Expectations and outcomes of prolonged mechanical ventilation*

Abstract

Objective: Prolonged mechanical ventilation (PMV) provision is increasing markedly despite poor patient outcomes. Misunderstanding prognosis in the PMV decision making process could provide an explanation to this phenomenon. Therefore, we aimed to compare PMV decision makers' expectations for long-term patient outcomes with prospectively observed outcomes. Design, Setting, and Patients: 126 patients undergoing PMV, their surrogates, and their intensive care unit physicians were enrolled consecutively (total n=378) at an academic medical center between April 2006 and April 2007 and followed prospectively for one year. Measurements: Participants were interviewed at the time of tracheostomy placement about their expectations for one-year patient survival, functional status, and quality of life. These expectations were then compared to observed one-year outcomes measured with validated questionnaires. Results: One-year follow up was 100%, with the exception of patient death or cognitive inability to complete interviews. At one year, only 11 (9%) patients were alive and independent of major functional status limitations. Most surrogates reported high baseline expectations for one-year patient survival (117 [93%]), functional status (90 [71%]), and quality of life (105 [83%]). In contrast, fewer physicians described high expectations for survival (54 [43%]), functional status (7 [6%]), and quality of life (5 [4%]). Surrogate-physician pair concordance in expectations was poor (all κ<0.08), as was their accuracy in outcome prediction (range 23-44%). Just 33 (26%) surrogates reported that physicians discussed what to expect for patients' likely future survival, general health, and caregiving needs. Conclusions: One-year patient outcomes for PMV patients were significantly worse than expected by patients' surrogates and physicians. Lack of prognostication about outcomes, discordance between surrogates and physicians about potential outcomes, and surrogates' unreasonably optimistic expectations appear to be potentially modifiable deficiencies in surrogate-physician interactions.

Chronic Critical Illness. Is This a New Term or an Old Problem?

“…Потребность в трахеостомии для нужд продленной респираторной поддержки, как и трахеостомия через 96 ч с момента начала искусственной вентиляции легких, также указываются среди критериев ХКС [13].…”

“…Существуют интересные комбинированные критерии (например, хотя бы 4 дня респираторной поддержки в сочетании с трахеостомией и пребыванием в реанимационном отделении 21 и более дней) [7,12,13]. Обсуждается возможная диагностическая и прогностическая значимость маркеров системного воспаления [12,30].…”

“…Считается, что если восстановить приемлемую для самообслуживания социальную адаптацию удается единицам, то физическое состояние у подавляющего большинства пациентов существенно нарушено [9,10,13,21]. Список литературы…”

Prolonged Mechanical Ventilation: Are You a Lumper or a Splitter?

“…Furthermore, surrogate decision makers for PMV patients reported that few physicians discussed what to expect about the patient's future survival, general health, and care-giving needs. 24 Involvement of palliative care should be incorporated into the comprehensive care of PMV patients, in an effort to align expectations and improve communication between physicians and patients and their surrogates. 5,22 Additional longitudinal studies will provide physicians with muchneeded data to help guide the care of PMV patients throughout the healthcare continuum.…”

Communicating with Patients' Families and Physicians About Prognosis and Goals of Care

“…2 Yet, a patient's family members are not well informed about the patient's prognosis, and goals of care are often not discussed. 2,3 These findings have raised concerns that many patients receive invasive treatments that are not in accord with the patients' wishes. Furthermore, patients' families experience psychological distress during and after patients' ICU stay.…”