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Chronic Critical Illness. Keri Holmes- Maybank , MD Leigh Vaughan, MD June 18, 2013 Medical University of South Carolina. Learning Objectives. Define chronic critical illness (CCI). List the long term physical and emotional disabilities caused by CCI.

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Chronic critical illness

Chronic Critical Illness

Keri Holmes-Maybank, MD

Leigh Vaughan, MD

June 18, 2013

Medical University of South Carolina


Learning objectives
Learning Objectives

  • Define chronic critical illness (CCI).

  • List the long term physical and emotional disabilities caused by CCI.

  • Recognize who is at greatest risk for death within one year of CCI.

  • Describe the impact of CCI on caregivers.

  • Recognize the financial costs of CCI.


Key messages
Key Messages

  • The number of patients with CCI is increasing.

  • The likelihood of patients with CCI recovering full functional status is poor.

  • Caregivers of patients with CCI are substantially impacted.

  • Good communication is essential for appropriate decision making in patients with CCI.


Chronic critical illness definition
Chronic Critical Illness - Definition

  • Survived but not recovered from acute critical illness

  • Distinct syndrome: respiratory failure, metabolic, neuroendocrine, neuropsychiatric, immune derangements

  • Respiratory failure requiring prolonged ventilation

    • Anywhere from 2-21 days

    • CMS >6h/day on vent for >21 consecutive days

  • Tracheotomy

    • Indicates long expected wean time

    • Marker of transition from acute to chronic


Syndrome
Syndrome

  • Profound weakness

    • Myopathy

    • Neuropathy

    • Alterations of body composition: loss of lean body mass, increased adiposity, anasarca

  • Endocrine

    • Impaired anabolism

    • Low target organ hormone levels

    • Bone hyperresorption

    • Male hypogonadism


Syndrome

  • Severe, prolonged, and permanent brain dysfunction

  • Coma

  • Delirium

    • Increased LOS

    • Higher mortality and morbidity

  • Risk factors

    • Long time in ICU

    • Multiple medications

    • Long LOS


Syndrome

  • Recurrent infections (often MDR)

  • Skin breakdown/pressure ulcers

  • Nutritional deficiencies/undernutrition

  • Symptoms of distress

    • Pain 44%

    • Thirst

    • Dyspnea

    • Depression

    • Anxiety

    • Inability to communicate 94%

    • Hunger

    • Sadness, worry, nervousness >60%


Prognosis of respiratory failure
Prognosis of Respiratory Failure

  • 10% of ventilated patients become CCI

  • 30-53% of CCI patients will wean

  • Highest time for death is 60-100 days after initiation of ventilation for CCI

  • If do not wean in 60 days will likely not wean

  • Successful wean does not equal survival


Cci mortality
CCI Mortality

  • 48-68% one year mortality across study populations

  • Mortality 6 months after discharge 56%

  • DC survival ~55d


Prognosis for functional recovery
Prognosis for Functional Recovery

  • 21% alive but severe dependency

  • 26% alive but fair dependency

  • <10% independent

  • 53% survived but poor qol

  • Very rare to go back to previous functional level


Outcome
Outcome

  • Most CCI require long term care for physical dysfunction and/or cognitive impairment

  • DC from hospital to rehab, more likely to be home at 6 months

  • If institutionalized at 6 months, will not go home

  • 50% higher readmission compared to other post vent patients


Worst prognosis
Worst Prognosis

  • <65 yo and poor prior functional status

  • 75 yo

  • 95% mortality

  • Residual organ dysfunction

  • Diabetes

  • Renal failure


Multidisciplinary approach
Multidisciplinary Approach

  • Nutrition

  • Physical Therapy

  • Occupational Therapy

  • Speech Therapy

  • Respiratory Therapy

  • Nursing

  • Case Managers

  • Wound Care


Improve o utcomes
Improve Outcomes

  • Nutrition

    • Avoid overfeeding

  • Stress hyperglycemia

  • Early mobilization

  • Prevent infections: line sepsis, pneumonia, C. diff

    • Remove catheters

    • Restrict antibiotic use

    • Handwashing

    • Isolation

    • Maintain skin integrity

  • Palliative care


Utilization of resources
Utilization of Resources

  • 10% of all vented patients become CCI

  • 100,000 patients/yr US

  • 20-40% of ICU beds/critical care resources

  • $24 billion annually

  • $3.5 billion additional for survivors (LTAC, nursing, home health)


Utilization of resources1
Utilization of Resources

  • Advances in critical care enable more patients to survive acute critical illness

  • Increase in tracheotomy: 1993 - 8.3/100,000 to 2002 - 24.2/100,000

  • Project 600,000 CCI patients in 2020


Utilization of resources2
Utilization of Resources

  • Use disproportionate amount of health care resources

  • Poor outcomes

    • High 1 year mortality

    • Diminished quality of life

    • Important functional and cognitive limitations

    • Prolonged assistance


Caregivers
Caregivers

  • Neglect their own physical health and decline

  • Increased Overload (negative attitudes & emotional reactions to the caregiving experience)

  • Increased Burden (disruptions/changes in the caregiver’s life and household - increases over time)

  • 84% caregivers quit work or significantly alter work schedule

  • Financial hardship (even in insured)


Caregivers1
Caregivers

  • Depression - worsens

    • Increased functional impairment and cognitive impairment of the dependent

    • Poor health, perception of overload and burden, female, and younger age of the caregiver

  • 49% caregivers reported “a lot” or “severe” stress associated with caregiving


Caregivers2
Caregivers

  • Caregivers with patients in institution had higher depression, overload, poor health, and burden scores

  • Patients in institution have higher physical dysfunction and cognitive impairment

  • Caregivers in the home receive less assistance from family members and friends than those in institution


Expectations
Expectations

  • Due to survival from the acute illness there is misplaced optimism for:

    • Meaningful recovery

    • Recovery from life-threatening illness

    • Survival

    • Functional independence

      • by family, patient and often MD

  • Misunderstanding prognosis caused by

    • Surrogate hopes for survival

    • Surrogate does not understand prognosis

    • Lack of prognostication by MD

    • Discordance between surrogates and physicians about potential outcomes


Expectations1
Expectations

Surrogates had higher expectations than physicians


Communication
Communication

  • Despite poor outcomes, life-sustaining treatments are continued for CCI

  • Partly from a lack of understanding of outcomes from inadequate communication between clinician, patients, and families

  • 80-93% decision makers report were not told

    • Functional dependency

    • 1-year survival

    • Caregiving needs


Ineffective communication
Ineffective Communication

  • SUPPORT Trial (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment)

  • <40% reported discussion about prognosis or preference for life-sustaining therapy

  • 50% preferring palliative care felt treatment received was contrary to their goals

  • 25% felt they did not know the team’s approach to care

  • Family conferences, MD missed opportunities to explore comments about patient treatment preferences


Ineffective communication1
Ineffective Communication

  • 31% felt physician made decision to prolong ventilation

  • 80% said not given choice besides vent

  • 50% said not given expected hospital survival

  • Almost 100% said not given expected survival after discharge

  • 54% of families failed to understand diagnosis, prognosis or treatment after meeting with MD

  • Many families report fragmented, scant, conflicting communication

  • “Usual care” in academics = info from nurses and trainees


Barriers to communication
Barriers to Communication

  • MD:

    • May not give basic info necessary for decision making

    • Uncomfortable discussing prognosis

    • Uncomfortable with uncertainty

  • Patient/caregiver receptivity:

    • Stress, anxiety, depression, and denial are distractions impair families’ comprehension and decision-making

  • 66% caregivers had anxiety and depression 2/2 to inadequate communication from MD that affected decision-making


Caregiver desires
Caregiver Desires

  • 100% want MD honest

  • 91% Optimistic


Decision making
Decision-Making

  • Most older adults would refuse life-sustaining treatments if the expected outcome were survival with severe functional or cognitive impairment

  • Impairment influenced treatment preferences even more than the likelihood of death

  • Would decline treatment if there was even a 50% chance of severe functional or cognitive impairment

  • Cognitive impairment is heaviest burden and worse than death - most important part of decision making


Improved communication
Improved Communication

  • Help to align treatment decisions with values and preferences

  • Results of systematic attempts to improve communication

    • Shorter ICU stay

    • Shorter hospital stay

    • Greater comprehension of relevant information

    • Higher levels of family satisfaction

    • Appropriate discontinuation of life-sustaining treatment for patients who would not benefit

    • Less anxiety/depression/PTSD among families


W hat to discuss
What to Discuss

  • Nature of illness and treatments

  • Prognosis for outcomes including

    • Ventilator independence

    • Function

    • Quality of life

  • Impact of treatment on symptom burden

  • Potential complications of treatment

  • Alternatives to continued treatment

  • Expected care needs after hospitalization


References
References

  • Camhi SL, Nelson JE. Chronic Critical Illness. Intensive Care Medicine. Springer 2007. 908-917.

  • Carson SS, Bach PB, Brzozowski L, Leff A. Outcomes after long-term acute care. An analysis of 133 mechanically ventilated patients. Am J RespirCrit Care Med 1999;159:1568-1573.

  • Cox CE, Marinu T, Sathy SJ, et al. Expectations and outcomes of prolonged mechanical ventilation. Crit Care Med. 2009 November;37(11):2888-2894.

  • Douglas SL, Daly BJ. Caregivers of long-term ventilator patients. Physical and psychological outcomes. Chest 2003;123:1073-1081.

  • Fried TR, Bradley EH, O’Leary J. Prognosis communication in serious illness: Perceptions of older patients, caregivers, and clinicians. Am J Geriatric Soc 2003;51:1398-1403.

  • Girard K, Farrin TA. The chronically critically ill: To save or let diet? Respir Care. 1985 May;30(50):113-347.

  • Nelson JE, Mercado AF, Camhi SL, et al. Communication about chronic critical illness. Arch Intern Med. 2007;167(22):2509-2515.

  • Nelson JE, Cox CE, Hope AA, Carson SS. Chronic critical illness. Am J RespirCrit Care Med. 2010;182:446-454.

  • Nelson JE, Tandon N, Mercado AF, et al. Brain dysfunction. Another burden for the chronically critically ill. Arch Intern Med 2006;166:1993-1999.

  • The SUPPORT Principal Investigators. A controlled trial to improve care for seriously ill hospitalized patients: The study to understand prognoses and preferences for outcomes and risks of treatments. JAMA 1995;274(20):1591-1598.

  • Unroe M, Kahn JM, Carson SS, et al. One-year trajectories of care and resource utilization for recipients of prolonged mechanical ventilation. A cohort study. Ann Intern Med. 2010;153:167-175.


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