1) Death from chronic illnesses such as cardiovascular disease and cancer account for 80% of total deaths in the US each year, compared to 20% from sudden causes like heart attacks or trauma.
2) Physicians often have difficulty discussing prognosis and end-of-life care with terminally ill patients, and these discussions tend to occur late in the disease course or after patients' conditions have deteriorated.
3) Early involvement of palliative care teams in the ICU can help improve patient and family outcomes by ensuring patients' treatment preferences are known and followed, managing symptoms better, and reducing non-beneficial treatments.
The research interest of the investigator has focused on the molecular and cellular pathogenesis of sepsis. In particular, he has worked on soluble proteins involved in the innate recognition of bacteria such as soluble CD14 and MD-2, as well as in the Toll-like receptors activated by Gram-negative and Gram-positive bacteria. Another area of study is the molecular pathogenesis and cell signaling of ventilator-induced lung injury, and lung inflammation in the context of acute respiratory distress syndrome. He has also identified and tested biomarkers in the field of clinical sepsis.
Watch the presentation on Youtube: https://www.youtube.com/watch?v=CyWN7JlhlmI&
The research interest of the investigator has focused on the molecular and cellular pathogenesis of sepsis. In particular, he has worked on soluble proteins involved in the innate recognition of bacteria such as soluble CD14 and MD-2, as well as in the Toll-like receptors activated by Gram-negative and Gram-positive bacteria. Another area of study is the molecular pathogenesis and cell signaling of ventilator-induced lung injury, and lung inflammation in the context of acute respiratory distress syndrome. He has also identified and tested biomarkers in the field of clinical sepsis.
Watch the presentation on Youtube: https://www.youtube.com/watch?v=CyWN7JlhlmI&
Slides From Hot Topics in NASH:New Strategies for the Diagnosis of NASH.2019hivlifeinfo
Slides From Hot Topics in NASH: New Strategies for the Diagnosis of NASH
xpert faculty present key data on current and emerging NASH treatment options for your patients.
Rita Basu, MD
Wing-Kin Syn, MBChB, PhD, FACP, FRCP
Format: Microsoft PowerPoint (.ppt)
File Size: 3.84 MB
Released: February 11, 2019
poster presentation Study of hematological parameters in sepsis patients and...RahulGupta1687
The current study was a cross-sectional study with a sample size of 117 patients with sepsis. Various hematological parameters of all the patients were obtained on day of admission (day 1) and seventh day (day 7) using hemogram reports and the difference of their statistical mean and standard deviation was estimated.There was a significant statistical difference in the mean and standard deviation of neutrophil lymphocyte count ratio (NLCR), red cell distribution width standard deviation (RDW SD), Platelet count (PLT) and Platelet crit (PCT) whereas Mean platelet volume (MPV), Platelet distribution width (PDW) and Platelet large cell ratio (PLCR) showed no significant changes on day 1 and day 7 of observation in patients taken for the study.
Slides From Hot Topics in NASH:New Strategies for the Diagnosis of NASH.2019hivlifeinfo
Slides From Hot Topics in NASH: New Strategies for the Diagnosis of NASH
xpert faculty present key data on current and emerging NASH treatment options for your patients.
Rita Basu, MD
Wing-Kin Syn, MBChB, PhD, FACP, FRCP
Format: Microsoft PowerPoint (.ppt)
File Size: 3.84 MB
Released: February 11, 2019
poster presentation Study of hematological parameters in sepsis patients and...RahulGupta1687
The current study was a cross-sectional study with a sample size of 117 patients with sepsis. Various hematological parameters of all the patients were obtained on day of admission (day 1) and seventh day (day 7) using hemogram reports and the difference of their statistical mean and standard deviation was estimated.There was a significant statistical difference in the mean and standard deviation of neutrophil lymphocyte count ratio (NLCR), red cell distribution width standard deviation (RDW SD), Platelet count (PLT) and Platelet crit (PCT) whereas Mean platelet volume (MPV), Platelet distribution width (PDW) and Platelet large cell ratio (PLCR) showed no significant changes on day 1 and day 7 of observation in patients taken for the study.
The goal of this webinar is to help the healthcare professional understand how to identify patients with advanced Dementia/Alzheimer’s who may be eligible for the Medicare hospice benefit, and how the timely use of hospice care can address many of the challenges and complications experienced by these patients as they approach the end of life.
Deborah Stein SMACC Chicago talk Trauma is Risky Business - delves into the risk patients and physicians undergo when treating or being treated for Trauma.
Stein’s speaks of the Risk Benefit Determination that physicians make daily and how this is used to best answer on going questions such as; can a patient have?, how do we care for this patient? and how do we best make all the these decisions?. Stein’s suggests a thorough Risk Benefit Determination will include:
Analysis of best available data
Use of best available judgement
Gathering of different opinions
An understanding that you won’t always make the right decision
To document the 'crap' out of it!
And to remember you’ll never know what you prevented from not occurring.
Stein’s also focuses on the risk to patients due to missed injuries and the processes physicians can take to help ensure that a patient injuries are not missed. Stating that 1.3-39% of injuries in trauma are missed (a majority of which present as orthopaedic cases).
Touching on the processes designed to prevent missed injuries such as;
Territory Trauma Survey
Roles of clinical decision rules
To scan the living ‘crap’ out of them - whole body CT scans (can decrease mortality but comes attached with its own risks).
Stein’s then delves into the risks trauma providers (physicians) face on a daily bases. Stating that in the USA trauma providers are one of the highest categories of physicians to be sued, have higher indemnity payment awarded against them and achieve a higher risk score in studies for being sued. While, lawsuits are more likely to increase the chance of physician burnout, career burnout, depression and are emotionally and physically exhausting. Steins sights recent studies that suggest the more open, honest and forthright a physician is with their error with their peers and their hospital the likelihood of being sued reduces.
Stein’s also notes that needle stick injuries in most departments have decreased in recent years due to universal precautions, yet have increased in trauma care due to the nature of the ER environment and proper precautions not being taken. Violence is of risk to attending ER nurses, physicians and paramedics, sighting an Australian study that 79% of triage nurses have experienced physical violence from patients. And, the emotional harm the trauma environment can have on trauma providers.
Steins suggests that trauma providers must be aware and learn how to manage risk better to ensure patient and provider safety.
This webinar provides expert guidance and clear answers to common myths about hospice care. Learn about the history and philosophy of hospice care, common hospice prognoses, who pays for hospice, and the difference between hospice and palliative care. Explore the four levels of care and the role of the interdisciplinary hospice team to provide medical, psychosocial and spiritual solutions that support quality of life at the end of life for patients and families. Learn how advance directives can ensure patients are referred to hospice care early in the disease process to enjoy its full benefits.
Matt Anstey is an intensivist from Sir Charles Gardiner hospital in Perth, Australia.
He gave this talk on outcomes after intensive care at an ICN WA meeting in Perth last year.
Understanding Death with Dignity Legislation: A Necessity for the Palliative ...wwuextendeded
Understanding Death with Dignity Legislation: A Necessity for the Palliative Care Provider - Frances DeRook, MD, FACC
Presented at the 2015 Palliative Care Summer Institute conference at Bellingham Technical College
The who, what, where, why and how of end-of-life care. A continuing education webinar presented by VITAS Healthcare on March 15, 2018. For more information or future webinars, please visit: https://www.vitas.com/partners/continuing-education
Paul Lane is an intensivist from Townsville, in the tropical north of Queensland, Australia. He gave this talk at last year's bedside critical care conference straight after Ed Morris' talk on the same subject. In this talk, Paul brings the intensivist's perspective. Not too late to join the 550 others coming to SMACC - see the website for details and see ICN for Paul's slides that go with this talk.
Peritoneal dialysis is an important modality to treat patients with end stage renal disease. It's outcome is comparable to haemodialysis. In fact it if two modalities are properly used the outcome improves.
Deciding When Hospice Care is Needed | VITAS HealthcareVITAS Healthcare
The goal of this webinar is to help healthcare professionals address the specific challenges of end-of-life care when determining a terminal prognosis, so they can provide the optimum care for the patient and family during the final stages of life.
The goal of this webinar was to help hospice and healthcare professionals understand the history, philosophy, and practice of hospice and palliative care, including common misconceptions, typical diagnoses for hospice referrals, identification of hospice-eligible patients, reimbursement for hospice services, and the
benefits of advance care planning and early referrals.
Similar to Disucssion on EOL care and prognosis (20)
2. Disease-specific Mortality Rates in USA
Total Number of Deaths
800,000
700,000
600,000
500,000
400,000
300,000
200,000
100,000
0
US Census Bureau 2010
Total Number of Deaths
3. Death and Dying
• 20% sudden death
• MI
• Trauma
• PE
• 80% death from chronic illnesses
• Cardiovascular diseases
• Cancer
• COPD
5. Where do People Die?
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•
National Mortality Followback Survey (NMFS)
10,122 deaths analyzed in 1993
58% patients died in Hospital
22% died at home
20% in Nursing Home
Teno JM et al. Med Care 2003;41:323-35
6. Deaths in ICU
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552,157 deaths in 1999 in FL, MA, NJ, NY, VA, WA
38.3% of deaths in hospitals
22.4% of deaths after ICU admission
Death in ICU after a median LOS of 12.9 days
Cost: $24,541.00
Angus DC et al. Crit Care Med 2004;32:638-43
7. ICU use in Last Month of Life
• Were these patients offered the opportunity to
discuss their preferences?
Teno JM et al. JAMA 2013;309:3470-477
8. Discomfort and Lack of Training
• Medical oncologists do not routinely discuss prognosis
• Survey of 729 MD Oncologists
• 73% admitted that training on prognosis communication was lacking
• 96% believed that such education should be part of cancer care
training
• Physicians caring for advanced cancers
• Provide frank estimate 37%
• No estimate or inaccurate estimate (consciously) 63%
• Physicians tend to make different treatment
recommendations to their patients than they would
choose for themselves
Daugherty CK et al. J Clin Oncol 2008;26:5988-93 Lamont EB et al. Ann Intern Med 2001;134:1096-105 Ubel PA et al. Arch Intern Med 2011;17:630-4
9. Physicians Reluctance on EOL care
• > 4000 physicians surveyed
• Most physicians would not discuss EOL options with
terminally ill patients who are feeling well
• They rather wait for symptoms to develop
• They may discuss prognosis when they have no more
treatment to offer
• They do not discuss sites of death (that would
respect patient’s preferences)
Keating NL et al. Cancer 2010;116:998-1006
10. Timing of EOL discussions
• A majority (55%) of patients with cancer at MD
Anderson did not access PC before they died
• PC at 1.4 month before death
• 55% EOL-care discussions occurred in the hospital
• Oncologists documented EOL-care discussions with
only 27% of patients
• Among 959 patients with documented EOL-care
discussions who died during follow-up, discussions
took place a median of 33 days before death
Hui D et al. 2012;17:1574-80
Mack J et al. Ann Intern Med 2012;156:204-10
11. Other Barriers to EOL Discussions
• Most physicians lack knowledge or insight into a
meaningful discussion about prognosis
• Misinterpretation of what patients/surrogates want
• Fear of judgment
• Perfect is sometimes the enemy of the good
• Most surrogates want physicians to disclose
prognostic estimates even if they cannot be certain
of their accuracy
Evans LR et al. Am J Resp Crit Care Med 2009:179:48-53
14. Data from MSKCC
• Identification of poor prognostic factors among patients
requiring mechanical ventilation after HSCT
Bach et al. Blood 2001
15. Accuracy of Prognosis
• Estimate of survival time in individual patients
with cancer can be accurate
Glare P A et al. JCO 2013;31:3565-3571
16. Cardiac Arrest
• OHCA carries 92% mortality
• CPR in hospitalized patients
• ROSC: 44%
• Alive at hospital discharge: 17%
• CPR in ICU patients
• Hospital survival: 15.9%
• VP, MV, and age > 65 y (worse outcome)
• CPR in patients with cancer
• Survival: 10.1% for general medical/surgical wards
• 2.2% in ICU
Roger VL et al. Ciculation 2011;123:e18-209
Tian J et al. Am J Respir Crit Care Med 2010;182:501-6
Peberdy MA et al. Resuscitation 2003;58:297-308
Reisfield GM et al. Resuscitation 2006;71:152-60
17. Place of Death: QOL and Caregiver MH
• Prospective, longitudinal study of terminally ill
patients with cancer and their caregivers at
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Yale Cancer Center
West Haven VA CT Comprehensive Cancer Clinic
Simmons Comprehensive Cancer Center
Parkland Hospital
MSKCC
Dana-Farber
New Hampshire Oncology-Hematology
• Study population: 342 dyads
• Hospital deaths associated with prolonged grief
• ICU deaths associated with higher risk of PTSD
Wright AA et al. J Clin Oncol 2010;28:4457-4464
18. EOL Discussions and Outcomes
• 325 patients from 8 sites
• 68% received EOL care consistent with thir
preferences
• Patients more likely to receive EOL care consistent
with preferences if wishes were discussed with
physicians
• Distress lower among patients who received no lifeextending measures and their caregivers
Mack JW et al. J Clin Oncol 2010;28:1203-1208
19. Domains of EOL Discussions in ICU
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Communication
Seek patient’s preferences
Support to family/surrogate
Spiritual needs
Relief of symptoms
Support caregiver grieving (SW + Psychiatry)
Use of available resources
EOL care after death
20. Benefits of PC-ICU
Outcome
Selected Relevant Studies
↓ Intensive care unit/hospital length of stay
Campbell et al; Norton et al; Curtis et al
↓ Use of nonbeneficial treatments
Campbell et al; O’Mahony et al; Pierucci et al
↓ Duration of mechanical ventilation
Payen et al
↑ Family satisfaction/comprehension
Azoulay et al
↓ Family anxiety/depression, PTSD
Lautrette et al
↓ Conflict over goals of care
Lilly et al
↓ Time from poor prognosis to comfort-focused goals Campbell et al
↑ Symptom assessment/patient comfort
Nelson et al. Crit Care Med 2010;38:1765-1772
Erdek and Pronovost ; Chanques et al
23. Recommendations
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•
Would I be surprised if the patient dies in < 1 y?
EOL Discussion in clinic or on admission
Inquire about patient’s preferences
Include surrogate or agent with patient’s
permission
• Shared decision making process
• Discuss options