Seminars in respiratory and critical care medicine
-
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.
-
Semin Respir Crit Care Med · Aug 2012
ReviewEconomics at the end of life: hospital and ICU perspectives.
Not all feasible care is desirable care. At the end of life, aggressive interventions may not only be futile but also inappropriate because they may impair the quality of the remaining life for both the patient and the caregiver. Although it is challenging to identify patients with a poor prognosis, certain terminal conditions among the elderly, such as end-stage dementia, heart failure, and metastatic cancer, demand a more measured use of aggressive care. Frank discussions with patients and family about their desires in the context of the prognosis, as well as symptom support, can yield both economic savings and better quality of life.
-
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.
-
Semin Respir Crit Care Med · Aug 2012
ReviewIntensivist time allocation: economic and ethical issues surrounding how intensivists use their time.
Intensivists' time is a fundamentally constrained resource. Many factors can put intensivists under conditions in which demands for their time outstrip the amount of time available. ⋯ In deciding how to allocate their time, intensivists face many challenges. This article highlights two of these challenges: (1) How should intensivists approach two common scheduling-related issues (24/7 intensive care unit coverage and long blocks of service time that promote continuity but sacrifice weekends off) and balance these issues with the very real workforce concern of accelerated professional burnout? (2) What are the hidden financial impacts of intensivist participation in quality improvement programs, given current reimbursement systems?
-
Medical care offered to the critically ill often occurs by default, unfolding automatically unless concerted effort is made to do otherwise. In their scope, defaults include traditional approaches to treatment and decision making, as well as policies deliberately set to promote specific health outcomes. ⋯ Unfortunately in practice, some defaults lead to ineffective, unwanted, and expensive care. This article reviews the ethical and economic impact of defaults, paying special attention to their influence on the practice of cardiopulmonary resuscitation and admission to the intensive care unit.