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Beil M, Moreno R, Fronczek J, Kogan Y, Moreno RPJ, Flaatten H, Guidet B, de Lange D, Leaver S, Nachshon A, van Heerden PV, Joskowicz L, Sviri S, Jung C, Szczeklik W. Prognosticating the outcome of intensive care in older patients-a narrative review. Ann Intensive Care 2024; 14:97. [PMID: 38907141 PMCID: PMC11192712 DOI: 10.1186/s13613-024-01330-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 06/10/2024] [Indexed: 06/23/2024] Open
Abstract
Prognosis determines major decisions regarding treatment for critically ill patients. Statistical models have been developed to predict the probability of survival and other outcomes of intensive care. Although they were trained on the characteristics of large patient cohorts, they often do not represent very old patients (age ≥ 80 years) appropriately. Moreover, the heterogeneity within this particular group impairs the utility of statistical predictions for informing decision-making in very old individuals. In addition to these methodological problems, the diversity of cultural attitudes, available resources as well as variations of legal and professional norms limit the generalisability of prediction models, especially in patients with complex multi-morbidity and pre-existing functional impairments. Thus, current approaches to prognosticating outcomes in very old patients are imperfect and can generate substantial uncertainty about optimal trajectories of critical care in the individual. This article presents the state of the art and new approaches to predicting outcomes of intensive care for these patients. Special emphasis has been given to the integration of predictions into the decision-making for individual patients. This requires quantification of prognostic uncertainty and a careful alignment of decisions with the preferences of patients, who might prioritise functional outcomes over survival. Since the performance of outcome predictions for the individual patient may improve over time, time-limited trials in intensive care may be an appropriate way to increase the confidence in decisions about life-sustaining treatment.
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Affiliation(s)
- Michael Beil
- Department of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Rui Moreno
- Unidade Local de Saúde São José, Hospital de São José, Lisbon, Portugal
- Centro Clínico Académico de Lisboa, Lisbon, Portugal
- Faculdade de Ciências da Saúde, Universidade da Beira Interior, Covilhã, Portugal
| | - Jakub Fronczek
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Yuri Kogan
- Institute for Medical Biomathematics, Bene Ataroth, Israel
| | | | - Hans Flaatten
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway
| | - Bertrand Guidet
- INSERM, Institut Pierre Louis d'Epidémiologie Et de Santé Publique, AP-HP, Hôpital Saint Antoine, Sorbonne Université, Service MIR, Paris, France
| | - Dylan de Lange
- Department of Intensive Care Medicine, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Susannah Leaver
- General Intensive Care, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Akiva Nachshon
- General Intensive Care Unit, Department of Anaesthesiology, Critical Care and Pain Medicine, Faculty of Medicine, Hebrew University and, Hadassah University Medical Center, Jerusalem, Israel
| | - Peter Vernon van Heerden
- General Intensive Care Unit, Department of Anaesthesiology, Critical Care and Pain Medicine, Faculty of Medicine, Hebrew University and, Hadassah University Medical Center, Jerusalem, Israel
| | - Leo Joskowicz
- School of Computer Science and Engineering and Center for Computational Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sigal Sviri
- Department of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Christian Jung
- Department of Cardiology, Pulmonology and Vascular Medicine, Faculty of Medicine, Heinrich-Heine-University, University Duesseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
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Stein D, Sviri S, Beil M, Stav I, Marcus EL. Prognosis of Chronically Ventilated Patients in a Long-Term Ventilation Facility: Association with Age, Consciousness and Cognitive State. J Intensive Care Med 2022; 37:1587-1597. [PMID: 35350916 PMCID: PMC9647314 DOI: 10.1177/08850666221088800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background: The number of adults requiring prolonged mechanical ventilation (PMV) including those with cognitive impairment or disorders of consciousness is escalating. We aimed to compare in a long-term acute care hospital (LTACH) mortality and length of stay (LOS) among three age groups (40-59y, 60-79y, ≥80y) of hospitalized PMV patients, and according to consciousness and cognitive state at admission. Methods: We obtained data from the health records of 308 adults aged ≥40 years requiring PMV hospitalized at a Chronic Ventilator Dependent Unit in a LTACH between 01/01/2015 to 06/30/2019 and followed-up until discharge or death or until 12/31/2019. Results: At admission to LTACH, 42.2% of PMV patients were in a vegetative state/ minimally conscious state (VS/MCS); 32.5% were severely cognitively impaired, 11.0% were mildly to moderately cognitively impaired, 12.3% had no cognitive impairment, and 1.9% had intellectual disability/psychiatric disorder. In-LTACH LOS (months) decreased from 34.6 ± 42.6 at age 40-59y, 19.1 ± 22.3 at 60-79y to 14.4 ± 19.3 at age ≥80y (p = .006). In-LTACH mortality was 30.6% for 40-59y, 41.1% for 60-79y and 54.8% for age ≥80y. In-LTACH LOS (months) was 23.8 ± 30.7 for VS/MCS, 15.1 ± 19.5 for the severely cognitively impaired, 10.0 ± 12.8 for mild to moderate cognitive impairment and 18.9 ± 21.9 for those without cognitive impairment (p = .02). In-LTACH mortality was 50.8% for VS/MCS, 58.0% for the severely cognitively impaired, 26.5% for mild to moderate cognitive impairment and 13.2% for those without cognitive impairment (p < .001). Conclusion: In this population requiring PMV, mortality and in-LTACH LOS worsened with age. In-LTACH LOS was longest for VS/MCS patients, who had a mean survival of about two years, followed by those without cognitive impairment and then those with severe cognitive impairment. Mortality was associated with worse consciousness and cognitive state. These findings highlight the importance of discussing end-of-life decisions with patients and family members regarding resuscitation/intubation and the long-term management of these patients.
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Affiliation(s)
- David Stein
- Medical Intensive Care Unit, Hadassah Medical Center and Faculty of
Medicine, Hebrew University of Jerusalem, Israel
- David Stein, Hadassah Medical Center,
Jerusalem, Israel. E-mail:
| | - Sigal Sviri
- Medical Intensive Care Unit, Hadassah Medical Center and Faculty of
Medicine, Hebrew University of Jerusalem, Israel
| | - Michael Beil
- Medical Intensive Care Unit, Hadassah Medical Center and Faculty of
Medicine, Hebrew University of Jerusalem, Israel
| | - Ilana Stav
- Medical Intensive Care Unit, Hadassah Medical Center and Faculty of
Medicine, Hebrew University of Jerusalem, Israel
| | - Esther-Lee Marcus
- Chronic Ventilator-Dependent Division, Herzog Medical Center and Faculty of
Medicine, Hebrew University of Jerusalem, Israel
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Marcus EL, Jacobs JM, Stessman J. Prolonged mechanical ventilation and caregiver strain: Home vs. long-term care facility. Palliat Support Care 2022; 21:429-437. [PMID: 35266449 DOI: 10.1017/s147895152200027x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The number of patients treated with prolonged mechanical ventilation (PMV) is steadily rising. Traditionally treated within specialized long-term care facilities (LTCFs), healthcare providers are increasingly promoting homecare as a technologically safe, humane, and cheaper alternative. Little is known concerning their informal caregivers (ICGs), despite their crucial role in facilitating care. This study examines caregiver strain among the primary ICG of PMV patients treated at home vs. LTCF. METHOD This study was an observational cross-sectional study. The study enrolled 120/123 PMV patients ≥18 years within the study region (46 treated with homecare/74 treated at the LTCF) and 106 ICGs (34 ICGs/46 homecare patients and 72 ICGs/74 LTCF patients). Caregiver assessment included the 13-item Modified Caregiver Strain Index (Mod CSI) (0-26 maximum); patient assessment included symptom burden (the revised Edmonton Symptom Assessment System). RESULTS The mean age of ICGs was 58.9 years old; 60.4% were females; 82.1% were married; 29.2% were patient's spouses; and 40.6% were patient's children. The total Mod CSI was 13.58 (SD 6.52) and similar between home vs. LTCF (14.30 SD 7.50 vs. 13.26 SD 6.03, p = 0.50), or communicative vs. non-communicative patients (13.50 SD 7.12 vs. 13.64 SD 6.04, p = 0.93). Hierarchical analysis identified three clusters of caregiver strain, with ICGs at home vs. LTCF reporting significantly lower mood strain, higher burden, and similar levels of lifestyle disturbance. In adjusted models, homecare was significantly associated with reduced mood strain and increased burden, while increased patient symptomatology was significantly associated with total strain, mood, and burden strain clusters. SIGNIFICANCE OF RESULTS Recognizing the different patterns of caregiver strain at home or LTCF is a prerequisite for addressing their palliative care needs and improving the wellbeing and resilience of informal caregivers, who often play a critical role in deciding whether to treat the PMV patient at home or LTCF.
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Affiliation(s)
- Esther-Lee Marcus
- Chronic Ventilator-Dependent Division, Herzog Medical Center, Jerusalem, Israel
- Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Jeremy M Jacobs
- Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
- Jerusalem Home Hospital Unit, Institute of Geriatric Medicine, Clalit Health Services, Jerusalem, Israel
- Department of Geriatrics and Geriatric Rehabilitation, Hadassah Medical Organization, Jerusalem, Israel
- Institute for Aging Research, Hadassah Medical Organization, Jerusalem, Israel
| | - Jochanan Stessman
- Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
- Jerusalem Home Hospital Unit, Institute of Geriatric Medicine, Clalit Health Services, Jerusalem, Israel
- Department of Geriatrics and Geriatric Rehabilitation, Hadassah Medical Organization, Jerusalem, Israel
- Institute for Aging Research, Hadassah Medical Organization, Jerusalem, Israel
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Factors associated with surrogate families’ life-sustaining treatment preferences for patients at home or in a geriatric health service facility: A cross-sectional study. Palliat Support Care 2021; 20:334-341. [DOI: 10.1017/s1478951521001401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Abstract
Objective
Recently, end-of-life preference in palliative care has been gaining attention in Japan. The Ministry of Health, Labor, and Welfare established the Japanese basic policy in November 2018. Patients’ decision-making is recommended; however, patients with dementia or other disorders cannot make such decisions by themselves. Thus, healthcare providers may contact surrogates and consider their backgrounds for better decision-making. Hence, the preferences of home caregivers’ and geriatric health service facility (GHSF) residents’ families on patient life-sustaining treatment (LST) were investigated.
Method
This cross-sectional study involved home caregivers’ and GHSF residents’ families in Japan. We distributed 925 self-reported questionnaires comprising items, such as the number of people living together, care duration, comprehension of doctor's explanations, the Patient Health Questionnaire (PHQ)-9 and Short Form (SF)-8, and families’ LST preference for patients.
Results
In all, 619 valid responses were obtained [242 men and 377 women (309 in the HOME Caregivers Group, response rate = 61.1%; 310 in the GHSF Group, response rate = 74.0%)]. LST preference was significantly associated with sex, the number of people living together, care duration, and comprehension of doctors’ explanations in the HOME Caregivers Group but was not significantly associated with the GHSF Group. Furthermore, PHQ-9/SF-8 scores were not significantly associated with LST preference.
Significance of results
There were many differences in opinions about LST preference between home caregivers’ and GHSF residents’ families. The results suggested that the burden of nursing care was greater and harder in home caregiver families, and these factors may be related to the LST preference for a patient.
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Shaku F, Tsutsumi M, Nakamura A, Takagi H, Otsuka T, Maruoka S. Factors Relating to Caregivers' Preference for Advance Care Planning of Patients in Japan: A Cross-Sectional Study. Am J Hosp Palliat Care 2020; 36:727-733. [PMID: 31256612 DOI: 10.1177/1049909119844517] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES The aim of this study was to examine the preferences of home caregivers on patient advance care planning (ACP), including life-sustaining treatment (LST) and the factors relating to these preferences. BACKGROUND Personalized ACP aims to respect the autonomy and choices of terminally ill patients regarding end-of-life care. However, there have been cases wherein doctors must instead discuss ACP with surrogates (including caregivers) for various reasons such as dementia, intractable neurologic diseases, and cerebrovascular accident. METHODS In this cross-sectional study, self-written questionnaires (filled by individuals themselves) were distributed to 506 in-home caregivers in 6 Japanese prefectures; the questionnaires contained items on caregiver and patient demographics, number of people living together in a caregiver's home (aside from patients), care duration, comprehension level of doctors' explanations regarding their patient's condition, patient diseases, whether caregivers have or have not told patients about their disease, level of nursing care, and caregiver LST preference (preferred or not preferred). The questionnaire package also contained the Burden Index of Caregiver-11, Patient Health Questionnaire-9, and Short Form-8 Health Survey. RESULTS Valid responses were obtained from 309 caregivers. More than half of them were not sure of their patient's LST preference. Sex, number of people living together in a care home, comprehension level of doctors' explanations, and care duration were found to be the significant factors relating to caregivers' LST preference (P < .05). CONCLUSION Health providers should be cognizant of the background factors relating to caregiver ACP preference when deciding on LST for terminal patients.
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Affiliation(s)
- Fumio Shaku
- 1 Department of Psychosomatic Internal Medicine, Nihon University Itabashi Hospital, Itabashi-ku, Tokyo, Japan.,2 Department of Internal Medicine, Division of Respiratory Medicine, Nihon University School of Medicine, Tokyo, Japan
| | | | | | | | | | - Shuichiro Maruoka
- 1 Department of Psychosomatic Internal Medicine, Nihon University Itabashi Hospital, Itabashi-ku, Tokyo, Japan.,2 Department of Internal Medicine, Division of Respiratory Medicine, Nihon University School of Medicine, Tokyo, Japan
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DeFilippis EM. Without Words. JAMA Cardiol 2019; 3:561-562. [PMID: 29562075 DOI: 10.1001/jamacardio.2018.0232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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The Experience of Surrogate Decision Makers on Being Approached for Consent for Patient Participation in Research. A Multicenter Study. Ann Am Thorac Soc 2018; 14:238-245. [PMID: 27849142 DOI: 10.1513/annalsats.201606-425oc] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Recruitment in critical care research differs from other contexts in important ways: patients lack decision-making capacity, uncertainty exists regarding patient prognosis, and critical illnesses are often associated with appreciable morbidity and mortality. OBJECTIVES We aimed to describe the experiences of surrogate decision makers (SDMs) in being approached for consent for critically ill patients to participate in research. METHODS A multicenter, qualitative study involving semistructured interviews with 26 SDMs, who provided or declined surrogate consent for research participation, at 5 Canadian centers nested within a multicenter observational study of research recruitment practices. Transcripts were reviewed by three qualitative researchers, and data were analyzed using grounded theory and a narrative critical analysis. MEASUREMENTS AND MAIN RESULTS SDMs were guided by an overarching desire for the patient to live. Surrogate research decision-making involved three sequential stages: (1) being approached; (2) reflecting on participation; and (3) making a decision. In stage 1, SDMs identified factors (their expectations, how they were approached, the attributes of the person approaching, and study risks and benefits) that characterized their consent encounter and affirmed a preference to be approached in person. If SDMs perceived the risk of participation to be too high or felt patients may not benefit from participation, they did not contemplate further. In stage 2, SDMs who knew the patient's wishes or had a deeper understanding of research prioritized the patient's wishes and the perceived benefits of participation. Without this information, SDMs prioritized obtaining more and better care for the patient, considered what was in their mutual best interests, and valued healthcare professional's knowledge. Trust in healthcare professionals was essential to proceeding further. In stage 3, SDMs considered six factors in rendering decisions. CONCLUSIONS SDMs engaged in three sequential stages and considered six factors in making surrogate decisions for research participation. Surrogates' assessments of the risks and benefits of participation and their trust in healthcare professionals were critical factors in research decision-making. By conceptualizing surrogate decision-making for research in stages, future research can develop and test procedures to enhance the surrogate research decision-making process.
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Tang ST, Wen FH, Liu LN, Chiang MC, Lee SCK, Chou MC, Feng WL, Lin YC, Liu IP, Kuo YH, Chi SC, Lee KC. A Decade of Changes in Family Caregivers' Preferences for Life-Sustaining Treatments for Terminally Ill Cancer Patients at End of Life in the Context of a Family-Oriented Society. J Pain Symptom Manage 2016; 51:907-915.e2. [PMID: 26921491 DOI: 10.1016/j.jpainsymman.2015.12.326] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 12/20/2015] [Accepted: 12/24/2015] [Indexed: 11/22/2022]
Abstract
CONTEXT Temporal changes in different family caregiver cohorts' preferences for life-sustaining treatments (LSTs) at end of life (EOL) have not been examined nor have the concept of whether caregivers' LST preferences represent a homogeneous or heterogeneous construct. Furthermore, LST preferences are frequently assessed from multiple treatments, making clinical applications difficult/infeasible. OBJECTIVES To identify parsimonious patterns and changes in the pattern of LST preferences for two independent cohorts of family caregivers for terminally ill Taiwanese cancer patients. METHODS Preferences for cardiopulmonary resuscitation, intensive care unit care, cardiac massage, intubation with mechanical ventilation, intravenous nutritional support, tube feeding, and dialysis were assessed among 1617 and 2056 family caregivers in 2003-2004 and 2011-2012, respectively. Patterns and changes in LST preferences were examined by multigroup latent class analysis. RESULTS Five distinct classes were identified: uniformly preferring, uniformly rejecting, uniformly uncertain, and favoring nutritional support but rejecting or uncertain about other treatments. Class probability significantly decreased from 29.3% to 23.7% for the uniformly rejecting class, remained largely unchanged for the uniformly preferring (16.9%-18.6%), and favoring nutritional support but rejecting (37.1%-37.5%) or uncertain about other treatments (8.0%-10.4%) classes, but significantly increased from 7.0% to 11.5% for the uniformly uncertain class over time. CONCLUSION Family caregivers' LST preferences for terminally ill cancer patients are a heterogeneous construct and shifted from uniformly rejecting all LSTs toward greater uncertainty. Surrogate EOL-care decision making may be facilitated by earlier and thorough assessments of caregivers' LST preferences and tailoring interventions to the unique needs of caregivers in each class identified in this study.
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Affiliation(s)
- Siew Tzuh Tang
- Chang Gung University School of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Tao-Yuan, Taiwan, Republic of China; Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Tao-Yuan, Taiwan, Republic of China.
| | - Fur-Hsing Wen
- Department of International Business, Soochow University, Taipei, Taiwan
| | - Li Ni Liu
- Department of Nursing, Fu Jen Catholic University, New Taipei City, Taiwan, Republic of China
| | - Ming-Chu Chiang
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Tao-Yuan, Taiwan, Republic of China
| | - Shiuyu C K Lee
- School of Nursing, National Taipei University of Nursing and Health Science, Taipei City, Taiwan, Republic of China
| | - Man Chun Chou
- Department of Nursing, Chang Gung Memorial Hospital at Kaohsiung, Tao-Yuan, Taiwan, Republic of China
| | - Wei-Lien Feng
- National Institute of Cancer Research, National Health Research Institutes, Taipei, Taiwan, Republic of China
| | - Yu-Chuan Lin
- Department of Nursing, Tzu Chi University, Hualien City, Taiwan, Republic of China
| | - I-Ping Liu
- Chi-Mei Hospital, Chi Ali, Taiwan, Republic of China
| | - Ya-Hui Kuo
- Chia-Yi Christian Hospital, Chiayi City, Taiwan, Republic of China
| | - Shu Ching Chi
- Department of Nursing, E-Da Hospital and I-Shou University, Kaohsiung City, Taiwan, Republic of China
| | - Kwo C Lee
- School of Nursing, China Medical University, Taichung, Taiwan, Republic of China; Department of Nursing, China Medical University Hospital, Taichung, Taiwan, Republic of China
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Dillworth J, Dickson VV, Mueller A, Shuluk J, Yoon HW, Capezuti E. Nurses' perspectives: hospitalized older patients and end-of-life decision-making. Nurs Crit Care 2015; 21:e1-e11. [PMID: 25892177 DOI: 10.1111/nicc.12125] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 05/18/2014] [Accepted: 07/10/2014] [Indexed: 11/28/2022]
Abstract
AIMS To explore pressing issues identified by nurses caring for older patients in US NICHE (Nurses Improving Care for the Healthsystem Elders) hospitals, regarding palliative care and end-of-life (EOL) decision-making. Objectives are to (1) identify the most pressing palliative care and EOL decision-making issues and strategies to address them and (2) identify the association of nursing demographics (age, gender, race, education and experience), institutional/unit characteristics and these issues. BACKGROUND Critical care nurses have an integral role in supporting older patients and families faced with palliative care and EOL decision-making issues. Despite national imperatives to improve the quality of palliative care, patients continue to experience uncontrolled pain, inadequate communication, disregard of their wishes and life prolonging interventions. These contribute to increased hospitalizations and costs. Understanding the prevalent issues is needed to address patient needs at the end-of-life. DESIGN It is a mixed method study. METHODS A secondary analysis of the NICHE Geriatric Institutional Assessment Profile (GIAP) database (collected 1/08-9/13) was conducted using the sample of Critical Care RNs who provided comments regarding palliative care and EOL decision-making. Qualitative data were analyzed using Dedoose software. Data clusters and patterns of co-occurring codes were explored through an iterative analysis process. Themes were examined across nurse demographics, institutional and unit characteristics. RESULTS Comments specifically addressing issues regarding EOL decision-making were provided by 393 critical care nurses from 156 hospitals (x‾ age = 42·3 years, 51% BSN degree). Overarching theme was discordance in goals of care (prolonging life versus quality of life), ineffective physician-patient-family communication, lack of time and unrealistic expectations. CONCLUSIONS Nurses' descriptions highlight the need for increased communication, staff education and availability of palliative care services. RELEVANCE TO PRACTICE Palliative care and EOL decision-making will remain a nursing priority as people age and require increased care.
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Affiliation(s)
- Judy Dillworth
- New York University, College of Nursing, New York, NY, USA
| | | | - Anna Mueller
- New York University, College of Nursing, New York, NY, USA
| | - Joseph Shuluk
- New York University, College of Nursing, New York, NY, USA
| | - Hye W Yoon
- New York University, College of Nursing, New York, NY, USA
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Abstract
Most major decisions in the intensive care unit (ICU) regarding goals of care are shared by clinicians and someone other than the patient. Multicenter clinical trials focusing on improved communication between clinicians and these surrogate decision makers have not reported consistently improved outcomes. We suggest that acquired maladaptive reasoning may contribute importantly to failure of the intervention strategies tested to date. Surrogate decision makers often suffer significant psychological morbidity in the form of stress, anxiety, depression, and post-traumatic stress disorder. Family members in the ICU also suffer cognitive blunting and sleep deprivation. Their decision-making abilities are eroded by anticipatory grief and cognitive biases, while personal and family conflicts further impact their decision making. We propose recognizing a family ICU syndrome to describe the morbidity and associated decision-making impairment experienced by many family members of patients with acute critical illness (in the ICU) and chronic critical illness (in the long-term, acute care hospital). Research rigorously using models of compromised decision making may help elucidate both mechanisms of impairment and targets for intervention. Better quantifying compromised decision making and its relationship to poor outcomes will allow us to formulate and advance useful techniques. The use of decision aids and improving ICU design may provide benefit now and in the near future. In measuring interventions targeting cognitive barriers, clinically significant outcomes, such as time to decision, should be considered. Statistical approaches, such as survival models and rank statistic testing, will increase our power to detect differences in our interventions.
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Chapman AR, Litton E, Chamberlain J, Ho KM. The effect of prognostic data presentation format on perceived risk among surrogate decision makers of critically ill patients: a randomized comparative trial. J Crit Care 2014; 30:231-5. [PMID: 25480457 DOI: 10.1016/j.jcrc.2014.11.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 09/23/2014] [Accepted: 11/07/2014] [Indexed: 11/19/2022]
Abstract
PURPOSE The purpose of this study is to determine whether varying the format used to present prognostic data alters the perception of risk among surrogate decision makers in the intensive care unit (ICU). METHODS This was a prospective randomized comparative trial conducted in a 23-bed adult tertiary ICU. Enrolled surrogate decision makers were randomized to 1 of 2 questionnaires, which presented hypothetical ICU scenarios, identical other than the format in which prognostic data were presented (eg, frequencies vs percentages). Participants were asked to rate the risk associated with each prognostic statement. RESULTS We enrolled 141 surrogate decision makers. The perception of risk varied significantly dependent on the presentation format. For "quantitative data," risks were consistently perceived as higher, when presented as frequencies (eg, 1 in 50) compared with equivalent percentages (eg, 2%). Framing "qualitative data" in terms of chance of "death" rather than "survival" led to a statistically significant increase in perceived risks. Framing "quantitative" data in this way did not significantly affect risk perception. CONCLUSION Data format had a significant effect on how surrogate decision makers interpreted risk. Qualitative statements are interpreted widely and affected by framing. Where possible, multiple quantitative formats should be used for presenting prognostic information.
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Affiliation(s)
- Andy R Chapman
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, 6000, Western Australia.
| | - Edward Litton
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, 6000, Western Australia; School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia
| | - Jenny Chamberlain
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, 6000, Western Australia
| | - Kwok M Ho
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, 6000, Western Australia; School of Population Health, University of Western Australia, Perth, Western Australia
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Attitudes of legal guardians in the ICU - a qualitative report. Intensive Crit Care Nurs 2013; 30:86-92. [PMID: 24211049 DOI: 10.1016/j.iccn.2013.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 09/28/2013] [Accepted: 10/02/2013] [Indexed: 11/21/2022]
Abstract
UNLABELLED Decision-making in intensive care units (ICUs) is often made by surrogates, since patients are unconscious or incompetent. In Israel, Legal Guardians (LGs), appointed by the court, are required to make these decisions. OBJECTIVE To qualitatively assess the attitudes of LGs required to make decisions on behalf of their relatives. RESEARCH DESIGN Demographic and semi-structured questionnaires were used to assess the attitudes of LGs regarding difficulties, positive aspects and areas for improvement with regard to surrogate decision-making. The study sampled sixty-four LGs in two large Israeli hospitals. After reading and analysing the responses provided by the LGs, the authors categorised the pertinent topics raised using a thematic analysis. RESULTS Themes were: bureaucratic and legal issues, unclear or unknown patient preferences and fear of outcomes. Family and medical staff support was stated as the most beneficial. Suggestions for improvement included alleviation of bureaucracy and improved communication with the medical staff. CONCLUSIONS The importance of communication and bureaucratic difficulties, making the best decision for the patient and uncertainty regarding decision outcomes were found to be important issue for the LGs. The healthcare team should try and alleviate some of these burdens, mostly by improving communication with relatives, stressing and educating the importance of advance directives. Reporting the problems found in the decision making process of LGs to the legislators in order to revise and simplify the current legal requirements is advised.
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Kuniavsky M, Ganz FD, Linton DM, Sviri S. The legal guardians' dilemma: Decision making associated with invasive non-life-saving procedures. Isr J Health Policy Res 2012; 1:36. [PMID: 23006738 PMCID: PMC3467171 DOI: 10.1186/2045-4015-1-36] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2012] [Accepted: 07/17/2012] [Indexed: 11/24/2022] Open
Abstract
Background ICU patients frequently undergo non-life-saving invasive procedures. When patient informed consent cannot be obtained, legal guardianship (LG), often from a close relative, may be required by law. The objective of this cohort study was to investigate the attitudes of LGs of ICU patients regarding the process of decision making for invasive non-life-saving procedures. Methods The study was conducted from May 2009 until June 2010 in general medical/surgical ICUs in two large Israeli medical centers. All 64 LGs who met the study criteria agreed to participate in the study. Three questionnaires were administered: a demographic data questionnaire, the Family Satisfaction with ICU 34 Questionnaire, and the Attitudes towards the LG Decision Making Process questionnaire, developed by the authors. Results The sample consisted of 64 LGs. Most participants were married (n = 56, 87.5%), male (n = 33, 51.6%), who had either a high school (n = 24, 37.5%) or college (n = 19, 29.7%) education, and were at a mean age of 49.2 (±11.22). Almost all of the procedures performed were tracheotomies (n = 63, 98.4%). About two-thirds of the LGs preferred decisions to be made by the medical staff after discussing options with them (n = 42, 65.6%) and about three-fifths stated that decisions could be made without the need for the appointment of an LG (n = 37, 57.8%). Attitudes towards ease of obtaining information and honesty of information were more positive compared to those of consistency and understanding of information. Conclusions The legal guardianship process requires better communication and more understandable information in order to assist LGs in making decisions for others in at times vague and stressful situations.
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Affiliation(s)
- Michael Kuniavsky
- General ICU, Asaf HaRofeh Medical Center, Beer Jaacov 70300, Israel.
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Scheunemann LP, Arnold RM, White DB. The facilitated values history: helping surrogates make authentic decisions for incapacitated patients with advanced illness. Am J Respir Crit Care Med 2012; 186:480-6. [PMID: 22822020 PMCID: PMC3480534 DOI: 10.1164/rccm.201204-0710cp] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Accepted: 07/07/2012] [Indexed: 11/16/2022] Open
Abstract
Many patients who develop incapacitating illness have not expressed clear treatment preferences. Therefore, surrogate decision makers are asked to make judgments about what treatment pathway is most consistent with the patient's values. Surrogates often struggle with such decisions. The difficulty arises because answering the seemingly straightforward question, "What do you think the patient would choose?" is emotionally, cognitively, and morally complex. There is little guidance for clinicians to assist families in constructing an authentic picture of the patient's values and applying them to medical decisions, in part because current models of medical decision making treat the surrogate as the expert on the patient's values and the physician as the expert on technical medical considerations. However, many surrogates need assistance in identifying and working through the sometimes conflicting values relevant to medical decisions near the end of life. We present a framework for clinicians to help surrogates overcome the emotional, cognitive, and moral barriers to high-quality surrogate decision making for incapacitated patients.
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Affiliation(s)
- Leslie P Scheunemann
- Division of Geriatric Medicine and Center for Aging and Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Finley MR, Becho J, Macias RL, Wood RC, Hernandez AE, Espino DV. Attitudes regarding the use of ventilator support given a supposed terminal condition among community-dwelling Mexican American and non-Hispanic white older adults: a pilot study. ScientificWorldJournal 2012; 2012:852564. [PMID: 22629214 PMCID: PMC3353561 DOI: 10.1100/2012/852564] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Accepted: 12/11/2011] [Indexed: 11/30/2022] Open
Abstract
Purpose. To determine the factors that are associated with Mexican Americans' preference for ventilator support, given a supposed terminal diagnosis. Methods. 100 Mexican Americans, aged 60–89, were recruited and screened for MMSE scores above 18. Eligible subjects answered a questionnaire in their preferred language (English/Spanish) concerning ventilator use during terminal illness. Mediator variables examined included demographics, generation, religiosity, occupation, self-reported depression, self-reported health, and activities of daily living. Results. Being first or second generation American (OR = 0.18, CI = 0.05–0.66) with no IADL disability (OR = 0.11, CI = 0.02–0.59) and having depressive symptoms (OR = 1.43, CI = 1.08–1.89) were associated with preference for ventilator support. Implications. First and second generation older Mexican Americans and those functionally independent are more likely to prefer end-of-life ventilation support. Although depressive symptoms were inversely associated with ventilator use at the end of life, scores may more accurately reflect psychological stress associated with enduring the scenario. Further studies are needed to determine these factors' generalizability to the larger Mexican American community.
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Affiliation(s)
- M Rosina Finley
- Department of Family & Community Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX 78229, USA
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Venkat A. Surrogate Medical Decision Making on Behalf of a Never-Competent, Profoundly Intellectually Disabled Patient Who Is Acutely Ill. THE JOURNAL OF CLINICAL ETHICS 2012. [DOI: 10.1086/jce201223110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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[Out-of-hospital assessment of elderly patients' preference for ICU care]. ACTA ACUST UNITED AC 2011; 31:114-9. [PMID: 22152996 DOI: 10.1016/j.annfar.2011.10.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Accepted: 10/18/2011] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To estimate the adequacy between elderly patients' preference for ICU care when treated for a life-threatening pathology, and the strategy proposed by the medical team on scene. STUDY DESIGN Prospective, observational study. PATIENTS AND METHODS All patients older than 80 treated out-of-hospital for a life threatening pathology were included, except in case of language barrier, or when patients were unable to answer and absence of next-of-kin. The results of the questionnaire on quality of life and patients' preference concerning ICU care were compared to the responses provided blindly by the medical team. RESULTS Fifty-five patients were included. Quality of life as expressed by the patients was 7 (5-10) and by the physician 7 (6-8) (P=0.69). Thirty-six patients (65%) expressed the wish to be resuscitated, while ICU admission would have been proposed for 44 patients (80%) by the doctors (P=0.01). Among the 14 patients reluctant to ICU admission, 11 would have been proposed for ICU admission. In multivariate analysis, age (OR: 1.55 [1.04-2.32], P=0.03) and history of neurological pathology (OR: 11,91 [5.68->100], P=0.04) were associated with such an inadequacy. CONCLUSION The inadequacy between elderly patients' preferences and doctors' opinion concerning ICU cares is frequent. The present results support a more systematic collection of patients' preferences when treated on scene for a life-threatening pathology.
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Current World Literature. Curr Opin Support Palliat Care 2010; 4:207-27. [DOI: 10.1097/spc.0b013e32833e8160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bibliography. PROGRESS IN PALLIATIVE CARE 2009. [DOI: 10.1179/096992609x12455871937224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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