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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
slide6

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
slide7

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.