Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Aug 2012
The burdens of survivorship: an approach to thinking about long-term outcomes after critical illness.
Internationally accepted approaches to the study of functioning and disability can inform critical care practitioners and scholars in their study of functional limitations, disability, and quality of life after critical illness and intensive care. Therefore this article provides an introduction to the World Health Organization's International Classification of Functioning, Disability and Health (ICF). The Institute of Medicine has also recommended this approach for the study of disability. ⋯ The ICF draws attention to effect modifiers that can prevent problems at one level from progressing (or conversely can hasten their progression) to profound decrements in a patient's quality of life. It is particularly relevant for studies of long-term outcomes after critical illness and post-intensive care syndrome (PICS). This article provides a discussion of the ICF specific to the intensive care unit and the disablement process, with particular attention to new opportunities for intervention and their implications for cost and quality of life.
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Semin Respir Crit Care Med · Aug 2012
ReviewShaping end-of-life care: behavioral economics and advance directives.
A central but unmet challenge in health care delivery is to increase the probability that the care patients receive near the end of their life is consistent with their goals, values, and preferences. Providing patient-centered care at the end of life is challenging. In their final days, nearly a third of older Americans need critical decisions made regarding the use or nonuse of life-sustaining interventions, but the patients themselves cannot participate in those decisions. ⋯ This article provides a new framework, based in behavioral economic theory, that may explain the current failures of ADs and point to potential solutions. Specifically, it discusses how five well-described cognitive biases that pervade human decision making (affective forecasting errors, optimism bias, present-biased preferences, focusing effects, and default options) may account for deficiencies in the uptake, efficacy, and patient-centeredness of ADs. The text suggests potential solutions in need of evaluation, discusses metrics for assessing these interventions' benefits, and considers alternatives to the approaches advocated.
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Semin Respir Crit Care Med · Aug 2012
ReviewMedical and economic implications of cognitive and psychiatric disability of survivorship.
Current research indicates that the majority of survivors of critical illness develop post-intensive care syndrome (PICS), which includes new or worsening cognitive or psychiatric disorders that persist for months to years after critical illness. These cognitive impairments and psychiatric disorders are profound and long-lasting, adversely affecting survivors' daily functioning, ability to return to work, and quality of life, as well as altering the lives of their family members. The medical effects of cognitive and psychiatric disability after critical illness translate directly into a large economic burden. A large and growing body of intensive care unit (ICU) survivors with cognitive and psychiatric morbidities presents challenges for research and identification of best practices and interventions, both during and after the ICU, including rehabilitation to prevent or remediate long-term neurological outcomes.
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Semin Respir Crit Care Med · Aug 2012
ReviewMedical and economic implications of prolonged mechanical ventilation and expedited post-acute care.
This article describes the increasingly common phenomenon of prolonged mechanical ventilation in the context of the transition between the acute care hospital and post-acute care. Prolonged mechanical ventilation or chronic critical illness is associated with hospital mortality in the range of 20 to 40%, with median hospital length of stay ranging from 14 to 60 days. Fewer than 10% of patients are discharged home, and most hospital survivors require institutionalized post-acute care in the form of long-term acute care, skilled nursing facilities, or inpatient rehabilitation. ⋯ Survivors experience significant functional limitations. The prolonged institutional care and poor long-term outcomes of these patients bring into question the cost-effectiveness of prolonged mechanical ventilation after acute illness, especially for patients with poor long-term prognoses. New measures to facilitate assessments of long-term prognosis and improve communication with surrogate decision makers may reduce the amount of ineffective care for some patients requiring prolonged mechanical ventilation.
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Semin Respir Crit Care Med · Aug 2012
ReviewMedical and economic implications of physical disability of survivorship.
Interventions developed in the last decade have led to impressive rates of survival from extreme critical illness. However, surviving an episode of critical illness is just the beginning. Discharge from the intensive care unit (ICU) is often the start of a long and challenging rehabilitation, mood disorders, cognitive impairment, financial hardship, and caregiver burden, burnout, and psychological distress. ⋯ The spectrum of muscle, nerve, and brain dysfunction may be permanent and can significantly change the disposition for those who were previously independent. Furthermore, it may impose a substantial health care cost burden and compromise the reserve of even the most resilient family members. Important limitations in the current literature relate to our poor understanding of how to risk stratify, how to systematically educate and inform our patients and family caregivers about physical morbidity and complex patient care in the community, and how to develop, test, and implement rehabilitation programs tailored to individual need.