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ICU ADMISSION AND DISCHARGE: Communication and Decision making. J. Randall Curtis, MD, MPH President-elect, ATS Professor of Medicine University of Washington. American Thoracic Society: An International Society. International society with 15,000 members 28 % from outside the US - PowerPoint PPT Presentation
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ICU ADMISSION AND DISCHARGE:
COMMUNICATION AND DECISION MAKING
J. Randall Curtis, MD, MPHPresident-elect, ATS
Professor of MedicineUniversity of Washington
American Thoracic Society: An International Society
• International society with 15,000 members – 28% from outside the US
• ATS disseminates latest medical and science information in pulmonary, critical care and sleep
• ATS Annual International Conference features over 5,500 research abstracts with over 16,000 attendees– Half of participants from outside the US
• Premier journals: Am J Resp Crit Care Med; Am J Resp Cell Molec Biol; PATS– AJRCCM highest impact factor in respiratory medicine
• Over half of articles submitted to ATS journals are from outside the US
Outline
• Criteria and decision-making for ICU admit and discharge
• Shared decision-making and communication with families
• Role of interdisciplinary communication
Principles for Fair Allocation of ICU Resources: ATS Statement
• Every life is valuable and equally so• Respect for patient autonomy is a central
tenet of healthcare• Primary duty of ICU team is patient welfare• ICU care, when appropriate, is basic care• Duty of ICU team to benefit patient has limits
if care unfairly compromises care of others
AJRCCM 1997; 156:1282
Prioritization Model: SCCM
1. Critically ill, unstable patients in need of ICU treatment and monitoring
2. Require intensive monitoring and may need immediate intervention
3. Critically ill, unstable patients with “reduced likelihood of recovery”
4. Little or no anticipated benefit from ICU because too sick or too well
Crit Care Med 1999; 27:633
Basis for Criteria
• Severity of illness scoring systems–APACHE, SOFA
• Disease-specific criteria–Acute MI, SAH
• Organ dysfunction requiring support–Acute respiratory failure, acute renal failure
Decisions to Admit Patients to ICU: Survey of 121 MICU Directors in US
Walter, Crit Care Med 2008; 36:414
Proportion of ICUs with Written Guidelines for Decision-making
Walter, Crit Care Med 2008; 36:414
Proportion of Time Guidelines Used
Walter, Crit Care Med 2008; 36:414
ICU Beds per 100,000 Compared to Hospital Beds per 100,000
Wunsch, Crit Care Med 2008; 36:2787
ICU Beds per 100,000 Associated with ICU Mortality
Wunsch, Crit Care Med 2008; 36:2787
Sprung, JAMA 2003; 290:790n=4248
Regional Variations in Withholding and Withdrawing Life Support in Europe
Outline
• Criteria and decision-making for ICU admit and discharge
• Shared decision-making and communication with families
• Role of interdisciplinary communication
What Do We Know About End-of-life Communication in the ICU?
• <5% of patients can participate in ICU decisions about withholding treatments–Communication is primarily with family
• Families rate communication as of equal or more importance than clinical skill
• Families under immense burdens–High level of anxiety and depression
Prendergast, AJRCCM, 1997 Prochard, Crit Care Med, 2001
Shared Decision-making About End-of-life Care
• Key factors– Prognosis– Level of certainty– Family preferences
• Roles– Patient/family:
patient values & preferences
– Clinician: treatments that are indicated
Clinician decision
Family decision
Carlet, Intensive Care Med 2004; 30:770
Family Preferences for Role in Decision-making
Heyland, Intens Care Med, 2003; 29:75
n=1123 families of patients in 6 ICUS
Parentalism or Doctor Decides
Autonomy or “Informed Choice”
New Paradigm for “Right Approach” New Paradigm for “Right Approach” to Parentalism vs. Autonomyto Parentalism vs. Autonomy
Shared Decision Making
Default Starting Place
Family preferencePrognosis and Certainty
Curtis, Chest, 2008; 134:835
Study of ICU Family Conferences
• Daily screen of all ICUs in 4 hospitals• If conference planned, contact attending:– Is discussion of withholding or withdrawing
life support likely?–Willing to have conference recorded?
• Consent/survey all participants• 51 family conferences recorded (46%)
Curtis, J Crit Care, 2002; 17:147
DirectiveProvide some infoMake decision
InformativeProvide infoMake no recommendation
New Paradigm for “Right Approach” New Paradigm for “Right Approach” to Parentalism vs. Autonomyto Parentalism vs. Autonomy
Shared Decision Making
FacilitativeElicit patient valuesPlace in context
CollaborativeElicit patient valuesOffer recommendation
White, submitted, 2008
VALUE: 5-step Approach to Improving Communication in ICU with Families
• V… Value family statements• A… Acknowledge family emotions• L… Listen to the family• U… Understand patient as a person• E… Elicit family questions
Curtis, J Crit Care, 2002; 17:147
Randomized Trial of Communication Strategy
• Randomized 126 patients if attending believed “patient would die in a few days”
• Intervention–Proactive family conference using VALUE
strategy–Bereavement pamphlet for family
Lautrette, NEJM, 2007; 356:469
Family Member Outcomes: Clinically Significant Morbidity at 3 Months
Lautrette, NEJM, 2007; 356:469
p<0.02 for all
Outline
• Criteria and decision-making for ICU admit and discharge
• Shared decision-making and communication with families
• Role of interdisciplinary communication
Physician-Nurse Collaboration in the ICU
Interdisciplinary collaboration associated with decreased– ICU mortality– ICU length of stay– ICU readmission rates–Physician and nurse conflict– Job stress for nurses
Doctor and Nurse Ratings of Interdisciplinary Communication
Reader, Br J Anaesth, 2007; 98:347
p<0.001 for all
Percent of Deaths with Physician-Nurse Collaboration in Decision-making
Ferrand, Am J Resp Crit Care Med, 2003; 167:1210
Percent of Physicians Involving Nurses in Decisions about Withdrawal
Yaguchi, Arch Intern Med, 2005; 165:1970
Nurse-Family Communication Before ICU Family Conferences
Curtis, Crit Care Med; 2001; 29:N26
Summary: Decision-making for Admission and Discharge in the ICU
• Significant variability in approaches• Guidelines useful in some cases• Important role of the family conference–V.A.L.U.E.– Listen as much as you speak–Assess family’s desired role
• If family involved, support family decisions• Interdisciplinary communication important
opportunity for improvement