Outcomes research at the end of life

[Psychologists working as members of the intensive care team could reduce the length of stay]

Both short and long term outcome of mechanically ventilated patients are dependent on the time spent on ventilator and on the intensive care unit. Health related quality of life of the survival of intensive care has been proved to be related with the physical and psychological effects of the intensive care itself. In our previous multicenter randomized trial we have demonstrated the effect of psychological support delivered at the time of intensive care.

AIM

The aim of this post hoc analysis is to demonstrate the effect of the psychological support given by an ICU staff psychologist providing continuous care by the same therapist.

METHODS

36 patients were included in the post hoc analysis, 17 in the control and 19 in the treatment group. The treatment group received daily psychological support based on positive suggestions delivered by the same therapist at least in 50% of the time. The control group received the same ICU care but without the involvement of the psychologist. There were no differences between the two groups in age, sex, SAPSII score and basic medical treatment.

RESULTS

RESULTS showed a significant reduction in mechanical ventilation (3.6 days shorter, p < 0.014) and length of stay (4.2 days shorter, p < 0.022) of the treatment group compared to the control.

CONCLUSIONS

These results suggest the value of a psychologist working as a full member of the ICU team and providing supplementary psychological support of patients.

End-of-life care in the intensive care unit: where are we now?

A growing body of evidence and experience has effaced what were once thought to be clear distinctions between "critical illness" and "terminal illness" and has exposed the problems of postponing palliative care for intensive care patients until death is obviously imminent. Integration of palliative care as a component of comprehensive intensive care is now seen as more appropriate for all critically ill patients, including those pursuing aggressive treatments to prolong life. At present, however, data on which to base practice in this integrated model remain insufficient, and forces of the healthcare economy and other factors may constrain its application. The purpose of this article is to map where we are now in seeking to improve palliative care in the intensive care unit. We review existing evidence, which suggests that both symptom management and communication about preferences and goals of care warrant improvement and that prevailing practices for limitation of life-sustaining treatments are inconsistent and possibly irrational. We also address the need for assessment tools for research and quality improvement. We discuss recent initiatives and ongoing obstacles. Finally, we identify areas for further exploration and suggest guiding principles.