Tuesday, 19 May 2009

Articles from Critical Care Medicine

Link to full text of journal
Wood, Gordon J. MD; Arnold, Robert M. MD;
How can we be helpful? Triggers for palliative care consultation in the surgical intensive care unit .[Editorial]
Critical Care Medicine. 37(3):1147-1148, March 2009.

Degenholtz, Howard B. PhD
Two and a half weeks: Time enough for end-of-life care planning? .[Editorial]
Critical Care Medicine. 37(3):1145, March 2009.

Bradley, Ciaran T. MD; Brasel, Karen J. MD, MPH;
Developing guidelines that identify patients who would benefit from palliative care services in the surgical intensive care unit
Critical Care Medicine. 37(3):946-950, March 2009.
Objective: The convergence of end-of-life care and surgical practice often occurs in the surgical intensive care unit (SICU). Because many patients who encounter difficult end-of-life issues in the SICU do not receive palliative care services, there is a need to educate surgeons on how to better identify those patients.Design: A group of 29 national and local experts were identified based on qualifications as surgical intensivists, palliative care specialists, or members of the American College of Surgeons Surgical Palliative Care Task Force. A smaller representative group initially identified responses to the question, "Which patients in the SICU should receive a palliative care consultation?" Using a modified Delphi technique, 31 proposed criteria were distributed electronically to the larger group and ranked through three rounds to generate a final list of ten.Setting: E-mail-based Delphi consensus panel.Subjects: National and local surgical palliative care experts.Interventions: Survey in three rounds.Results: Thirteen participants responded to the first round and 12 to the second. In the third round, the entire group was given the ten criteria for final approval. One half of the respondents were national authorities and the other half were local experts. The top five "triggers" for a palliative care consultation in descending order were: family request; futility considered or declared by the medical team; family disagreement with the medical team, the patient's advance directive, or each other lasting >7 days; death expected during the same SICU stay; and SICU stay >month.Conclusions: We offer a set of consensus guidelines derived from expert opinion that identifies critically ill surgical patients who would benefit from palliative care consultation. These criteria can be used to educate surgeons at large on the variety of clinical scenarios where palliative care specialists can offer support.

Camhi, Sharon L. ; Mercado, Alice F. ; Morrison, R Sean; Du, Qingling et al
Deciding in the dark: Advance directives and continuation of treatment in chronic critical illness
Critical Care Medicine. 37(3):919-925, March 2009.
Objective: Chronic critical illness is a devastating syndrome for which treatment offers limited clinical benefit but imposes heavy burdens on patients, families, clinicians, and the health care system. We studied the availability of advance directives and appropriate surrogates to guide decisions about life-sustaining treatment for the chronically critically ill and the extent and timing of treatment limitation.Design: Prospective cohort study.Setting: Respiratory Care Unit (RCU) in a large, tertiary, urban, university-affiliated, hospital.Patients: Two hundred three chronically critically ill adults transferred to RCU after tracheotomy for failure to wean from mechanical ventilation in the intensive care unit.Interventions: None.Measurements and Main Results: We interviewed RCU caregivers and reviewed patient records to identify proxy appointments, living wills, or oral statements of treatment preferences, resuscitation directives, and withholding/withdrawal of mechanical ventilation, nutrition, hydration, renal replacement and vasopressors. Forty-three of 203 patients (21.2%) appointed a proxy and 33 (16.2%) expressed preferences in advance directives. Do not resuscitate directives were given for 71 patients (35.0%). Treatment was limited for 39 patients (19.2%). Variables significantly associated with treatment limitation were proxy appointment prior to study entry (time of tracheotomy/RCU transfer) (odds ratio = 6.7, 95% confidence interval [CI], 2.3-20.0, p = 0.0006) and palliative care consultation in the RCU (OR = 40.9, 95% CI, 13.1-127.4, p < 0.0001). Median (interquartile range) time to first treatment limitation was 39 (31.0-45.0) days after hospital admission and 13 (8.0-29.0) days after RCU admission. For patients dying after treatment limitation, median time from first limitation to death ranged from 3 days for mechanical ventilation and hydration to 7 days for renal replacement.Conclusions: Most chronically critically ill patients fail to designate a surrogate decision-maker or express preferences regarding life-sustaining treatments. Despite burdensome symptoms and poor outcomes, limitation of such treatments was rare and occurred late, when patients were near death. Opportunities exist to improve communication and decision-making in chronic critical illness.

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