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Adaptive coping after critical illness: a novel mobile patient-centered intervention

Christopher CoxDuke University Pulmonary, Critical Care, and Palliative Medicine

Mike: 48yo with ARDS from pneumonia. Gets home—weak, PTSD. Why am I like

this?

Patient-centered care…dimensions & conceptsOpen information access

Collaborative management

Family & friends involved

Non-medical & spiritual needs

Respect for patient preferences

Physical / emotional symptoms

Balint 1969 Picker Institute/Commonwealth 1993 Curtis, Rubenfeld, Angus, Herridge, Needham, Carson, Hopkins PCORI 2011

1

Patient-centered care…dimensions & conceptsinformation access

collaborative management

family & friends involved

non-medical & spiritual needs

respect for patient preferences

physical / emotional symptoms

Balint 1969 Picker Institute/Commonwealth 1993 Curtis, Rubenfeld, Angus, Herridge, Needham, Carson, Hopkins PCORI 2011

1 2

Challenges of patient-centered outcomesDefine, prioritize, measure, ask?

How to engage patients in research?

When you have a hammer…aligning patient interests & research capacity

Patient – provider translator?

Gabriel SE 2012

Herridge, Stelling, Covinsky, Carson, Nelson, Cox, Bienvenu, Needham, 1990s-2000s

Past and current: the impact of critical illness is profound and persistent

Psychological distress symptoms are serious among ICU survivors

Distress = depression, anxiety, PTSD

40% saw a mental health provider

50% using psych meds after discharge

Many patients describe in their own words: “People sometimes do not know what you go through. They think that because you are in one piece, everything is fine. But inside I’m all screwed up now.”

Weinert 2006; Cox 2009; Bienvenu 2013

Delusional memories

Treatment (sedation,

PaO2, glucose)

Social support

Communication

Comorbidities &

psych history

Caregiving

needsSymptoms Cogniti

on

Illness severity

Davydow 2011, Azoulay 2005, Bienvenu 2013

Psychological distress: difficult to prevent, complicated to treat

cancer chem

o

septic shock

health status

Trajectories of post-discharge health are complicated and tough to predict

depression, anxiety, PTSD

Trajectories of post-discharge health are complicated and tough to predict

cancer chem

o

septic shock

And other challenges…Heterogeneous patients

Very disabled—hard to return to clinic

Logistical challenges

Transient and permanent disability

Few targeted therapies

Gabriel SE 2012

How can I get my life back?

inability to cope with new disability

critical illness defining sense of self

patient-family relationship strain

day to day impact of critical illness

pervasive traumatic memories

Study 1Cox 2009

What is coping: thoughts and actions used to manage stress…not a passive

process

Conceptual model of coping & distress

Study 2: Poor coping ability is common among ICU survivors

Cox, Porter, Keefe, et al. 2012

Study 2: Maladaptive coping is correlated

with psychological distress & QOL

Cox, Porter, Keefe, et al. 2012

Study 3: Can we develop a coping skills intervention that is feasible, acceptable, and shows promise?

Study 3: Can we develop a coping skills intervention that is feasible, acceptable, and shows promise?

Cox, Porter, Keefe, et al. 2012

Cox, White, Carson, Hough, Kahn, Porter, Keefe 2012

Study 3: Individualization, self-management, collaborative care

Study 3: Coping skills intervention elements for specific distress targets

How does coping training work in practice?

Mrs. Edwards says main stressor is post-ICU physical disability. She also has troubling memories of the ICU.

Session 1 starts with activity-rest cycling, focusing on activities of daily living that she values. She reviews the material in the guidebook and discusses it with her daughter.

At Session 2, she is more confident in her ability to manage distress. The next topic most relevant to her distress about troubling memories is begun (cognitive restructuring).

This strategy of personalization, self-management, and feedback continues through other phone sessions.

Study 3: Coping skills training may reduce distress

Cox, Porter, Keefe, et al. 2012

Study 3: Conceptual model validated: distress reduction correlates with enhanced self-efficacy & adaptive

coping

Cox, Porter, Keefe, et al. 2012

Study 3: Evaluation: coping skills program

feasible & acceptable

Current RCT: adaptive coping skills vs. education programs by phone &

web

I can get back on track faster

PS: challenges of patient-centered outcomesDefine, prioritize, measure, ask?

How to engage patients in research?

When you have a hammer…aligning patient interests & research capacity

Patient – provider translator?

Gabriel SE 2012

What about the future of this and similar interventions?

Choice & precision: Preference- and needs-based, individualizable treatment.

Self-management: Self-pacing, logic-based content, non-professional interventionists, and feedback on effect

Convenience & mobility: Balancing people (human but more expensive) with mobile devices (cheap, high tech, widely used).

Future?

Summary: coping skills training to reduce distress using patient-centered

methodology

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