Icu admission and discharge communication and decision making
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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

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ICU ADMISSION AND DISCHARGE: Communication and Decision making

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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

  • 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

  • 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

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

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

Wunsch, Crit Care Med 2008; 36:2787


Icu admission and discharge communication and decision making

Regional Variations in Withholding and Withdrawing Life Support in Europe

n=4248

Sprung, JAMA 2003; 290:790


Outline1

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

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

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

Family Preferences for Role in Decision-making

n=1123 families of patients in 6 ICUS

Heyland, Intens Care Med, 2003; 29:75


Icu admission and discharge communication and decision making

New Paradigm for “Right Approach” to Parentalism 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

  • 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


Icu admission and discharge communication and decision making

New Paradigm for “Right Approach” to Parentalism 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

  • 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

  • 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

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

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

Curtis, Crit Care Med; 2001; 29:N26


Summary decision making for admission and discharge in the icu

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


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