We appreciate the attention given by Andy Haines and Philip J Landrigan to the findings of The Lancet's Taskforce on NCDs and economics and our Series paper. 1 Haines and Landrigan emphasise our main findings that many premature NCD deaths will occur in lowincome and middle income countries by 2030, and that investments to manage NCDs cannot only reduce those premature deaths, but also provide economic gains and help achieve SustainableThe Lancet Taskforce on NCDs and economics could substantially enhance its influence and further increase the return on investment in NCD prevention if it were to expand its scope to include a new focus on prevention of pollution. The greatest beneficiaries will be people in the world's most rapidly developing and severely affected countries.We declare no competing interests.
IntroductionFrailty is associated with reduced functional capacity, decreased resistance to stressors and is predictive of a range of adverse health outcomes, including dependency, hospitalisation and mortality. Early identification of frailty may prevent, reduce and postpone adverse health outcomes. However, there is a need for additional evidence to guide decision-making for the care of frail patients since frail persons are frequently excluded from studies, the differential impact of frailty is often not examined in clinical trials and few large-scale clinical trials examining frail cohorts have been conducted. Randomised control trials (RCTs) published to date have used a diverse range of definitions of frailty, as well as a variety of outcome measures. The objective of this systematic review is to comprehensively characterise the frail populations enrolled and the end points reported in frailty RCTs.Methods and analysisWe will identify all RCTs reporting on the outcome of interventions in adult (age ≥18 years) frail populations as defined by authors, in all settings of care. Databases will include MEDLINE, CINAHL, EMBASE, PsycInfo, Global Health, the Joanna Briggs database and Cochrane Library. Two reviewers will independently determine trial eligibility. For each included trial, we will conduct duplicate independent data extraction, inter-rater reliability, risk of bias assessment and evaluation of the quality of the evidence using the Grading of Recommendations, Assessment, Development and Evaluations approach.Ethics and disseminationThis systematic review will comprehensively identify RCTs including frail patients to identify how frailty is measured and which outcomes are reported. The results of this systematic review may inform clinicians caring for persons with frailty, facilitate conduct of future RCTs and inform future efforts to develop common data elements and core outcomes for frailty studies. Our findings will be disseminated through conference presentation and publication in peer-reviewed journals.PROSPERO registration numberCRD42017065233.
Family members wish to be present for ICU procedures, and there are no adverse psychological effects.
To the Editor,Family meetings are an integral component of patient care in the intensive care unit (ICU). These are formal meetings held between the patient's family or caregiver(s) and the inter-professional team. Often, critically ill patients cannot communicate directly with physicians; therefore, families depend on meetings to obtain information and advocate on behalf of patients to help guide care. 1 The quality of communication between the ICU team and family can vary, with a survey of ICU directors citing family-related issues, such as patient inability to participate in discussions and suboptimal physician-family communication in end-of-life issues, as the largest barrier to improving ICU care. 2 Family members value strong communication skills as much as physicians' clinical skills. [3][4][5] Communication between the ICU team and families is a priority in improving overall ICU care. Most research surrounding family meetings has involved audiotaped physician-family interactions, staff surveys, or development of mnemonics to aid clinicians facilitating a family meeting. Although family meetings have been linked to increased family satisfaction, literature is inconclusive on what elements make a family meeting effective from the perspective of families. We conducted a single-centre survey of 100 family meetings in the ICU to understand the perceptions of patient's families and caregivers with respect to the ICU family meeting and identify aspects of family meetings that correspond with family member satisfaction. This study was approved by the Mount Sinai Hospital Research Ethics Board on 20 August 2015. We identified five main domains of interest pertaining to the ICU family meeting: 1) trust, 2) comfort, 3) understanding, 4) decision-making, and 5) satisfaction. Questions focused on communication between the physicians and family members, understanding of terminology used during meetings, the sense of trust between physician and family members, and comfort provided in the meetings as perceived by respondents. The questionnaire also explored models of decisionmaking, type and timing of meetings, and included space for respondents to provide textual comments on their overall satisfaction and impressions of the family meeting.Overall, 154 family members or caregivers participated in 100 family meetings in the ICU between September 2013 and June 2014. Of those surveyed, 94.6% were satisfied with the family meetings. Comfort and acknowledgement of caregivers' experience improved communication as well as trust in the medical team. Families tend to prefer shared decision-making models and, if given a choice, prefer meetings that take place early within an ICU admission (between 24 and 48 hr).
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