Keri T. Holmes-Maybank, MD Medical University of South Carolina June 18, 2013.
Keri Holmes-Maybank, MD Leigh Vaughan, MD June 18, 2013 Medical University of South Carolina.
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Transcript of Keri Holmes-Maybank, MD Leigh Vaughan, MD June 18, 2013 Medical University of South Carolina.
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Chronic Critical IllnessKeri Holmes-Maybank, MDLeigh Vaughan, MDJune 18, 2013Medical University of South Carolina
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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.
Learning Objectives
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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.
Key Messages
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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
Chronic Critical Illness - Definition
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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
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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
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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%
Syndrome
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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
Prognosis of Respiratory Failure
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48-68% one year mortality across study populations
Mortality 6 months after discharge 56%
DC survival ~55d
CCI Mortality
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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
Prognosis for Functional Recovery
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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
Outcome
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<65 yo and poor prior functional status 75 yo 95% mortality
Residual organ dysfunction Diabetes Renal failure
Worst Prognosis
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Nutrition Physical Therapy Occupational Therapy Speech Therapy Respiratory Therapy Nursing Case Managers Wound Care
Multidisciplinary Approach
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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
Improve Outcomes
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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 Resources
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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 Resources
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Use disproportionate amount of health care resources
Poor outcomes◦ High 1 year mortality◦ Diminished quality of life◦ Important functional and cognitive limitations◦ Prolonged assistance
Utilization of Resources
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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)
Caregivers
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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
Caregivers
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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
Caregivers
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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
Expectations
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Surrogates had higher expectations than physicians
Expectations
Expectation Caregiver MD
Patient survival 93% 44%
Good QOL 83% 4%
Good function 71% 6%
Cox CE, Marinu T, Sathy SJ, et al. Expectations and outcomes of prolonged mechanical ventilation. Crit Care Med. 2009 November;37(11):2888-2894.
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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
Communication
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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 Communication
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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
Ineffective Communication
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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
Barriers to Communication
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100% want MD honest
91% Optimistic
Caregiver Desires
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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
Decision-Making
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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
Improved Communication
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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
What to Discuss
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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 Respir Crit 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 Respir Crit 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.
References