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Hauschildt KE, Vick JB, Ashana DC. Racial, Ethnic, and Socioeconomic Differences in Critical Care Near the End of Life: A Narrative Review. Crit Care Clin 2024; 40:753-766. [PMID: 39218484 DOI: 10.1016/j.ccc.2024.05.007] [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: 09/04/2024]
Abstract
Patients from groups that are racially/ethnically minoritized or of low socioeconomic status receive more intensive care near the end of life, endorse preferences for more life-sustaining treatments, experience lower quality communication from clinicians, and report worse quality of dying than other patients. There are many contributory factors, including system (eg, lack of intensive outpatient symptom management resources), clinician (eg, low-quality serious illness communication), and patient (eg, cultural norms) factors. System and clinician factors contribute to disparities and ought to be remedied, while patient factors simply reflect differences in care and may not be appropriate targets for intervention.
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Affiliation(s)
- Katrina E Hauschildt
- Department of Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, #520, Baltimore, MD 21205, USA
| | - Judith B Vick
- Durham VA Health Care System; Department of Medicine, Duke University School of Medicine; National Clinician Scholars Program, Duke Clinical and Translational Science Institute, 701 West Main Street, Durham, NC 27701, USA
| | - Deepshikha Charan Ashana
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA; Department of Population Health Sciences, Duke University, Hanes House, 315 Trent Drive, Durham, NC 27705, USA.
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2
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Rachoin JS, Debski N, Hunter K, Cerceo E. Factors Associated with Do Not Resuscitate Status and Palliative Care in Hospitalized Patients: A National Inpatient Sample Analysis. Palliat Med Rep 2024; 5:331-339. [PMID: 39144137 PMCID: PMC11319862 DOI: 10.1089/pmr.2024.0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2024] [Indexed: 08/16/2024] Open
Abstract
Introduction Patients from diverse sociocultural backgrounds and with differing medical conditions may have varying levels of acceptance of advanced care planning and palliative care. Methods We performed a retrospective analysis of the National Inpatient Sample for patients discharged from January 1, 2016, to December 31, 2019, with conditions associated with frequently terminal conditions. We recorded demographic variables, do not resuscitate (DNR) status, and palliative care (PC) status and analyzed the associations between outcomes, mortality, and length of stay (LOS). Results A total of 23,402,637 patient records were included in the study, of which 2% were DNR and PC, 5% were DNR only, and 1% was PC only. From 2016 to 2019, the percentage of patients with PC increased from 2.55% to 3.27% and DNR from 6.31% to 7.7%. Black patients were less likely to have DNR status (odds ratio [OR] 0.72 [0.71-0.72]) but had similar PC rates. Male patients were less likely to have a DNR order in place (OR 0.89 [0.89-0.89]) but more likely to be in PC (OR 1.05 [1.04-1.05]). The diagnoses with the highest association with DNR status were lung cancer (OR 4.1 [4.0-4.5]), pancreatic cancer (OR 4.6 [4.5-4.7]), and sepsis (OR 2.9 [2.9-2.9]) The diagnoses most associated with PC were lung cancer (OR 6.3 [6.2-6.4]), pancreatic cancer (OR 8.1 [7.1-8.3]), colon cancer (OR 4.9 [4.8-5.1]), and senile brain degeneration of the brain OR 6.5 [5.3-7.9]). Mortality and LOS decreased between 2016 and 2019, but hospital charges increased (p < 0.001). Black race and male gender were associated with higher inpatient mortality (OR 1.12 [1.12-1.14]), LOS, and hospital charges. Conclusion In the United States, the proportion of hospitalized patients with DNR, PC, and DNR with PC increased from 2016 to 2019. Overall, inpatient mortality and LOS fell, but hospital charges per patient increased. Significant gender and ethnic differences emerged. Black patients and males were less likely to have DNR status and had higher inpatient mortality, LOS, and hospital charges.
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Affiliation(s)
- Jean-Sebastien Rachoin
- Cooper University Healthcare, Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Nicole Debski
- Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Krystal Hunter
- Cooper University Healthcare, Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Elizabeth Cerceo
- Cooper University Healthcare, Cooper Medical School of Rowan University, Camden, New Jersey, USA
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Andersen SK, Herridge MS, Fiest KM. Recovery from Sepsis: Management beyond Acute Care. Semin Respir Crit Care Med 2024; 45:523-532. [PMID: 38968959 DOI: 10.1055/s-0044-1787993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2024]
Abstract
Recovery from sepsis is a key global health issue, impacting 38 million sepsis survivors worldwide per year. Sepsis survivors face a wide range of physical, cognitive, and psychosocial sequelae. Readmissions to hospital following sepsis are an important driver of global healthcare utilization and cost. Family members of sepsis survivors also experience significant stressors related to their role as informal caregivers. Increasing recognition of the burdens of sepsis survivorship has led to the development of postsepsis recovery programs to better support survivors and their families, although optimal models of care remain uncertain. The goal of this article is to perform a narrative review of recovery from sepsis from the perspective of patients, families, and health systems.
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Affiliation(s)
- Sarah K Andersen
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Alberta, Canada
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Margaret S Herridge
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kirsten M Fiest
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
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Doherty C, Feder S, Gillespie-Heyman S, Akgün KM. Easing Suffering for ICU Patients and Their Families: Evidence and Opportunities for Primary and Specialty Palliative Care in the ICU. J Intensive Care Med 2024; 39:715-732. [PMID: 37822226 DOI: 10.1177/08850666231204305] [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: 10/13/2023]
Abstract
Intensive care unit (ICU) admissions are often accompanied by many physical and existential pressure points that can be extraordinarily wearing on patients and their families and surrogate decision makers (SDMs). Multidisciplinary palliative support, including physicians, advanced practice nurses, nutritionists, chaplains and other team members, may alleviate many of these sources of potential suffering. However, the palliative needs of ICU patients undoubtedly exceed the bandwidth of current consultative specialty palliative medicine teams. Informed by standard-of-care palliative medicine domains, we review common ICU symptoms (pain, dyspnea and thirst) and their prevalence, sources and their treatment. We then identify palliative needs and impacts in the domains of communication, SDM support and transitions of care for patients and their families through their journey in the ICU, from discharge and recovery at home to chronic critical illness, post-ICU disability or death. Finally, we examine the evidence for strategies to incorporate specialty palliative medicine and palliative principles into ICU care for the improvement of patient- and family-centered care. While randomized controlled studies have failed to demonstrate measurable improvement in pre-determined outcomes for patient- and family-relevant outcomes, embracing the principles of palliative medicine and assuring their delivery in the ICU is likely to translate to overall improvement in humanistic, person-centered care that supports patients and their SDMs during and following critical illness.
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Affiliation(s)
- Christine Doherty
- Department of Internal Medicine New Haven, Yale New Haven Hospital, New Haven, CT, USA
- Yale School of Medicine, New Haven, CT, USA
| | - Shelli Feder
- Yale University School of Nursing, Orange, CT, USA
| | | | - Kathleen M Akgün
- Yale School of Medicine, New Haven, CT, USA
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, VA-Connecticut and Yale University School of Medicine, New Haven, CT, USA
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5
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Brutus NN, Howe AS, Rehfuss A, Giramonti K, Feustel PJ, Kogan BA. Parent decisional regret regarding neonatal circumcision in an American outpatient pediatric urology clinic. J Pediatr Urol 2024:S1477-5131(24)00375-9. [PMID: 39153922 DOI: 10.1016/j.jpurol.2024.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/23/2024] [Accepted: 07/23/2024] [Indexed: 08/19/2024]
Abstract
INTRODUCTION/BACKGROUND Requests for circumcision revision are common in our American pediatric urology clinic. As parents are the surrogate decision maker for their child, there are several influences that can impact a parent's decision for or against circumcision. OBJECTIVE We sought to assess parents' regret regarding their child's circumcision status and to correlate regret to factors that might have affected the original decision. STUDY DESIGN From March 2023 to January 2024, we surveyed parents who brought their male child to our office for any reason, independent of circumcision status. The questionnaire was two-fold: a validated Decisional Regret Scale (DRS) (0-100 where higher scores = higher regret) and our questions regarding their decision-making process and outcome. Regret scores served as a function of each of the independent decision making and outcome variables. RESULTS Overall, decisional regret scores from both uncircumcised and circumcised parent groups were positively skewed with a median 0, mean 22, and ranged from 0 to 75. For those circumcised (n = 91), the median regret score was 0 (IQR 0-25). For those uncircumcised (n = 28), median regret score was 0 (IQR 0-24). Overall, 55% of both groups reported no regret (DRS = 0), 24% had low-mild regret (DRS 5-25), and 21% yielded moderate-strong regret (DRS 30-100). Parents who felt they made an informed decision or were counseled by any physician had lower regret scores. Parents who presented for issues related to their child's uncircumcised or circumcised penis (DRS score 37.5 and 25 respectively) had higher regret scores. DISCUSSION We found that a large portion of parents expressed no regret regarding their decision to have or not have their child circumcised (55%). There also was no difference in median regret scores between parent groups. However, a significant portion of parents did express moderate-strong regret (21%) and several influential factors were correlated with regret scores. These factors included informed decision making, physician counseling, appearance satisfaction, and problems related to their child's circumcised or uncircumcised penis. These factors are supported by other literature using the DRS and population studies. The limitations of our study included the limited recruitment of participants and potential time dependent bias of responses. CONCLUSION One in five parents of both circumcised and uncircumcised boys expressed moderate to strong regret regarding their decision about neonatal circumcision in our pediatric urology clinic. Our data suggests that ensuring parents have sufficient counseling prior to a decision regarding neonatal circumcision is important.
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Affiliation(s)
| | - Adam S Howe
- Department of Urology, Albany Medical Center, USA
| | | | | | - Paul J Feustel
- Department of Neuroscience, Director of Research Administration and Basic Science, Albany Medical College, USA
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6
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Santangelo E, Wozniak H, Herridge MS. Meeting complex multidimensional needs in older patients and their families during and beyond critical illness. Curr Opin Crit Care 2024:00075198-990000000-00198. [PMID: 39150056 DOI: 10.1097/mcc.0000000000001188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
PURPOSE OF REVIEW To highlight the emerging crisis of critically ill elderly patients and review the unique burden of multidimensional morbidity faced by these patients and caregivers and potential interventions. RECENT FINDINGS Physical, psychological, and cognitive sequelae after critical illness are frequent, durable, and robust across the international ICU outcome literature. Elderly patients are more vulnerable to the multisystem sequelae of critical illness and its treatment and the resultant multidimensional morbidity may be profound, chronic, and significantly affect functional independence, transition to the community, and quality of life for patients and families. Recent data reinforce the importance of baseline functional status, health trajectory, and chronic illness as key determinants of long-term functional disability after ICU. These risks are even more pronounced in older patients. SUMMARY The current article is an overview of the outcomes of older survivors of critical illness, putative interventions to mitigate the long-term morbidity of patients, and the consequences for families and caregivers. A multimodal longitudinal approach designed to follow patients for one or more years may foster a better understanding of multidimensional morbidity faced by vulnerable older patients and families and provides a detailed understanding of recovery trajectories in this unique population to optimize outcome, goals of care directives, and ongoing informed consent to ICU treatment.
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Affiliation(s)
- Erminio Santangelo
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Hannah Wozniak
- Division of Critical Care, Department of Acute Medicine, Geneva University Hospitals, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Margaret S Herridge
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
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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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Legrand M, Bagshaw SM, Bhatraju PK, Bihorac A, Caniglia E, Khanna AK, Kellum JA, Koyner J, Harhay MO, Zampieri FG, Zarbock A, Chung K, Liu K, Mehta R, Pickkers P, Ryan A, Bernholz J, Dember L, Gallagher M, Rossignol P, Ostermann M. Sepsis-associated acute kidney injury: recent advances in enrichment strategies, sub-phenotyping and clinical trials. Crit Care 2024; 28:92. [PMID: 38515121 PMCID: PMC10958912 DOI: 10.1186/s13054-024-04877-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 03/17/2024] [Indexed: 03/23/2024] Open
Abstract
Acute kidney injury (AKI) often complicates sepsis and is associated with high morbidity and mortality. In recent years, several important clinical trials have improved our understanding of sepsis-associated AKI (SA-AKI) and impacted clinical care. Advances in sub-phenotyping of sepsis and AKI and clinical trial design offer unprecedented opportunities to fill gaps in knowledge and generate better evidence for improving the outcome of critically ill patients with SA-AKI. In this manuscript, we review the recent literature of clinical trials in sepsis with focus on studies that explore SA-AKI as a primary or secondary outcome. We discuss lessons learned and potential opportunities to improve the design of clinical trials and generate actionable evidence in future research. We specifically discuss the role of enrichment strategies to target populations that are most likely to derive benefit and the importance of patient-centered clinical trial endpoints and appropriate trial designs with the aim to provide guidance in designing future trials.
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Affiliation(s)
- Matthieu Legrand
- Division of Critical Care Medicine, Department of Anesthesia and Perioperative Care, UCSF, 521 Parnassus Avenue, San Francisco, CA, 94143, USA.
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Canada
| | - Pavan K Bhatraju
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, USA
- Kidney Research Institute, University of Washington, Seattle, USA
| | - Azra Bihorac
- Department of Medicine, University of Florida, Gainesville, FL, USA
- Intelligent Critical Care Center (IC3), University of Florida, Gainesville, FL, USA
| | - Ellen Caniglia
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Outcomes Research Consortium, Cleveland, OH, USA
- Perioperative Outcomes and Informatics Collaborative, Winston-Salem, NC, USA
| | - John A Kellum
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jay Koyner
- University Section of Nephrology, Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Michael O Harhay
- Clinical Trials Methods and Outcomes Lab, Department of Biostatistics, Epidemiology, and Informatics, PAIR (Palliative and Advanced Illness Research) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Fernando G Zampieri
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Canada
| | | | | | - Kathleen Liu
- Divisions of Nephrology and Critical Care Medicine, Departments of Medicine and Anesthesia, University of California San Francisco, San Francisco, CA, USA
| | - Ravindra Mehta
- Department of Medicine, University of California, San Diego, USA
| | - Peter Pickkers
- Intensive Care Medicine, Radboudumc, Nijmegen, The Netherlands
| | - Abigail Ryan
- Chronic Care Policy Group, Division of Chronic Care Management, Center for Medicare and Medicaid Services, Center for Medicare, Baltimore, MD, USA
| | | | - Laura Dember
- Renal-Electrolyte and Hypertension Division, Department of Medicine, Department of Biostatistics, Epidemiology and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Martin Gallagher
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Patrick Rossignol
- FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
- INSERM CIC-P 1433, CHRU de Nancy, INSERM U1116, Université de Lorraine, Nancy, France
- Medicine and Nephrology-Hemodialysis Departments, Monaco Private Hemodialysis Centre, Princess Grace Hospital, Monaco, Monaco
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, UK
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Guidet B, Vallet H, Flaatten H, Joynt G, Bagshaw SM, Leaver SK, Beil M, Du B, Forte DN, Angus DC, Sviri S, de Lange D, Herridge MS, Jung C. The trajectory of very old critically ill patients. Intensive Care Med 2024; 50:181-194. [PMID: 38236292 DOI: 10.1007/s00134-023-07298-z] [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] [Received: 10/02/2023] [Accepted: 11/27/2023] [Indexed: 01/19/2024]
Abstract
The demographic shift, together with financial constraint, justify a re-evaluation of the trajectory of care of very old critically ill patients (VIP), defined as older than 80 years. We must avoid over- as well as under-utilisation of critical care interventions in this patient group and ensure the inclusion of health care professionals, the patient and their caregivers in the decision process. This new integrative approach mobilises expertise at each step of the process beginning prior to intensive care unit (ICU) admission and extending to long-term follow-up. In this review, several international experts have contributed to provide recommendations that can be universally applied. Our aim is to define a minimum core dataset of information to be shared and discussed prior to ICU admission and to facilitate the shared-decision-making process with the patient and their caregivers, throughout the patient journey. Documentation of uncertainty may contribute to a tailored level of care and ultimately to discussions around possible limitations of life sustaining treatments. The goal of ICU care is not only to avoid death, but more importantly to maintain an acceptable quality of life and functional autonomy after hospital discharge. Societal consideration is important to highlight, together with alternatives to ICU admission. We discuss challenges for the future and potential areas of research. In summary, this review provides a state-of-the-art current overview and aims to outline future directions to address the challenges in the treatment of VIP.
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Affiliation(s)
- Bertrand Guidet
- Medical ICU, Assistance Publique, Hôpitaux de Paris, Hôpital Saint-Antoine, Service de Réanimation Médicale, 75012, Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, 75013, Paris, France.
| | - Helene Vallet
- Department of Geriatrics, Sorbonne Université, Institut National de la Santé Et de la Recherche Médicale (INSERM), UMRS 1135, Centre d'immunologie et de Maladies Infectieuses (CIMI), Saint Antoine, Assistance Publique Hôpitaux de Paris (AP-HP), 75012, Paris, France
| | - Hans Flaatten
- Department of Clinical Medicine, Haukeland University Hospital, University of Bergen, Department of Research and Development, Haukeland University Hospital, Bergen, Norway
| | - Gavin Joynt
- Department of Anaesthesia and Intensive Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Canada
| | | | - Michael Beil
- Department of Medical Intensive Care, Faculty of Medicine, Hebrew University and Hadassah University Medical Center, Jerusalem, Israel
| | - Bin Du
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Daniel N Forte
- Departament of Emergency Medicine, Faculdade de Medicina, Universidade de São Paulo, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Derek C Angus
- Critical Care Medicine, UPMC and University of Pittsburgh, Pittsburgh, USA
| | - Sigal Sviri
- Department of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Dylan de Lange
- Department of Intensive Care Medicine, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Margaret S Herridge
- Interdepartmental Division of Critical Care Medicine, Critical Care and Respiratory Medicine, University Health Network, Toronto General Research Institute, Institute of Medical Sciences, University of Toronto, Toronto, Canada
| | - Christian Jung
- Department of Cardiology, Pulmonology and Angiology, University Hospital, Düsseldorf, Germany
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10
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Lu SJ, Ku SC, Liu KF, Chien CH. Decision Self-Efficacy and Decisional Conflict on Reintubation among Surrogates of Ventilated Patients Undergoing Planned Extubation. Asian Nurs Res (Korean Soc Nurs Sci) 2023; 17:235-244. [PMID: 37838098 DOI: 10.1016/j.anr.2023.10.001] [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] [Received: 06/12/2023] [Revised: 09/26/2023] [Accepted: 10/04/2023] [Indexed: 10/16/2023] Open
Abstract
PURPOSE Although the medical decision-making process can be overwhelming for some surrogates, there is a lack of understanding regarding their experiences. The objectives of this study were to examine the decision self-efficacy and decisional conflict experienced by surrogates in intensive care units (ICUs) when faced with the decision of whether to reintubate patients with respiratory failure after a planned extubation. In addition, predictors and mediators influencing these decision-making processes were identified. METHODS This study utilized a cross-sectional design to investigate the decision-making processes of 174 surrogates who were faced with the decision of whether to reintubate patients with respiratory failure after a planned extubation in the internal ICU of a medical center between August 2021 and February 2022. Structured questionnaires were administered to collect data on the surrogates' background information, decision self-efficacy, decisional conflict, and positive and negative affect. The patients' background information was also collected. Univariate and multivariate analyses were performed to model the data. RESULTS The mean decision self-efficacy score of the surrogates was 82.41 points, and 20.7% surrogates had decisional conflict scores exceeding 37.5 points, suggesting that they faced challenges in the decision-making process. Surrogates' employment status and negative affect significantly predicted their decision self-efficacy. In addition, patients' activities of daily living prior to hospitalization and the decision self-efficacy of the surrogate significantly predicted surrogate decisional conflict. The impact of surrogates' negative affect on decisional conflict was fully mediated by decision self-efficacy. CONCLUSIONS Surrogate decision self-efficacy mediates the relationship between negative affect and decisional conflict. Providing clinical care interventions that focus on enhancing surrogate self-efficacy and reducing negative affect can help alleviate decisional conflict in this population.
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Affiliation(s)
- Shu-Ju Lu
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Shih-Chi Ku
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Kuei-Fen Liu
- School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Ching-Hui Chien
- School of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan.
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11
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Lazaridis C. Informed Consent and Decision-Making for Patients with Acquired Cognitive Impairment. Neurol Clin 2023; 41:433-442. [PMID: 37407097 DOI: 10.1016/j.ncl.2023.03.001] [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: 07/07/2023]
Abstract
Informed consent (IC) is an ethical and legal requirement grounded in the principle of autonomy. Cognitive impairment may often interfere with decision-making capacity necessitating alternative models of ethically sound deliberation. In cases where the patient lacks decision-making capacity, one must determine the appropriate decision-maker and the criteria used in making a medical decision appropriate for the patient. In this article, I critically discuss the traditional approaches of IC, advance directives, substituted judgment, and best interests. A further suggestion is that thinking about sufficient reasons for or against a course of action is a conceptual enrichment in addition to the concepts of interests and well-being. Finally, I propose another model of collective consensus-seeking decision-making.
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Affiliation(s)
- Christos Lazaridis
- Department of Neurology, University of Chicago, IL, USA; Department of Neurosurgery, University of Chicago, IL, USA; MacLean Center for Clinical Medical Ethics, University of Chicago, IL.
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