Critical care involves managing organ system failures while considering the overall clinical picture of the patient. Less invasive interventions are preferred when possible to avoid iatrogenic harm. Prognostication is difficult, and outcomes depend on the individual patient's values and preferences. Family meetings require skilled communication to make difficult end-of-life decisions. The goal is providing humane care that aligns with patient priorities through a team-based approach.
Three hour slide deck for basics of palliative care including what is palliative care, symptom management (pain, dyspnea, nausea, constipation), goals-of-care, family meetings, comfort care, and issues around artificial nutrition.
Five priorities for care of the dying personMarie Curie
Dr Bill Noble, Medical Director of Marie Curie Cancer Care, speaks at the end of life sesion with Dr Adam Firth (RCGP Clinical Support Fellow for End of Life Care).
This session was chaired by Dr Peter Nightingale, Marie Curie and RCGP End of life lead at the RCGP Annual Conference, ACC Liverpool, 2-4 October, 2014.
For more information visit: mariecurie.org.uk/rcgp
Carle Palliative Care Journal Club for 7/3/18Mike Aref
Journal club review of "Effect of Lorazepam With Haloperidol vs Haloperidol Alone on Agitated Delirium in Patients With Advanced Cancer Receiving Palliative Care: A Randomized Clinical Trial" by D. Hui et. al. in JAMA. 2017 Sep 19;318(11):1047-1056.
Carle Palliative Care Journal Club 1/15/2020Mike Aref
A journal club review and criticism of J Natl Cancer Inst. 2019 Dec 17. pii: djz233. doi: 10.1093/jnci/djz233 Emergency Department Visits for Opioid Overdoses Among Patients with Cancer by Jairam V, Yang DX, Yu JB, Park HS.
Three hour slide deck for basics of palliative care including what is palliative care, symptom management (pain, dyspnea, nausea, constipation), goals-of-care, family meetings, comfort care, and issues around artificial nutrition.
Five priorities for care of the dying personMarie Curie
Dr Bill Noble, Medical Director of Marie Curie Cancer Care, speaks at the end of life sesion with Dr Adam Firth (RCGP Clinical Support Fellow for End of Life Care).
This session was chaired by Dr Peter Nightingale, Marie Curie and RCGP End of life lead at the RCGP Annual Conference, ACC Liverpool, 2-4 October, 2014.
For more information visit: mariecurie.org.uk/rcgp
Carle Palliative Care Journal Club for 7/3/18Mike Aref
Journal club review of "Effect of Lorazepam With Haloperidol vs Haloperidol Alone on Agitated Delirium in Patients With Advanced Cancer Receiving Palliative Care: A Randomized Clinical Trial" by D. Hui et. al. in JAMA. 2017 Sep 19;318(11):1047-1056.
Carle Palliative Care Journal Club 1/15/2020Mike Aref
A journal club review and criticism of J Natl Cancer Inst. 2019 Dec 17. pii: djz233. doi: 10.1093/jnci/djz233 Emergency Department Visits for Opioid Overdoses Among Patients with Cancer by Jairam V, Yang DX, Yu JB, Park HS.
Palliative Care and Acute Oncology IntegrationRecoveryPackage
Dr Catherine O'Doherty, Consultant in Palliative Medicine, Trust Acute Oncology Lead and Lead Cancer Clinician, Basildon and Thurrock University Hospitals NHS Foundation Trust
Karen Andrews, Head of Nursing for Macmillan/Acute Oncology and EOL services, Basildon and Thurrock University Hospitals NHS Foundation Trust
Basics of palliative care including symptom management: pain, dyspnea, nausea and constipation; family meetings, goals-of-care, end-of-life care, and artificial nutrition.
5 years of “Rare” Progress Research: Cheryl Rockman-Greenberg, Max Rady College of Medicine, University of Manitoba
Rare Disease Day Conference 2020 March 9-10
Palliative care is about providing well-being and the highest quality of life to patients with serious, progressive, chronic life-limiting illness, including during the dying process.
Consolidating, Improving, and Novel Palliative Care: Order SetsMike Aref
A selection of slides, taken from a series of presentations, showing the evolution of consolidating and developing order sets for delivery of primary palliative care in our healthcare system.
Ethical Issues Regarding Nutrition and Hydration in Advanced IllnessMike Aref
Be able to discuss and clarify “pleasure feeding” with patients and their families
Identify ethical issues with continuing or stopping artificial nutrition and hydration
Understand complications of artificial nutrition and hydration that are not ethically justifiable
Be able to discuss issues of self-dehydration and self-starvation
Out-patient Primary and Specialty Palliative CareMike Aref
Presentation on primary and specialty palliative care, covering what is palliative care, basics of primary palliative care including pain and symptom management, and referral criteria for out-patient specialty palliative care.
Scoring Suffering to Address Patient Needs in Palliative Care: The "Maslow Sc...Mike Aref
Introduction
Palliative care patients have been scored by their symptom burden and performance but there is little standardization of their multidimensional suffering, needs, and wants. Maslow’s Hierarchy of Needs is a model for describing these needs as physiological, safety, love/ belonging, esteem, and self-actualization. The functional pain score is a validated method of scoring pain based on patient report and provider assessment. Using these two frameworks, the “Maslow Score” seeks to use Maslow’s Hierarchy to score the current patient situation based on symptom burden, plan, network, and meaning.
Methods
The scores are four-digit codes describing the patient situation at a given time base on team consensus. Each digit is a score from most secure, 0, to most vulnerable, 5. Both written examples and an algorithmic approach have been provided to obtain each score.
Results
Morning huddle has been expedited by utilizing scores recorded the previous day. Also if sudden changes have been reported they can be compared rapidly against a team standard. This triaging helps direct team resources as to whether patients should be reassessed by the entire team or specific members. The discussion has improved assessment of patients from an interdisciplinary perspective. In general, patients cannot improve their network and meaning scores until symptom and planning scores have been optimized.
Discussion
The “Maslow Score” appears to have improved the quality of care that our service delivers by improving efficiency. Further development and study is needed to standardize and validate our method.
Carle General Surgery Grand Rounds presentation on palliative care symptom management, specifically pain, nausea, constipation, and malignant bowel obstruction.
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.
Palliative Care and Acute Oncology IntegrationRecoveryPackage
Dr Catherine O'Doherty, Consultant in Palliative Medicine, Trust Acute Oncology Lead and Lead Cancer Clinician, Basildon and Thurrock University Hospitals NHS Foundation Trust
Karen Andrews, Head of Nursing for Macmillan/Acute Oncology and EOL services, Basildon and Thurrock University Hospitals NHS Foundation Trust
Basics of palliative care including symptom management: pain, dyspnea, nausea and constipation; family meetings, goals-of-care, end-of-life care, and artificial nutrition.
5 years of “Rare” Progress Research: Cheryl Rockman-Greenberg, Max Rady College of Medicine, University of Manitoba
Rare Disease Day Conference 2020 March 9-10
Palliative care is about providing well-being and the highest quality of life to patients with serious, progressive, chronic life-limiting illness, including during the dying process.
Consolidating, Improving, and Novel Palliative Care: Order SetsMike Aref
A selection of slides, taken from a series of presentations, showing the evolution of consolidating and developing order sets for delivery of primary palliative care in our healthcare system.
Ethical Issues Regarding Nutrition and Hydration in Advanced IllnessMike Aref
Be able to discuss and clarify “pleasure feeding” with patients and their families
Identify ethical issues with continuing or stopping artificial nutrition and hydration
Understand complications of artificial nutrition and hydration that are not ethically justifiable
Be able to discuss issues of self-dehydration and self-starvation
Out-patient Primary and Specialty Palliative CareMike Aref
Presentation on primary and specialty palliative care, covering what is palliative care, basics of primary palliative care including pain and symptom management, and referral criteria for out-patient specialty palliative care.
Scoring Suffering to Address Patient Needs in Palliative Care: The "Maslow Sc...Mike Aref
Introduction
Palliative care patients have been scored by their symptom burden and performance but there is little standardization of their multidimensional suffering, needs, and wants. Maslow’s Hierarchy of Needs is a model for describing these needs as physiological, safety, love/ belonging, esteem, and self-actualization. The functional pain score is a validated method of scoring pain based on patient report and provider assessment. Using these two frameworks, the “Maslow Score” seeks to use Maslow’s Hierarchy to score the current patient situation based on symptom burden, plan, network, and meaning.
Methods
The scores are four-digit codes describing the patient situation at a given time base on team consensus. Each digit is a score from most secure, 0, to most vulnerable, 5. Both written examples and an algorithmic approach have been provided to obtain each score.
Results
Morning huddle has been expedited by utilizing scores recorded the previous day. Also if sudden changes have been reported they can be compared rapidly against a team standard. This triaging helps direct team resources as to whether patients should be reassessed by the entire team or specific members. The discussion has improved assessment of patients from an interdisciplinary perspective. In general, patients cannot improve their network and meaning scores until symptom and planning scores have been optimized.
Discussion
The “Maslow Score” appears to have improved the quality of care that our service delivers by improving efficiency. Further development and study is needed to standardize and validate our method.
Carle General Surgery Grand Rounds presentation on palliative care symptom management, specifically pain, nausea, constipation, and malignant bowel obstruction.
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.
Depression and CV diseases: cardiologist perspectives Essam Mahfouz
The presentation discusses the epidemiology, mechanism, screening and diagnosis of depression and cardiovascular disease and how to mange this association
Exploring Advances in the Early Diagnosis and Treatment of Alzheimer Disease ...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
In this slide deck, discover new insights into early diagnosis, emerging treatment modalities, and supportive care services for Alzheimer disease. An expert faculty member will discuss biological and clinical distinctions between mild cognitive impairment, dementia, and Alzheimer disease; methods for timely diagnosis; clinical trial data on novel monoclonal antibody therapies; prevention and management of side effects associated with monoclonal antibody therapies, including ARIA, and interdisciplinary support services for improving quality of life.
STATEMENT OF NEED
Alzheimer disease, the most common form of dementia among older adults, is a slowly progressive neurogenerative disease that affects approximately 6 million Americans aged 65 and older (Rajan et al, 2021). Symptoms of Alzheimer disease include memory loss, confusion, impulsive behavior, difficulty with language, mood and personality changes, hallucinations, and increased anxiety or aggression, with severe symptoms such as physical decline, difficulty swallowing, and inability to communicate developing as the disease progresses into its final stages (NIA, 2023). While new therapeutic agents have recently emerged to slow the progression of Alzheimer disease by targeting its underlying causes, the disease remains incurable, and the demands of day-to-day care place significant strain on both patients and their families and caregivers. Therefore, it is critical that clinicians remain up to date on early diagnosis, emerging treatment modalities, and supportive care services in order to provide optimal care for their patients. In this live webinar chaired by Nathaniel Chin, MD, Associate Professor of Medicine in the Division of Geriatrics and Gerontology at the University of Wisconsin-Madison, speakers will explore advances in the diagnosis and treatment of Alzheimer disease.
TARGET AUDIENCE
Geriatricians, neurologists, primary care physicians, psychiatrists, psychogeriatricians, nurse practitioners, physician assistants, nurses, and other health care professionals (HCPs) involved in the treatment of patients with Alzheimer disease (AD).
LEARNING OBJECTIVES
Upon completion of this activity, participants should be able to:
Utilize diagnostic methods that enable the timely identification of early Alzheimer disease (AD)
Evaluate the clinical utility of novel and emerging DMTs for the treatment of individual patients with early AD
Apply strategies to enhance interdisciplinary care for patients with early AD
Somatoform disorder include different entities. One of complex and difficult to treat ailment among the somatoform disorder is illness anxiety disorder, formerly known as hypochondriasis. My power point presentation is an attempt to simplify the mystery of this common psychiatric diagnosis. (Dr Satyajeet Singh, MD, Neuropsychiatrist, Aiims Patna)
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
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Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
1. Critical care: the big and little
picture(s)
Hashim Mehter, MD, MSc.
Pulmonary and Critical Care Medicine
Medicine residency noon conference
May 7, 2019
3. Little picture -> Big picture
Each decision on rounds -> managing organ
system failures -> integrating each problem/organ
system into the bigger clinical picture
Bigger clinical picture -> trying to visualize/predict
”arcs”
”arc” of critical illness
impact of critical illness on the “arc” of patient’s life
and quality of life
Prognostication -> best case scenario, worst case
scenario, likelihoods
Working to elicit patient values and preferences,
acceptable quality of life -> triangulating this with
clinical picture and prognostication
4. Conceptualizing problems
Problem-based ICU notes/presentations preferred
“A: Pulm: stable on current vent therapy”
does not help anyone understand the problems our patients
have
leads to missed diagnoses/treatments
A: Acute resp failure from fluMSSA pneumoniaARDS: initiate
low tidal volume ventilation, conservative fluid strategy
or
A: Septic shock due to MSSA pneumonia and ARDS: wean
norepinephrine, complete 8-day course cefazolin
Much better
5. Principles of organ system
failure
Acute respiratory failure / ARDS
Prevent iatrogenic/ventilator-induced further lung injury and
treat underlying cause. Proactively minimize sedation and
actively pursue ventilator liberation as soon as feasible/safe.
Hope for improvement/healing with time.
Septic shock
Control source, abx, judicious early fluid resuscitation,
vasopressor support, treat or supportively manage resultant
organ failures over time. De-resuscitate when appropriate.
Cardiogenic shock
Optimize preload and afterload, inotropic support,
sometimes bridging with mechanical support while waiting
for improvement with time (or other interventions, e.g. PCI,
CABG, transplant).
CNS
Limit damage (e.g. thrombolysis/clot retrieval in acute
stroke) and hope for the best with time.
6.
7. Management of septic shock
1995: Antibiotics. Fluids. Vasopressors.
PLUS: pulmonary artery catheter
2005: Antibiotics. Fluids. Vasopressors.
PLUS: activated protein C (Xigris)
PLUS: “early goal-directed therapy”/Rivers protocol
• Blood and inotropes to increase oxyen-carrying capacity
• Targeting fluid resuscitation to goal CVP – resulted in often-
massive fluid resuscitation
2015: Antibiotics. Fluids. Vasopressors.
DON’T do any of the stuff above
8. When less is more
• Lower tidal volume and lower plateau
pressures
• Less blood
• Less invasive hemodynamic monitoring
• Less fluids
• Less insulin and less intensive glycemic
control
• Less antibiotics; de-escalation of empiric
therapy and shorter course
• Less sedation and less benzodiazepines
• Less imaging; no daily CXR
• Less calories and protein; trophic feeds
and early underfeeding appear safe
• Less therapeutic hypothermia
• Less/later renal replacement therapy
• Less talking and more listening in family
meetings
• NO:
• CVP monitoring
• PAC monitoring
• EGDT for sepsis
• Supranormal hemodynamic targets
• Hetastarch
• Early tracheostomy
• Immediate central line for
vasopressors
• HFOV in ARDS
• Steroids in routine mgmt. of septic
shock
• Steroids in routine mgmt. of severe
ARDS
• Activate Protein C (Xigris) for septic
shock
9. Less is more
“The art of medicine consists of amusing the
patient while nature cures the disease.” – Voltaire
Makes the tried-and-true evidence-based
interventions we do have that much more
important
Avoid iatrogenesis
Unnecessary procedures, polypharmacy, etc.
Growing recognition that much of the good that we
can do comes from “de-ICU’ing” patients
ICU liberation initiative / ABCDEF bundle
11. Family engagement
Family presence (if desired)
At the bedside (“open or flexible”)
On rounds
During resuscitation
During invasive procedures
ICU diaries
Help patient to reconstruct incomplete memories
Gives family constructive task at time of great anxiety
Data suggests decreased downstream PTSD for both patient
and family
12. Sepsis survivors
Compared to case-matched cohorts of other
hospitalized patients, sepsis survivors experience
more:
Limitation of ADLs
Cognitive impairment
Mental health impairment (anxiety, depression, PTSD –
often with accompanying somatic symptoms)
Recurrent infection/sepsis
Exacerbation of chronic medical conditions
Prescott et al. JAMA 2018;319(1): 62-75.
13. ARDS survivors
Long-term neuropsychological
impairment is common at one year
Depression, PTSD, anxiety
Impaired memory, verbal fluency, executive
function
At five years, spirometry/PFTs near-
normal, but:
Decreased physical function / QOL
Decreased 6 MWT distance
Persistent psychological sequelae
Herridge et al NEJM 2011; 364:1293
Mikkelson et al AJRCCM; 185:1307
14. Post-ICU syndrome
No official definition, but generally agreed that
PICS constitutes new/worsened function in
Cognitive function – attention/concentration, memory,
mental processing speed, executive function
Psychiatric function – anxiety, depression, PTSD
Physical function – poor mobility, compromised ADLs,
compromised lung function in ARDS survivors
Epidemiology not well-studied, but
5.7 million annual ICU admissions in the U.S.
4.8 million will survive the ICU stay
Estimated that ½ or more will suffer from some
component of PICS
Risk factors: include delirium, age, mechanical
ventilation, duration of critical illness, specific
diagnoses (ARDS and severe sepsis)
15. Post-ICU syndrome
Important in the context of downstream care
Primary care
Hospital medicine
What can we do to prevent/mitigate PICS
DO LESS to patients in the ICU when possible
Get them out of the ICU sooner
“Activate” them – get them looking and functioning like
real people again as soon as possible
Emotionally and psychologically support patients and
their families (this is evidence-based)
Potential role for multidisciplinary ”post-ICU” clinics (?)
17. Prognostication in the ICU
We aren’t great at it
Mortality vs. other patient-centered outcomes
Functional independence, neuropsych sequelae
Predictive scoring systems: APACHE, SAPS,
MPM, SOFA
Not very good at predicting outcomes for individuals
Data from clinical trials and retrospective
studies for specific disease cohorts
e.g. cardiac arrest, ARDS
again, lacks precision for specific patients
Clinical experience/intuition (combined with
available data): doesn’t always lend itself well to
numbers
19. Prognostication in the ICU
Anderson et al. Annals ATS, 2015.
Key themes:
Help families to see prognosis through
education, pictures, radiographs, bedside
explanations
Convey possibility of poor outcomes early
Discuss prognosis regularly over the course
of ICU stay
Numeric estimates may be helpful for
families
Engage multiple clinical disciplines in
coordinating prognostic information
21. End-of-life issues in the ICU
Family meetings
Practical guidance and strategy
Triggers and frequency
“Substituted judgment”
Factors associated with conflict
Approaches to conflict
Family and care team
Intra-family
Within care team
Practicalities of transitioning to comfort care
Provider burnout
Integration of consultative services
e.g. palliative care, spiritual care
22. EoL issues - background
22% of all US deaths occur in ICUs
Most ICU deaths are associated with some
limitation of care
Most decisions to limit care in the ICU are made
by surrogate decision-makers talking to physicians
with whom they have no previously established
trust relationship
Inconsistent (at best) use of formal advance
directives
Families/proxies are asked to make difficult
decisions under exceedingly difficult
circumstances
“Substituted judgment” Angus et al. Crit Care Med, 2004.
Prendergast et al. Am J Respir Crit Care Med, 1998.
23. EoL issues - background
7 out of 10 Americans express a desire to die at
home
Chronically ill patients value:
Avoiding inappropriate prolongation of dying process
Symptom management near the end of life
Importance of optimizing end-of-life care widely
recognized
Not clear that outcomes are meaningfully improving
From 2000 to 2009, in-hospital death decreased but ICU
use in the last 30 days of life increased
Pritchard et al J Am Geriatr Soc, 1998.
Gruneir et al. Med Care Res Rev, 2007.
Steinhauser et al. JAMA, 2000.
Singer et al. JAMA, 1999.
Teno et al. JAMA, 2013.
24. The ICU family meeting
Complex interdisciplinary procedure
Can help achieve humane and effective care when patients and
families face end-of-life decisions
Deeply anxious patients and families are:
thrown into a hospital setting that is often strange
and frightening
working with unfamiliar healthcare professionals
(your PCP isn’t your intensivist anymore)
faced emergently with terrible choices
Difficult decisions and challenging discussions call
upon skilled communication competencies
Formal training hard to come by, and significant gaps in
communication competencies are common
Billings. J Pal Med, 2011.
Levy et al. Crit care med, 2006.
25. Shared Decision-making
Spectrum of ways in which physician
conceptualizes their role:
Parentalism/paternalism: the physician makes the
treatment decision with little input from the patient or
family
Informed choice: the physician provides all relevant
medical information but withholds his/her opinion and
places responsibility for the decision on the family
Shared decision-making: the physician and family each
share their opinions and jointly reach a decision
Curtis et al. Chest, 2008.
26. Shared decision-making often considered the
optimal paradigm, but easier said than done
Some proxies prefer to make decision without
physician input/opinion (some studies indicate a
substantial minority)
Some physicians don’t believe in offering an opinion
Conflict over EoL decision-making is common
• Provider-proxy conflict present in 20-50% of cases
• Significant source of stress and anxiety for both provider
and family
White et al. Crit Care Med, 2010.
Curtis et al. Chest, 2008.
White et al. Am J Respir Crit Care Med, 2009.
Breen et al. J Gen Intern Med, 2001.
Abbott et al. Crit Care Med, 2001.
Shared Decision-making in the ICU
29. Something to think about
THEME LOW INTENSITY HIGH INTENSITY
Goals of life-sustaining
treatment
The goal of life-sustaining treatment is a bridge to recovery. It
is a means to an end.
The goal of life-sustaining treatment is meeting narrow
physiologic objectives or averting death in the hospital. It can
be an end in itself.
Determination of "dying"
A patient is "dying" when they have a terminal underlying
condition, such as metastatic cancer, or if they are judged to
have a poor quality of life in the event life-sustaining
treatment is continued
There is conflict and ambivalence about when a patient is
"dying," although all agree that a patient whose vital signs
cannot be maintained despite maximal life-sustaining
treatment is dying.
Harms of commission vs.
ommision
Critical care physicians use concerns about harms of
commission, such as iatrogenic harms, prolonging dying, and
treating a patient against their preferences, to rationalize
limitation of life-sustaining treatment.
Critical care physicians express concerns about these harms of
commission, but these infrequently impact the treatment
plan. Concerns about harms of ommision, such as missing
something treatable or limiting life-sustaining treatment for a
patient who might survive, loom larger.
Physician decision-making
self-efficacy
Critical care physicians have a high degree of self-efficacy for
decision-making regarding life-sustaining treatment. They
view family requests for continued treatment as part of the
normal trajectory.
Critical care physicians externalize the locus of control for
decision-making to patients, families, and specialists who they
believe expect aggressive treatment. They view family
requests for continued treatment as a mandate.
Barnato et al. Intensive Care Med, 2012.
34. Summary
The ICU is chock full of uncertainty
Short term prognosis / “arc” of critical illness
Long-term prognosis
Patient preferences
Acceptable quality of life
All families are different and require thoughtful care in
how they are communicated with and engaged in
decision-making
Less is more
Sweat the details
Think about what you can do to “activate” your patient
Keep your eye on the big picture as it evolves
Often, the ICU is for buying time to let everything
sort itself out (with your active help)