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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
DukeProSPER.org
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