ICU ADMISSION AND DISCHARGE: Communication and Decision making

ICU ADMISSION AND DISCHARGE:Communication and Decision making J. Randall Curtis, MD, MPH President-elect, ATS Professor of Medicine University of Washington

American Thoracic Society: An International Society • International society with 15,000 members • 28% from outside the US • ATS disseminates latest medical and science information in pulmonary, critical care and sleep • ATS Annual International Conference features over 5,500 research abstracts with over 16,000 attendees • Half of participants from outside the US • Premier journals: Am J RespCrit Care Med; Am J Resp Cell MolecBiol; PATS • AJRCCM highest impact factor in respiratory medicine • Over half of articles submitted to ATS journals are from outside the US

Outline • Criteria and decision-making for ICU admit and discharge • Shared decision-making and communication with families • Role of interdisciplinary communication

Principles for Fair Allocation of ICU Resources: ATS Statement • Every life is valuable and equally so • Respect for patient autonomy is a central tenet of healthcare • Primary duty of ICU team is patient welfare • ICU care, when appropriate, is basic care • Duty of ICU team to benefit patient has limits if care unfairly compromises care of others AJRCCM 1997; 156:1282

Prioritization Model: SCCM • Critically ill, unstable patients in need of ICU treatment and monitoring • Require intensive monitoring and may need immediate intervention • Critically ill, unstable patients with “reduced likelihood of recovery” • Little or no anticipated benefit from ICU because too sick or too well Crit Care Med 1999; 27:633

Basis for Criteria • Severity of illness scoring systems • APACHE, SOFA • Disease-specific criteria • Acute MI, SAH • Organ dysfunction requiring support • Acute respiratory failure, acute renal failure

Decisions to Admit Patients to ICU: Survey of 121 MICU Directors in US Walter, Crit Care Med 2008; 36:414

Proportion of ICUs with Written Guidelines for Decision-making Walter, Crit Care Med 2008; 36:414

Proportion of Time Guidelines Used Walter, Crit Care Med 2008; 36:414

ICU Beds per 100,000 Compared to Hospital Beds per 100,000 Wunsch, Crit Care Med 2008; 36:2787

ICU Beds per 100,000 Associated with ICU Mortality Wunsch, Crit Care Med 2008; 36:2787

Regional Variations in Withholding and Withdrawing Life Support in Europe n=4248 Sprung, JAMA 2003; 290:790

What Do We Know About End-of-life Communication in the ICU? • <5% of patients can participate in ICU decisions about withholding treatments • Communication is primarily with family • Families rate communication as of equal or more importance than clinical skill • Families under immense burdens • High level of anxiety and depression Prendergast, AJRCCM, 1997 Prochard, Crit Care Med, 2001

Shared Decision-making About End-of-life Care • Key factors • Prognosis • Level of certainty • Family preferences • Roles • Patient/family: patient values & preferences • Clinician: treatments that are indicated Clinician decision Family decision Carlet, Intensive Care Med 2004; 30:770

Family Preferences for Role in Decision-making n=1123 families of patients in 6 ICUS Heyland, Intens Care Med, 2003; 29:75

New Paradigm for “Right Approach” to Parentalism vs. Autonomy Default Starting Place Prognosis and Certainty Family preference Parentalism or Doctor Decides Autonomy or “Informed Choice” Shared Decision Making Curtis, Chest, 2008; 134:835

Study of ICU Family Conferences • Daily screen of all ICUs in 4 hospitals • If conference planned, contact attending: • Is discussion of withholding or withdrawing life support likely? • Willing to have conference recorded? • Consent/survey all participants • 51 family conferences recorded (46%) Curtis, J Crit Care, 2002; 17:147

New Paradigm for “Right Approach” to Parentalism vs. Autonomy Collaborative Elicit patient values Offer recommendation Facilitative Elicit patient values Place in context Directive Provide some info Make decision Informative Provide info Make no recommendation Shared Decision Making White, submitted, 2008

VALUE: 5-step Approach to Improving Communication in ICU with Families • V… Value family statements • A… Acknowledge family emotions • L… Listen to the family • U… Understand patient as a person • E… Elicit family questions Curtis, J Crit Care, 2002; 17:147

Randomized Trial of Communication Strategy • Randomized 126 patients if attending believed “patient would die in a few days” • Intervention • Proactive family conference using VALUE strategy • Bereavement pamphlet for family Lautrette, NEJM, 2007; 356:469

Family Member Outcomes: Clinically Significant Morbidity at 3 Months p<0.02 for all Lautrette, NEJM, 2007; 356:469

Physician-Nurse Collaboration in the ICU Interdisciplinary collaboration associated with decreased • ICU mortality • ICU length of stay • ICU readmission rates • Physician and nurse conflict • Job stress for nurses

Doctor and Nurse Ratings of Interdisciplinary Communication p<0.001 for all Reader, Br J Anaesth, 2007; 98:347

Percent of Deaths with Physician-Nurse Collaboration in Decision-making Ferrand, Am J Resp Crit Care Med, 2003; 167:1210

Percent of Physicians Involving Nurses in Decisions about Withdrawal Yaguchi, Arch Intern Med, 2005; 165:1970

Nurse-Family Communication Before ICU Family Conferences Curtis, Crit Care Med; 2001; 29:N26

Summary: Decision-making for Admission and Discharge in the ICU • Significant variability in approaches • Guidelines useful in some cases • Important role of the family conference • V.A.L.U.E. • Listen as much as you speak • Assess family’s desired role • If family involved, support family decisions • Interdisciplinary communication important opportunity for improvement

ICU ADMISSION AND DISCHARGE: Communication and Decision making