Icu admission and discharge communication and decision making
Download
1 / 30

ICU ADMISSION AND DISCHARGE: Communication and Decision making - PowerPoint PPT Presentation


  • 78 Views
  • Uploaded on

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

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' ICU ADMISSION AND DISCHARGE: Communication and Decision making' - kimberley-edwards


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Icu admission and discharge communication and decision making
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
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 RespCrit Care Med; Am J Resp Cell MolecBiol; PATS

    • AJRCCM highest impact factor in respiratory medicine

  • Over half of articles submitted to ATS journals are from outside the US


Outline
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
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
Prioritization Model: SCCM Statement

  • Critically ill, unstable patients in need of ICU treatment and monitoring

  • Require intensive monitoring and may need immediate intervention

  • Critically ill, unstable patients with “reduced likelihood of recovery”

  • Little or no anticipated benefit from ICU because too sick or too well

Crit Care Med 1999; 27:633


Basis for criteria
Basis for Criteria Statement

  • 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
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
Proportion of ICUs with Written Guidelines for Decision-making

Walter, Crit Care Med 2008; 36:414


Proportion of time guidelines used
Proportion of Time Guidelines Used Decision-making

Walter, Crit Care Med 2008; 36:414


Icu beds per 100 000 compared to hospital beds per 100 000
ICU Beds per 100,000 Compared to Hospital Beds per 100,000 Decision-making

Wunsch, Crit Care Med 2008; 36:2787


Icu beds per 100 000 associated with icu mortality
ICU Beds per 100,000 Associated with ICU Mortality Decision-making

Wunsch, Crit Care Med 2008; 36:2787


Regional Variations in Withholding and Withdrawing Life Support in Europe

n=4248

Sprung, JAMA 2003; 290:790


Outline1
Outline Support in Europe

  • 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
What Do We Know About End-of-life Communication in the ICU? Support in Europe

  • <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
Shared Decision-making About End-of-life Care Support in Europe

  • 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
Family Preferences for Role in Support in EuropeDecision-making

n=1123 families of patients in 6 ICUS

Heyland, Intens Care Med, 2003; 29:75


New Paradigm for “Right Approach” to Support in EuropeParentalism vs. Autonomy

Default Starting Place

Prognosis and Certainty

Family preference

Parentalism or Doctor Decides

Autonomy or “Informed Choice”

Shared Decision Making

Curtis, Chest, 2008; 134:835


Study of icu family conferences
Study of ICU Family Conferences Support in Europe

  • 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


New Paradigm for “Right Approach” to Support in EuropeParentalism vs. Autonomy

Collaborative

Elicit patient values

Offer recommendation

Facilitative

Elicit patient values

Place in context

Directive

Provide some info

Make decision

Informative

Provide info

Make no recommendation

Shared Decision Making

White, submitted, 2008


Value 5 step approach to improving communication in icu with families
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 Trial of Communication Strategy with Families

  • 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
Family Member Outcomes: Clinically Significant Morbidity at 3 Months

p<0.02 for all

Lautrette, NEJM, 2007; 356:469


Outline2
Outline 3 Months

  • 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
Physician-Nurse Collaboration in the ICU 3 Months

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
Doctor and Nurse Ratings of Interdisciplinary Communication 3 Months

p<0.001 for all

Reader, Br J Anaesth, 2007; 98:347


Percent of deaths with physician nurse collaboration in decision making
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
Percent of Physicians Involving Nurses in Decisions about Withdrawal

Yaguchi, Arch Intern Med, 2005; 165:1970


Nurse family communication before icu family conferences
Nurse-Family Communication Before ICU Family Conferences Withdrawal

Curtis, Crit Care Med; 2001; 29:N26


Summary decision making for admission and discharge in the icu
Summary: WithdrawalDecision-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


ad