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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
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 associated with icu mortality
ICU Beds per 100,000 Associated with ICU Mortality

Wunsch, Crit Care Med 2008; 36:2787

slide12

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

slide17

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

slide19

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

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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