit from the experiences of family. METHODS A qualitative, longitudinal, multi-case design consisting of six cases from New Zealand intensive care units. Findings presented in this article only relate to the family's experiences, although patients and healthcare professionals formed part of each case. Data collection methods included observation, conversations, interviews and document review. Analysis was undertaken using thematic analysis, vignette development and trajectory mapping. FINDINGS Relentless uncertainty dominated all phases of the trajectory for the family during a family member's prolonged critical illness in the intensive care unit. When faced with a critical illness, family shifted rapidly into a world of unknowns. Family worked hard to navigate their way through the many uncertainties that dominated each phase of their family member's illness. CONCLUSIONS Nurses need to understand the levels of uncertainty families endure in order to provide care that meets the philosophical underpinnings of family centred care.
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Affiliation(s)
- Claire Minton
- School of Nursing, Massey University, Private Bag 11222, Palmerston North 4442, New Zealand.
| | - Lesley Batten
- College of Health, Massey University, Private Bag 11222, Palmerston North 4442, New Zealand.
| | - Annette Huntington
- School of Nursing, Massey University, PO Box 756, Wellington, New Zealand.
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25
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Implementing Family Meetings Into a Respiratory Care Unit: A Care and Communication Quality Improvement Project. Dimens Crit Care Nurs 2018; 36:157-163. [PMID: 28375991 DOI: 10.1097/dcc.0000000000000241] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Substantial evidence in critical care literature identifies a lack of quality and quantity of communication between patients, families, and clinicians while in the intensive care unit. Barriers include time, multiple caregivers, communication skills, culture, language, stress, and optimal meeting space. For patients who are chronically critically ill, the need for a structured method of communication is paramount for discussion of goals of care. OBJECTIVE The objective of this quality improvement project was to identify barriers to communication, then develop, implement, and evaluate a process for semistructured family meetings in a 9-bed respiratory care unit. METHODS Using set dates and times, family meetings were offered to patients and families admitted to the respiratory care unit. Multiple avenues of communication were utilized to facilitate attendance. Utilizing evidence-based family meeting literature, a guide for family meetings was developed. Templates were developed for documentation of the family meeting in the electronic medical record. RESULTS Multiple communication barriers were identified. Frequency of family meeting occurrence rose from 31% to 88%. Staff satisfaction with meeting frequency, meeting length, and discussion of congruent goals of care between patient/family and health care providers improved. Patient/family satisfaction with consistency of message between team members; understanding of medications, tests, and dismissal plan; and efficacy to address their concerns with the medical team improved. DISCUSSION This quality improvement project was implemented to address the communication gap in the care of complex patients who require prolonged hospitalizations. By identifying this need, engaging stakeholders, and developing a family meeting plan to meet to address these needs, communication between all members of the patient's care team has improved.
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Clinician Perspectives on an Electronic Portal to Improve Communication with Patients and Families in the Intensive Care Unit. Ann Am Thorac Soc 2018; 13:2197-2206. [PMID: 27700144 DOI: 10.1513/annalsats.201605-351oc] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Communication in the intensive care unit (ICU) often falls short of patient and family needs, putting them at risk for significant physical and emotional harm. As electronic patient portals rapidly evolve, one designed specifically for the ICU might potentially enhance communication among patients, family members, and clinicians; however, the views of frontline ICU staff on such technology are unknown. OBJECTIVES To identify clinician perspectives on the current state of communication among patients, families, and clinicians in the ICU, and assess their views on whether and how an electronic portal may address existing communication deficits and improve care. METHODS Three focus groups comprised altogether of 26 clinicians from 6 ICUs, representing several disciplines in an academic medical center in Boston, Massachusetts. Transcripts were analyzed inductively for major themes using grounded theory. MEASUREMENTS AND MAIN RESULTS We identified seven themes reflecting clinician perspectives on communication challenges and desired portal functionality: (1) comprehension and literacy; (2) results and updates; (3) patient and family preferences; (4) interclinician communication; (5) family informational needs; (6) the ICU as an unfamiliar environment; and (7) enhancing humanism through technology. Each theme included current gaps in practice, potential benefits and concerns related to an ICU communication portal, and participant recommendations. Benefits included enhanced education, patient/family engagement, and clinician workflow. Challenges included the stress and uncertainty of ICU care, fear of technology replacing human connection, existing interclinician communication failures, and the tension between informing families without overwhelming them. CONCLUSIONS Overall, clinicians were cautiously supportive of an electronic portal to enhance communication in the ICU and made several specific recommendations for design and implementation. As new technologies expand opportunities for greater transparency and participation in care, clinician buy-in and positive impact will depend, in large part, on the extent to which the concerns of stakeholders are addressed. At the same time, clinicians anticipate several potential benefits that could help support provider workflow and engage patients and families through enhanced communication and humanism.
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Abstract
Determining effective decision support strategies that enhance quality of end-of-life decision making in the intensive care unit is a research priority. This systematic review identified interventional studies describing the effectiveness of decision support interventions administered to critically ill patients or their surrogate decision makers. We conducted a systematic literature search using PubMed, CINAHL, and Cochrane. Our search returned 121 articles, 22 of which met the inclusion criteria. The search generated studies with significant heterogeneity in the types of interventions evaluated and varied patient and surrogate decision-maker outcomes, which limited the comparability of the studies. Few studies demonstrated significant improvements in the primary outcomes. In conclusion, there is limited evidence on the effectiveness of end-of-life decision support for critically ill patients and their surrogate decision makers. Additional research is needed to develop and evaluate innovative decision support interventions for end-of-life decision making in the intensive care unit.
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Abstract
OBJECTIVE Neonatal ICUs and PICUs increasingly admit patients with chronic critical illness: children whose medical complexity leads to recurrent and prolonged ICU hospitalizations. We interviewed participants who routinely care for children with chronic critical illness to describe their experiences with ICU care for pediatric chronic critical illness. DESIGN Semi-structured interviews. Interviews were transcribed and analyzed for themes. SETTING Stakeholders came from five regions (Seattle, WA; Houston, TX; Jackson, MS; Baltimore, MD; and Philadelphia, PA). SUBJECTS Fifty-one stakeholders including: 1) interdisciplinary providers (inpatient, outpatient, home care, foster care) with extensive chronic critical illness experience; or 2) parents of children with chronic critical illness. INTERVENTIONS Telephone or in-person interviews. MEASUREMENTS AND MAIN RESULTS Stakeholders identified several key issues and several themes emerged after qualitative analysis. Issues around chronic critical illness patient factors noted that patients are often relocated to the ICU because of their medical needs. During extended ICU stays, these children require longitudinal relationships and developmental stimulation that outstrip ICU capabilities. Family factors can affect care as prolonged ICU experience leads some to disengage from decision-making. Clinician factors noted that parents of children with chronic critical illness are often experts about their child's disease, shifting the typical ICU clinician-parent relationship. Comprehensive care for children with chronic critical illness can become secondary to needs of acutely ill patients. Lastly, with regard to system factors, stakeholders agreed that achieving consistent ICU care goals is difficult for chronic critical illness patients. CONCLUSIONS ICU care is poorly adapted to pediatric chronic critical illness. Patient, family, clinician, and system factors highlight opportunities for targeted interventions toward improvement in care.
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Nelson JE, Hanson LC, Keller KL, Carson SS, Cox CE, Tulsky JA, White DB, Chai EJ, Weiss SP, Danis M. The Voice of Surrogate Decision-Makers. Family Responses to Prognostic Information in Chronic Critical Illness. Am J Respir Crit Care Med 2017; 196:864-872. [PMID: 28387538 DOI: 10.1164/rccm.201701-0201oc] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
RATIONALE Information from clinicians about the expected course of the patient's illness is relevant and important for decision-making by surrogates for chronically critically ill patients on mechanical ventilation. OBJECTIVES To observe how surrogates of chronically critically ill patients respond to information about prognosis from palliative care clinicians. METHODS This was a qualitative analysis of a consecutive sample of audio-recorded meetings from a larger, multisite, randomized trial of structured informational and supportive meetings led by a palliative care physician and nurse practitioner for surrogates of patients in medical intensive care units with chronic critical illness (i.e., adults mechanically ventilated for ≥7 days and expected to remain ventilated and survive for ≥72 h). MEASUREMENTS AND MAIN RESULTS A total of 66 audio-recorded meetings involving 51 intervention group surrogates for 43 patients were analyzed using grounded theory. Six main categories of surrogate responses to prognostic information were identified: (1) receptivity, (2) deflection/rejection, (3) emotion, (4) characterization of patient, (5) consideration of surrogate role, and (6) mobilization of support. Surrogates responded in multiple and even antithetical ways, within and across meetings. CONCLUSIONS Prognostic disclosure by skilled clinician communicators evokes a repertoire of responses from surrogates for the chronically critically ill. Recognition of these response patterns may help all clinicians better communicate their support to patients and families facing chronic critical illness and inform interventions to support surrogate decision-makers in intensive care units. Clinical trial registered with www.clinicaltrials.gov (NCT 01230099).
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Affiliation(s)
- Judith E Nelson
- 1 Memorial Sloan Kettering Cancer Center and Weill Cornell Medical College, New York, New York
| | - Laura C Hanson
- 2 University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | | | - Shannon S Carson
- 2 University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | | | - James A Tulsky
- 5 Dana Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Douglas B White
- 6 University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | - Emily J Chai
- 3 Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Marion Danis
- 7 National Institutes of Health, Bethesda, Maryland
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Shapiro MC, Henderson CM, Hutton N, Boss RD. Defining Pediatric Chronic Critical Illness for Clinical Care, Research, and Policy. Hosp Pediatr 2017; 7:236-244. [PMID: 28351944 DOI: 10.1542/hpeds.2016-0107] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Chronically critically ill pediatric patients represent an emerging population in NICUs and PICUs. Chronic critical illness has been recognized and defined in the adult population, but the same attention has not been systematically applied to pediatrics. This article reviews what is currently known about pediatric chronic critical illness, highlighting the unique aspects of chronic critical illness in infants and children, including specific considerations of prognosis, outcomes, and decision-making. We propose a definition that incorporates NICU versus PICU stays, recurrent ICU admissions, dependence on life-sustaining technology, multiorgan dysfunction, underlying medical complexity, and the developmental implications of congenital versus acquired conditions. We propose a research agenda, highlighting existing knowledge gaps and targeting areas of improvement in clinical care, research, and policy.
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Affiliation(s)
- Miriam C Shapiro
- Johns Hopkins University School of Medicine, Baltimore, Maryland; .,Johns Hopkins Children's Center, Baltimore, Maryland.,Berman Institute of Bioethics, Baltimore, Maryland
| | - Carrie M Henderson
- University of Mississippi Medical Center, Jackson, Mississippi; and.,Center for Bioethics and Medical Humanities, Jackson, Mississippi
| | - Nancy Hutton
- Johns Hopkins University School of Medicine, Baltimore, Maryland.,Johns Hopkins Children's Center, Baltimore, Maryland
| | - Renee D Boss
- Johns Hopkins University School of Medicine, Baltimore, Maryland.,Johns Hopkins Children's Center, Baltimore, Maryland.,Berman Institute of Bioethics, Baltimore, Maryland
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Professional Responsibility, Consensus, and Conflict: A Survey of Physician Decisions for the Chronically Critically Ill in Neonatal and Pediatric Intensive Care Units. Pediatr Crit Care Med 2017; 18:e415-e422. [PMID: 28658198 DOI: 10.1097/pcc.0000000000001247] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe neonatologist and pediatric intensivist attitudes and practices relevant to high-stakes decisions for children with chronic critical illness, with particular attention to physician perception of professional duty to seek treatment team consensus and to disclose team conflict. DESIGN Self-administered online survey. SETTING U.S. neonatal ICUs and PICUs. SUBJECTS Neonatologists and pediatric intensivists. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We received 652 responses (333 neonatologists, denominator unknown; 319 of 1,290 pediatric intensivists). When asked about guiding a decision for tracheostomy in a chronically critically ill infant, only 41.7% of physicians indicated professional responsibility to seek a consensus decision, but 73.3% reported, in practice, that they would seek consensus and make a consensus-based recommendation; the second most common practice (15.5%) was to defer to families without making recommendations. When presented with conflict among the treatment team, 63% of physicians indicated a responsibility to be transparent about the decision-making process and reported matching practices. Neonatologists more frequently reported a responsibility to give decision making fully over to families; intensivists were more likely to seek out consensus among the treatment team. CONCLUSIONS ICU physicians do not agree about their responsibilities when approaching difficult decisions for chronically critically ill children. Although most physicians feel a professional responsibility to provide personal recommendations or defer to families, most physicians report offering consensus recommendations. Nearly all physicians embrace a sense of responsibility to disclose disagreement to families. More research is needed to understand physician responsibilities for making recommendations in the care of chronically critically ill children.
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Hickman RL, Pignatiello GA, Tahir S. Evaluation of the Decisional Fatigue Scale Among Surrogate Decision Makers of the Critically Ill. West J Nurs Res 2017; 40:191-208. [PMID: 28805132 DOI: 10.1177/0193945917723828] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Intense emotional distress and impaired information processing have been implicated in reducing a surrogate decision maker's ability to formulate informed health care decisions for a critically ill patient. The heightened intensity of negative emotions, mental effort, and impaired judgment is consistent with the manifestation of decision fatigue. The aim of this article is to describe the validity and reliability of the Decision Fatigue Scale (DFS) among surrogate decision makers of the critically ill. A convenience sample of 101 surrogate decision makers were administered the DFS and a battery of psychosocial instruments at two time points. The DFS was specified as a unidimensional measure with adequate internal consistency (Cronbach's αs = .87, .90) and stability reliability. Discriminant validity was established with measures of emotion regulation, anxiety, and depressive symptoms. The DFS is the first subjective measure of decision fatigue for surrogate decision makers of the critically ill that demonstrates satisfactory psychometric properties.
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Affiliation(s)
| | | | - Sadia Tahir
- 1 Case Western Reserve University, Cleveland, OH, USA
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33
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Crispin V, Bugge C, Stoddart K. Sufficiency and relevance of information for inpatients in general ward settings: A qualitative exploration of information exchange between patients and nurses. Int J Nurs Stud 2017; 75:112-122. [PMID: 28783488 DOI: 10.1016/j.ijnurstu.2017.07.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 05/24/2017] [Accepted: 07/17/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Information exchange as part of shared decision-making is widely discussed in research and policy literature as a means of improving patient involvement in treatment and care. To date information exchange between patients and nurses has not been explored in ward contexts. OBJECTIVE To explore the sufficiency of, and intentions behind, information exchanged by patients and nurses in surgical and medical ward settings using a recognised model of shared decision-making. DESIGN A multiple-case study design was used. Data were collected from 19 cases. Each case comprised one patient, the nurses interacting with that patient, the interactions between them, and their perceptions about the interactions. SETTINGS The study was undertaken across six surgical, six medical and one rehabilitation ward in a large teaching hospital in the United Kingdom. PARTICIPANTS Purposive sampling was used to first recruit nurses and then patients. Inclusion criteria included nurses registered with the Nursing and Midwifery Council, and patients who had been in hospital for more than 24h and who could consent to participating. Twenty-two nurses and 19 patients participated. METHODS Interactions from 19 cases were observed and audio-recorded. Individual interviews with patients and nurses followed, and were related to, the observed interactions. RESULTS Patients and nurses perceived they had exchanged sufficient information for their own needs including patient involvement, due to: information being shared previously and on an ongoing basis; having asked all their questions; therapeutic patient/nurse relationships; and, nurses speaking in lay terms. In contrast, the observational data suggested that insufficient information was exchanged between patients and nurses due to: lost opportunities for sharing information; paternalistic practice; and withholding information. CONCLUSION The elements of information exchange within a recognised model of shared decision-making do not adequately fit with patient/nurse interactions in ward settings. Participants generally perceived they had given and received enough information for their own needs. Therefore, the ways in which patients and nurses currently interact, could remain as they are. Policymakers should be aware of the varying contexts where healthcare staff work, and should promote information exchange and shared decision-making more strategically. Due to the complexities of patient/nurse interactions, consideration should be given to situation and context when applying these findings to practice.
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Affiliation(s)
- Vivianne Crispin
- University of Stirling, Bridge of Allan, Stirling, Scotland, FK9 4LA, UK.
| | - Carol Bugge
- University of Stirling, Bridge of Allan, Stirling, Scotland, FK9 4LA, UK
| | - Kathleen Stoddart
- University of Stirling, Bridge of Allan, Stirling, Scotland, FK9 4LA, UK
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Lamas DJ, Owens RL, Nace RN, Massaro AF, Pertsch NJ, Moore ST, Bernacki RE, Block SD. Conversations About Goals and Values Are Feasible and Acceptable in Long-Term Acute Care Hospitals: A Pilot Study. J Palliat Med 2017; 20:710-715. [DOI: 10.1089/jpm.2016.0485] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Daniela J. Lamas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Ariadne Labs at Brigham and Women's Hospital and Harvard T.H. Chen School of Public Health, Boston, Massachusetts
| | - Robert L. Owens
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, San Diego, California
| | - R. Nicholas Nace
- Department of Medicine, Spaulding Hospital for Continuing Medical Care, Cambridge, Massachusetts
| | - Anthony F. Massaro
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Nathan J. Pertsch
- Ariadne Labs at Brigham and Women's Hospital and Harvard T.H. Chen School of Public Health, Boston, Massachusetts
| | - Susan T. Moore
- Department of Medicine, Spaulding Hospital for Continuing Medical Care, Cambridge, Massachusetts
| | - Rachelle E. Bernacki
- Ariadne Labs at Brigham and Women's Hospital and Harvard T.H. Chen School of Public Health, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Palliative Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Susan D. Block
- Ariadne Labs at Brigham and Women's Hospital and Harvard T.H. Chen School of Public Health, Boston, Massachusetts
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Palliative Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts
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35
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Liu JF, Lu MC, Fang TP, Yu HR, Lin HL, Fang DL. Burden on caregivers of ventilator-dependent patients: A cross-sectional study. Medicine (Baltimore) 2017; 96:e7396. [PMID: 28682893 PMCID: PMC5502166 DOI: 10.1097/md.0000000000007396] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Caring for prolonged mechanical ventilation (PMV) patients imposes heavy psychological, physical, social, and financial burdens on caregivers. Currently, studies regarding the burden on caregivers of PMV patients are scant; therefore, the present study investigated the burden on caregivers of PMV patients.This cross-sectional study was approved by the Institutional Review Board of Zuoying Armed Forces General Hospital. A survey was conducted among the caregivers of PMV patients who were admitted to a chronic respiratory care ward (RCW) or were receiving home care from June to December 2010. The survey included basic demographic information of PMV patients and their caregivers and the Burden Assessment Scale scores for 4 domains comprising a total of 21 questions (physical burden, n = 5; psychological burden, n = 6; social burden, n = 6; financial burden, n = 4). Statistical analyses were conducted using the t test, 1-way analysis of variance with the Scheffé post hoc test, and the chi-square test, and P < .05 was considered statistically significant.A total of 160 caregivers (age, 50-53 years) were recruited (n = 80 each in the home care and RCW groups), and most of these caregivers were married women. Due to insufficient sleep, physical exhaustion, back pain, and caregiving, home caregivers had significantly higher physical burden levels than RCW caregivers (P < .01).Home caregivers experienced higher physical burden levels than RCW caregivers. Therefore, clinical and professional support must be provided to home caregivers of PMV patients.
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Affiliation(s)
- Jui-Fang Liu
- Department of Respiratory Therapy, Chang Gung Memorial Hospital-Kaohsiung Medical Center and Chang Gung University College of Medicine
- Department of Education, National Kaohsiung Normal University, Kaohsiung
- Department of Respiratory Therapy, Chang Gung University of Science and Technology
| | - Man-Chi Lu
- Department of Respiratory Therapy, Chang Gung Memorial Hospital-Kaohsiung Medical Center and Chang Gung University College of Medicine
| | - Tien-Pei Fang
- Department of Respiratory Therapy, Chang Gung University of Science and Technology
- Department of Respiratory Therapy, Chang Gung Memorial Hospital at Chiayi, Chiayi
| | - Hong-Ren Yu
- Department of Pediatrics, Chang Gung Memorial Hospital-Kaohsiung Medical Center and Chang Gung University College of Medicine, Kaohsiung
| | - Hui-Ling Lin
- Department of Respiratory Therapy, Chang Gung University of Science and Technology
- Department of Respiratory Therapy, Chang Gung Memorial Hospital at Chiayi, Chiayi
- Department of Respiratory Therapy, Chang Gung University, Taoyuan, Taiwan
| | - Der-Long Fang
- Department of Education, National Kaohsiung Normal University, Kaohsiung
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Chronic Critical Illness in Infants and Children: A Speculative Synthesis on Adapting ICU Care to Meet the Needs of Long-Stay Patients. Pediatr Crit Care Med 2016; 17:743-52. [PMID: 27295581 DOI: 10.1097/pcc.0000000000000792] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES In this review, we examine features of ICU systems and ICU clinician training that can undermine continuity of communication and longitudinal guidance for decision making for chronically critically ill infants and children. Drawing upon a conceptual model of the dynamic interactions between patients, families, clinicians, and ICU systems, we propose strategies to promote longitudinal decision making and improve communication for infants and children with prolonged ICU stays. DATA SOURCES We searched MEDLINE and PubMed from inception to September 2015 for English-language articles relevant to chronic critical illness, particularly of pediatric patients. We also reviewed bibliographies of relevant studies to broaden our search. STUDY SELECTION Two authors (physicians with experience in pediatric neonatology, critical care, and palliative care) made the final selections. DATA EXTRACTION We critically reviewed the existing data and models of care to identify strategies for improving ICU care of chronically critically ill children. DATA SYNTHESIS Utilizing the available data and personal experience, we addressed concerns related to family perspectives, ICU processes, and issues with ICU training that shape longitudinal decision making. CONCLUSIONS As the number of chronically critically ill infants and children increases, specific communication and decision-making models targeted at this population could improve the feedback between acute, daily ICU decisions and the patient's overall goals of care. Adaptations to ICU systems of care and ICU clinician training will be essential components of this progress.
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Carson SS, Cox CE, Wallenstein S, Hanson LC, Danis M, Tulsky JA, Chai E, Nelson JE. Effect of Palliative Care-Led Meetings for Families of Patients With Chronic Critical Illness: A Randomized Clinical Trial. JAMA 2016; 316:51-62. [PMID: 27380343 PMCID: PMC5538801 DOI: 10.1001/jama.2016.8474] [Citation(s) in RCA: 229] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
IMPORTANCE Family caregivers of patients with chronic critical illness experience significant psychological distress. OBJECTIVE To determine whether family informational and emotional support meetings led by palliative care clinicians improve family anxiety and depression. DESIGN, SETTING, AND PARTICIPANTS A multicenter randomized clinical trial conducted from October 2010 through November 2014 in 4 medical intensive care units (ICUs). Adult patients (aged ≥21 years) requiring 7 days of mechanical ventilation were randomized and their family surrogate decision makers were enrolled in the study. Observers were blinded to group allocation for the measurement of the primary outcomes. INTERVENTIONS At least 2 structured family meetings led by palliative care specialists and provision of an informational brochure (intervention) compared with provision of an informational brochure and routine family meetings conducted by ICU teams (control). There were 130 patients with 184 family surrogate decision makers in the intervention group and 126 patients with 181 family surrogate decision makers in the control group. MAIN OUTCOMES AND MEASURES The primary outcome was Hospital Anxiety and Depression Scale symptom score (HADS; score range, 0 [best] to 42 [worst]; minimal clinically important difference, 1.5) obtained during 3-month follow-up interviews with the surrogate decision makers. Secondary outcomes included posttraumatic stress disorder experienced by the family and measured by the Impact of Events Scale-Revised (IES-R; total score range, 0 [best] to 88 [worst]), discussion of patient preferences, hospital length of stay, and 90-day survival. RESULTS Among 365 family surrogate decision makers (mean age, 51 years; 71% female), 312 completed the study. At 3 months, there was no significant difference in anxiety and depression symptoms between surrogate decision makers in the intervention group and the control group (adjusted mean HADS score, 12.2 vs 11.4, respectively; between-group difference, 0.8 [95% CI, -0.9 to 2.6]; P = .34). Posttraumatic stress disorder symptoms were higher in the intervention group (adjusted mean IES-R score, 25.9) compared with the control group (adjusted mean IES-R score, 21.3) (between-group difference, 4.60 [95% CI, 0.01 to 9.10]; P = .0495). There was no difference between groups regarding the discussion of patient preferences (intervention, 75%; control, 83%; odds ratio, 0.63 [95% CI, 0.34 to 1.16; P = .14]). The median number of hospital days for patients in the intervention vs the control group (19 days vs 23 days, respectively; between-group difference, -4 days [95% CI, -6 to 3 days]; P = .51) and 90-day survival (hazard ratio, 0.95 [95% CI, 0.65 to 1.38], P = .96) were not significantly different. CONCLUSIONS AND RELEVANCE Among families of patients with chronic critical illness, the use of palliative care-led informational and emotional support meetings compared with usual care did not reduce anxiety or depression symptoms and may have increased posttraumatic stress disorder symptoms. These findings do not support routine or mandatory palliative care-led discussion of goals of care for all families of patients with chronic critical illness. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01230099.
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Affiliation(s)
| | | | | | - Laura C Hanson
- University of North Carolina School of Medicine, Chapel Hill
| | - Marion Danis
- National Institutes of Health, Bethesda, Maryland
| | - James A Tulsky
- Dana Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Emily Chai
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Judith E Nelson
- Memorial Sloan Kettering Cancer Center and Weill-Cornell Medical College, New York, New York
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Leung D, Angus JE, Sinuff T, Bavly S, Rose L. Transitions to End-of-Life Care for Patients With Chronic Critical Illness: A Meta-Synthesis. Am J Hosp Palliat Care 2016; 34:729-736. [PMID: 27188760 DOI: 10.1177/1049909116649986] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Adults with chronic critical illness (CCI) frequently experience a terminal trajectory but receive varying degrees of palliation and end-of-life care (EOLC) in intensive care units (ICUs). Why palliation (over curative treatment) is not augmented earlier for patients with CCI in ICU is not well understood. PURPOSE To identify the social structures that contribute to timely, context-dependent decisions for transition from acute care to EOLC for patients with CCI and their families. METHODS We conducted a meta-synthesis of qualitative and/or mixed-method studies that recruited adults with CCI, their families or close friends, and/or health-care providers (HCPs) in an ICU environment. RESULTS Five studies reported data from 83 patients, 109 family members, and 57 HCPs across 5 institutions in Canada and the United States. Overall, we found that morally ambiguous social expectations of treatment tended to lock in HCPs to focus on prescriptive work of preserving life, despite pathways that could "open" access to augmenting palliation and EOLC. This process limited space for families' reflexivity and reappraisal of CCI as a phase liminal to active dying. Notably, EOLC mechanisms were informal and less visible. CONCLUSION The management of dying is one of the central tenets of ICU care. Our findings suggest that patients and families need help in negotiating meanings of this situation and in using mechanisms that allow reappraisal and permit understanding of CCI as a phase liminal to dying. Moreover, these mechanisms may paradoxically reduce the ambiguity of patients' future, allowing them to live more fully in the present.
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Affiliation(s)
- Doris Leung
- 1 School of Nursing, The Hong Kong Polytechnic University, Hong Kong, China.,2 Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Jan E Angus
- 2 Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Tasnim Sinuff
- 3 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,4 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sherri Bavly
- 2 Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.,5 Toronto Public Health, Toronto, Ontario, Canada
| | - Louise Rose
- 2 Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.,3 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,4 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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Ernecoff NC, Witteman HO, Chon K, Chen YI, Buddadhumaruk P, Chiarchiaro J, Shotsberger KJ, Shields AM, Myers BA, Hough CL, Carson SS, Lo B, Matthay MA, Anderson WG, Peterson MW, Steingrub JS, Arnold RM, White DB. Key stakeholders' perceptions of the acceptability and usefulness of a tablet-based tool to improve communication and shared decision making in ICUs. J Crit Care 2016; 33:19-25. [PMID: 27037049 DOI: 10.1016/j.jcrc.2016.01.030] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 01/10/2016] [Accepted: 01/10/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE Although barriers to shared decision making in intensive care units are well documented, there are currently no easily scaled interventions to overcome these problems. We sought to assess stakeholders' perceptions of the acceptability, usefulness, and design suggestions for a tablet-based tool to support communication and shared decision making in ICUs. METHODS We conducted in-depth semi-structured interviews with 58 key stakeholders (30 surrogates and 28 ICU care providers). Interviews explored stakeholders' perceptions about the acceptability of a tablet-based tool to support communication and shared decision making, including the usefulness of modules focused on orienting families to the ICU, educating them about the surrogate's role, completing a question prompt list, eliciting patient values, educating about treatment options, eliciting perceptions about prognosis, and providing psychosocial support resources. The interviewer also elicited stakeholders' design suggestions for such a tool. We used constant comparative methods to identify key themes that arose during the interviews. RESULTS Overall, 95% (55/58) of participants perceived the proposed tool to be acceptable, with 98% (57/58) of interviewees finding six or more of the seven content domains acceptable. Stakeholders identified several potential benefits of the tool including that it would help families prepare for the surrogate role and for family meetings as well as give surrogates time and a framework to think about the patient's values and treatment options. Key design suggestions included: conceptualize the tool as a supplement to rather than a substitute for surrogate-clinician communication; make the tool flexible with respect to how, where, and when surrogates can access the tool; incorporate interactive exercises; use video and narration to minimize the cognitive load of the intervention; and build an extremely simple user interface to maximize usefulness for individuals with low computer literacy. CONCLUSION There is broad support among stakeholders for the use of a tablet-based tool to improve communication and shared decision making in ICUs. Eliciting the perspectives of key stakeholders early in the design process yielded important insights to create a tool tailored to the needs of surrogates and care providers in ICUs.
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Affiliation(s)
- Natalie C Ernecoff
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Holly O Witteman
- Department of Family Medicine and Emergency Medicine, Laval University, Quebec City, Quebec, Canada; Office of Education and Continuing Professional Development, Faculty of Medicine, Laval University, Quebec City, Quebec, Canada; Research Centre of the CHU de Québec, Quebec City, Quebec, Canada
| | - Kristen Chon
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Yanquan Iris Chen
- Human-Computer Interaction Institute, Carnegie Mellon University, Pittsburgh, PA
| | - Praewpannarai Buddadhumaruk
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jared Chiarchiaro
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Anne-Marie Shields
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Brad A Myers
- Human-Computer Interaction Institute, Carnegie Mellon University, Pittsburgh, PA
| | - Catherine L Hough
- Division of Pulmonary and Critical Care, Harborview Medical Center, University of Washington, Seattle, WA
| | - Shannon S Carson
- Division of Pulmonary and Critical Care Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | | | - Michael A Matthay
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA
| | - Wendy G Anderson
- Department of Medicine and Division of Hosiptal Medicine and Palliative Care Program, University of California San Francisco, San Francisco, CA
| | - Michael W Peterson
- Department of Medicine, University of California San Francisco Fresno Medical Education Program, Fresno, CA
| | - Jay S Steingrub
- Division of Pulmonary and Critical Care Medicine, Baystate Medical Center, Springfield, Massachusetts and Tufts University School of Medicine, Boston, MA
| | - Robert M Arnold
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Douglas B White
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
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Development and Validation of a Mortality Prediction Model for Patients Receiving 14 Days of Mechanical Ventilation. Crit Care Med 2016; 43:2339-45. [PMID: 26247337 DOI: 10.1097/ccm.0000000000001205] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The existing risk prediction model for patients requiring prolonged mechanical ventilation is not applicable until after 21 days of mechanical ventilation. We sought to develop and validate a mortality prediction model for patients earlier in the ICU course using data from day 14 of mechanical ventilation. DESIGN Multicenter retrospective cohort study. SETTING Forty medical centers across the United States. PATIENTS Adult patients receiving at least 14 days of mechanical ventilation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Predictor variables were measured on day 14 of mechanical ventilation in the development cohort and included in a logistic regression model with 1-year mortality as the outcome. Variables were sequentially eliminated to develop the ProVent 14 model. This model was then generated in the validation cohort. A simplified prognostic scoring rule (ProVent 14 Score) using categorical variables was created in the development cohort and then tested in the validation cohort. Model discrimination was assessed by the area under the receiver operator characteristic curve. Four hundred ninety-one patients and 245 patients were included in the development and validation cohorts, respectively. The most parsimonious model included age, platelet count, requirement for vasopressors, requirement for hemodialysis, and nontrauma admission. The area under the receiver operator characteristic curve for the ProVent 14 model using continuous variables was 0.80 (95% CI, 0.76-0.83) in the development cohort and 0.78 (95% CI, 0.72-0.83) in the validation cohort. The ProVent 14 Score categorized age at 50 and 65 years old and platelet count at 100×10(9)/L and had similar discrimination as the ProVent 14 model in both cohorts. CONCLUSION Using clinical variables available on day 14 of mechanical ventilation, the ProVent 14 model can identify patients receiving prolonged mechanical ventilation with a high risk of mortality within 1 year.
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Bice T, Nelson JE, Carson SS. To Trach or Not to Trach: Uncertainty in the Care of the Chronically Critically Ill. Semin Respir Crit Care Med 2015; 36:851-8. [PMID: 26595045 DOI: 10.1055/s-0035-1564872] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The number of chronically critically ill patients requiring prolonged mechanical ventilation and receiving a tracheostomy is steadily increasing. Early tracheostomy in patients requiring prolonged mechanical ventilation has been proposed to decrease duration of mechanical ventilation and intensive care unit stay, reduce mortality, and improve patient comfort. However, these benefits have been difficult to demonstrate in clinical trials. So how does one determine the appropriate timing for tracheostomy placement in your patient? Here we review the potential benefits and consequences of tracheostomy, the available evidence for tracheostomy timing, communication surrounding the tracheostomy decision, and a patient-centered approach to tracheostomy. Patients requiring > 10 days of mechanical ventilation who are expected to survive their hospitalization likely benefit from tracheostomy, but protocols involving routine early tracheostomy placement do not improve patient outcomes. However, patients with neurologic injury, provided they have a good prognosis for meaningful recovery, may benefit from early tracheostomy. In chronically critically ill patients with poor prognosis, tracheostomy is unlikely to provide benefit and should only be pursued if it is consistent with the patient's values, goals, and preferences. In this setting, communication with patients and surrogates regarding tracheostomy and prognosis becomes paramount. For the foreseeable future, decisions surrounding tracheostomy will remain relevant and challenging.
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Affiliation(s)
- Thomas Bice
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Judith E Nelson
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York
| | - Shannon S Carson
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Vahedian Azimi A, Ebadi A, Ahmadi F, Saadat S. Delirium in Prolonged Hospitalized Patients in the Intensive Care Unit. Trauma Mon 2015; 20:e17874. [PMID: 26290854 PMCID: PMC4538727 DOI: 10.5812/traumamon.17874] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 04/13/2014] [Accepted: 04/30/2014] [Indexed: 01/08/2023] Open
Abstract
Background: Prolonged hospitalization in the intensive care unit (ICU) can impose long-term psychological effects on patients. One of the most significant psychological effects from prolonged hospitalization is delirium. Objectives: The aim of this study was to assess the effect of prolonged hospitalization of patients and subsequent delirium in the intensive care unit. Patients and Methods: This conventional content analysis study was conducted in the General Intensive Care Unit of the Shariati Hospital of Tehran University of Medical Sciences, from the beginning of 2013 to 2014. All prolonged hospitalized patients and their families were eligible participants. From the 34 eligible patients and 63 family members, the final numbers of actual patients and family members were 9 and 16, respectively. Several semi-structured interviews were conducted face-to-face with patients and their families in a private room and data were gathered. Results: Two main themes from two different perspectives emerged, 'patients' perspectives' (experiences during ICU hospitalization) and 'family members' perspectives' (supportive-communicational experiences). The main results of this study focused on delirium, Patients' findings were described as pleasant and unpleasant, factual and delusional experiences. Conclusions: Family members are valuable components in the therapeutic process of delirium. Effective use of family members in the delirium caring process can be considered to be one of the key non-medical nursing components in the therapeutic process.
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Affiliation(s)
- Amir Vahedian Azimi
- Trauma Research Center, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
| | - Abbas Ebadi
- Behavioral Sciences Research Center, Nursing Faculty, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
- Corresponding author: Abbas Ebadi, Behavioral Sciences Research Center, Nursing Faculty, Baqiyatallah University of Medical Sciences, P.O. Box: 19575-174, Tehran, IR Iran. Tel: +98-9122149019, Fax: +98-2126127237, E-mail:
| | - Fazlollah Ahmadi
- Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, IR Iran
| | - Soheil Saadat
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
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Families’ experiences of their interactions with staff in an Australian intensive care unit (ICU): A qualitative study. Intensive Crit Care Nurs 2015; 31:51-63. [DOI: 10.1016/j.iccn.2014.06.005] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Revised: 06/05/2014] [Accepted: 06/16/2014] [Indexed: 11/24/2022]
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Changing support needs of survivors of complex critical illness and their family caregivers across the care continuum: a qualitative pilot study of Towards RECOVER. J Crit Care 2014; 30:242-9. [PMID: 25466314 DOI: 10.1016/j.jcrc.2014.10.017] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 09/03/2014] [Accepted: 10/16/2014] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Survivors of complex critical illness and their family caregivers require support during their recovery, rehabilitation, and return to community living; however, the nature of these supports and how they may change over time remain unclear. Using the Timing It Right framework as a conceptual guide, this qualitative pilot study explored survivors' and caregivers' needs during the episode of critical illness through their return to independent living. METHODS Five survivors and seven family caregivers were recruited and consented from the main Towards RECOVER pilot study, designed to characterize the long term outcomes of survivors of the ICU who have been mechanically ventilated for more than one week. Using the Timing It Right framework, we prospectively conducted qualitative interviews to explore participants' experiences and needs for information, emotional support, and training at 3, 6, 12, and 24 months after intensive care unit (ICU) discharge. We completed 26 interviews, which were audio recorded, professionally transcribed, checked for accuracy, and analyzed using framework methodology. RESULTS In this small pilot sample, caregiver and patient perspectives were related and, therefore, are presented together. We identified 1 overriding theme: survivors do not experience continuity of medical care during recovery after critical illness. Three subthemes highlighted the following: (1) informational needs change across the care continuum, (2) fear and worry exist when families do not know what to expect, and (3) survivors transition from dependence to independence. CONCLUSIONS Interventions designed to improve family outcomes after critical illness should address both survivors' and caregivers' support needs as they change across the illness and recovery trajectory. Providing early intervention and support and clarifying expectations for transitions in care and recovery may decrease fears of the unknown for both caregivers and survivors. Ongoing family-centered follow-up programs may also help survivors regain independence and help caregivers manage their perceived responsibility for the patients' health. Using these insights for intervention development could ultimately improve long-term outcomes for both survivors and caregivers.
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Affiliation(s)
- Daniela Lamas
- From the Departments of Pulmonary and Critical Care Medicine at Brigham and Women's Hospital, Beth Israel Deaconess Medical Center, and Massachusetts General Hospital - all in Boston
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46
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Karra V, Papathanassoglou ED, Lemonidou C, Sourtzi P, Giannakopoulou M. Exploration and classification of intensive care nurses' clinical decisions: a Greek perspective. Nurs Crit Care 2014; 19:87-97. [PMID: 24400657 DOI: 10.1111/nicc.12018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 01/18/2013] [Accepted: 02/05/2013] [Indexed: 11/27/2022]
Abstract
AIM The recording, identification, coding and classification of clinical decisions by intensive care nurses. BACKGROUND Clinical decision-making is an essential dimension of nursing practice as through this process nurses make choices to meet the goals of patient care. Intensive care nurses' decision-making has received attention because of the complexity and urgency associated with it, however, the types of nurses' clinical decisions have not been described systematically. METHODS Qualitative content analysis of daily diaries of clinical decisions recorded during nursing work by 23 purposefully selected intensive care nurses from three major hospitals of Greece. The process of data collection and analysis continued until the point of theoretical saturation. FINDINGS Eight categories of nursing clinical decisions emerged including decisions related to: (1) evaluation, (2) diagnosis, (3) prevention, (4) intervention, (5) communication with patients, (6) clinical information seeking, (7) setting of clinical priorities and (8) communication with health care professionals. Psychological assessment and support decisions were scarce, whereas patient input in care decisions appeared to be limited. The most frequent types of decisions were regarding intervention (29%), evaluation (25%) and clinical setting of priorities (17%), while clinical information seeking (3%) and communication with patients decisions (2%) were the least frequent. Additionally, recorded decisions were ranked in order of degree of urgency and of dependency on medical order. Non-urgent decisions were 78% of the total and 60% of nurses' intervention decisions were independent of medical order and were related to basic nursing care. CONCLUSIONS Intensive care nurses make multiple decisions that seem to be in line with the nursing process, although the latter is not officially implemented in Greek ICUs. RELEVANCE TO CLINICAL PRACTICE The types and frequency of clinical decisions made by intensive care nurses are related to features of ICU work environment, their professional autonomy and accountability, as well as their perceptions of their clinical role.
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Affiliation(s)
- Vassiliki Karra
- V. Karra, RN, MSN, MHCM, PhD(c), Faculty of Nursing, National and Kapodistrian University of Athens, Athens, Greece
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Moghaddasian S, Lak Dizaji S, Mahmoudi M. Nurses empathy and family needs in the intensive care units. J Caring Sci 2013; 2:197-201. [PMID: 25276727 DOI: 10.5681/jcs.2013.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Accepted: 11/29/2012] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The patients' families in intensive care units (ICUs) experience excessive stress which may disrupt their performance in daily life. Empathy is basic to the nursing role and has been found to be associated with improved patient outcomes and greater satisfaction with care in patient and his/her family. However, few studies have investigated the nursing empathy with ICU patients. This study aimed to assess nursing empathy and its relationship with the needs, from the perspective of families of patients in ICU. METHODS In this cross-sectional study, 418 subjects were selected among families of patients admitted to ICUs in Tabriz, Iran, by convenience sampling, from May to August 2012. Data were collected through Barrett-Lennard Relationship inventory (BLRI) empathy scale and Critical Care Family Needs Intervention (CCFNI) inventories and were analyzed using descriptive and inferential statistical tests. RESULTS Findings showed that most of the nurses had high level of empathy to the patients (38.8%). There was also statistically significant relationship between nurses' empathy and needs of patients' families (p < 0.001). CONCLUSION In this study we found that by increasing the nurse's empathy skills, we would be able to improve providing family needs. Through empathic communication, nurses can encourage family members to participate in planning for the care of their patients. However, further studies are necessary to confirm the results.
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Affiliation(s)
- Sima Moghaddasian
- Department of Medical Surgical Nursing, Faculty of Nursing and Midwifery, Tabriz University of Medical sciences, Tabriz, Iran
| | - Sima Lak Dizaji
- Department of Medical Surgical Nursing, Faculty of Nursing and Midwifery, Tabriz University of Medical sciences, Tabriz, Iran
| | - Mokhtar Mahmoudi
- Department of Medical Surgical Nursing, Faculty of Nursing and Midwifery, Tabriz University of Medical sciences, Tabriz, Iran
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Baldwin MR, Narain WR, Wunsch H, Schluger NW, Cooke JT, Maurer MS, Rowe JW, Lederer DJ, Bach PB. A prognostic model for 6-month mortality in elderly survivors of critical illness. Chest 2013; 143:910-919. [PMID: 23632902 DOI: 10.1378/chest.12-1668] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Although 1.4 million elderly Americans survive hospitalization involving intensive care annually, many are at risk for early mortality following discharge. No models that predict the likelihood of death after discharge exist explicitly for this population. Therefore, we derived and externally validated a 6-month postdischarge mortality prediction model for elderly ICU survivors. METHODS We derived the model from medical record and claims data for 1,526 consecutive patients aged ≥ 65 years who had their first medical ICU admission in 2006 to 2009 at a tertiary-care hospital and survived to discharge (excluding those patients discharged to hospice). We then validated the model in 1,010 patients from a different tertiary-care hospital. RESULTS Six-month mortality was 27.3% and 30.2% in the derivation and validation cohorts, respectively. Independent predictors of mortality (in descending order of contribution to the model's predictive power) were a do-not-resuscitate order, older age, burden of comorbidity, admission from or discharge to a skilled-care facility, hospital length of stay, principal diagnoses of sepsis and hematologic malignancy, and male sex. For the derivation and external validation cohorts, the area under the receiver operating characteristic curve was 0.80 (SE, 0.01) and 0.71 (SE, 0.02), respectively, with good calibration for both (P = 0.31 and 0.43). CONCLUSIONS Clinical variables available at hospital discharge can help predict 6-month mortality for elderly ICU survivors. Variables that capture elements of frailty, disability, the burden of comorbidity, and patient preferences regarding resuscitation during the hospitalization contribute most to this model's predictive power. The model could aid providers in counseling elderly ICU survivors at high risk of death and their families.
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Affiliation(s)
- Matthew R Baldwin
- Division of Pulmonary, Allergy, and Critical Care, Columbia University, New York, NY.
| | - Wazim R Narain
- Data Analytics Group, New York-Presbyterian Hospital, New York, NY
| | - Hannah Wunsch
- Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, NY; Department of Epidemiology, New York, NY
| | - Neil W Schluger
- Division of Pulmonary, Allergy, and Critical Care, Columbia University, New York, NY; Department of Epidemiology, New York, NY
| | - Joseph T Cooke
- Division of Pulmonary and Critical Care, Weill Cornell Medical College, New York, NY
| | - Mathew S Maurer
- Division of Cardiology, College of Physicians and Surgeons, Columbia University, New York, NY
| | - John W Rowe
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, NY
| | - David J Lederer
- Division of Pulmonary, Allergy, and Critical Care, Columbia University, New York, NY; Department of Epidemiology, New York, NY
| | - Peter B Bach
- Center for Health Policy and Outcomes, Memorial Sloan-Kettering Cancer Center, New York, NY
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Wortz K, Cade A, Menard JR, Lurie S, Lykens K, Bae S, Jackson B, Su F, Singh K, Coultas D. A qualitative study of patients' goals and expectations for self-management of COPD. PRIMARY CARE RESPIRATORY JOURNAL : JOURNAL OF THE GENERAL PRACTICE AIRWAYS GROUP 2013; 21:384-91. [PMID: 23138844 DOI: 10.4104/pcrj.2012.00070] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is an illness that affects patients on multiple levels, both physically and psychologically. While there is a growing body of evidence for the efficacy of self-management among patients with COPD, little evidence is available on the optimal content and methods for delivering self-management support. AIMS The purpose of this study was to address gaps in the literature on self-management support by examining patients' responses to questions about goals, needs, and expectations regarding self-management using qualitative methods in a broadly representative sample of patients with moderate to severe COPD. By focusing on patients' perceptions of their needs, we hoped to guide development of cognitive-behavioural interventions for self-management support. METHODS Patients >45 years of age with a physician diagnosis of COPD were recruited as part of a larger randomised controlled trial designed to determine the effectiveness of a lifestyle behavioural intervention to increase physical activity. In-depth interviews were conducted at baseline data collection using 10 standardised open-ended questions tailored to examine factors relevant to self-management support including concerns, fears, learning needs, barriers, facilitators, and goals. All interviews were audio recorded and analysed using qualitative methods. Responses were coded by three raters into thematic categories. RESULTS A sample of 47 interviews with patients of mean age 68.4 years, 53% male, 87% white were used in the analysis. The distribution of spirometric impairment based on percent predicted forced expiratory volume in 1 second (FEV1) was moderate (57.5%), severe (31.9%), and very severe (10.6%). In response to questions targeting needs and goals for care, three main themes (loss, fear, and desire for improved care) and seven associated sub-themes were identified. Because of breathlessness and fatigue as well as symptoms from conditions other than COPD, patients reported the loss of ability to participate in pleasurable and necessary activities of daily living and the desire to recover at least some of their functioning. They expressed problems with social isolation and uncertainty about their prognosis, as well as the hope to improve. In addition, fearful experiences associated with uncontrolled breathlessness and a wish for greater understanding and knowledge about treatment were major concerns. CONCLUSIONS These qualitative results suggest that the content of self-management support for patients with COPD should focus on addressing patients' fears associated with the uncertainty, progression, and suffering of their disease, their expectations about overcoming or replacing losses, their needs for improved health literacy and their desire for improved care. These responses indicate areas where cognitive-behavioural intervention should focus in order to enhance patient self-efficacy, motivation, and behavioural change for improved self-management.
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Affiliation(s)
- Kathryn Wortz
- University of Texas Health Science Center at Tyler, Department of Family Medicine, Tyler, Texas 75708, USA.
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Loss SH, Marchese CB, Boniatti MM, Wawrzeniak IC, Oliveira RP, Nunes LN, Victorino JA. Prediction of chronic critical illness in a general intensive care unit. Rev Assoc Med Bras (1992) 2013; 59:241-7. [PMID: 23680275 DOI: 10.1016/j.ramb.2012.12.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Revised: 10/29/2012] [Accepted: 12/03/2012] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To assess the incidence, costs, and mortality associated with chronic critical illness (CCI), and to identify clinical predictors of CCI in a general intensive care unit. METHODS This was a prospective observational cohort study. All patients receiving supportive treatment for over 20 days were considered chronically critically ill and eligible for the study. After applying the exclusion criteria, 453 patients were analyzed. RESULTS There was an 11% incidence of CCI. Total length of hospital stay, costs, and mortality were significantly higher among patients with CCI. Mechanical ventilation, sepsis, Glasgow score <15, inadequate calorie intake, and higher body mass index were independent predictors for CCI in the multivariate logistic regression model. CONCLUSIONS CCI affects a distinctive population in intensive care units with higher mortality, costs, and prolonged hospitalization. Factors identifiable at the time of admission or during the first week in the intensive care unit can be used to predict CCI.
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Affiliation(s)
- Sérgio H Loss
- Department of Critical Care Medicine, Hospital de Clínicas, Porto Alegre, RS, Brazil.
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