Biomedical subjects

Judith E Nelson

Publications and source records attributed to Judith E Nelson.

8 recordsLinked to original sources

PubMed2006

Brain dysfunction: another burden for the chronically critically ill.

BACKGROUND: Chronic critical illness is a devastating syndrome of prolonged respiratory failure and other derangements. To our knowledge, no previous research has addressed brain dysfunction in the chronically critically ill, although this topic is important for medical decision making. METHODS: We studied a prospective cohort of 203 consecutive, chronically critically ill adults transferred to our hospital's respiratory care unit (RCU) after tracheotomy for failure to wean. We measured prevalence and duration of coma and delirium during RCU treatment using the Confusion Assessment Method for the Intensive Care Unit with the Richmond Agitation-Sedation Scale. To assess survivors (at 3 and 6 months after RCU discharge), we used a validated telephone Confusion Assessment Method. RESULTS: Before hospitalization, most (153 [75.4%]) of the 203 patients in the study were at home, completely independent (115 [56.7%]), and cognitively intact (116 [82.0%]). In the RCU, 61 (30.0%) were comatose throughout the stay. Approximately half of patients (66 of 142) who were not in coma were delirious. Patients spent an average of 17.9 days (range, 1-153 days) in coma or delirium (average RCU stay, 25.6 days). Half of survivors (79 of 160) had one of these disturbances at RCU discharge. At 6 months, three fourths (151) of the study patients were dead or institutionalized; of 85 survivors, 58 (68.2%) were too profoundly impaired to respond to telephone cognitive assessment, and 53 (62.4%) were dependent in all activities of daily living. CONCLUSIONS: Severe, prolonged, and permanent brain dysfunction is a prominent feature of chronic critical illness. These data, together with previous reports of symptom distress and rates of mortality and institutionalization, describe burdens for chronically critically ill patients receiving continued life-prolonging treatment and for their families.

Adult↗

PubMed2006

Identifying and overcoming the barriers to high-quality palliative care in the intensive care unit.

Initiatives to improve end-of-life care in intensive care units face several important barriers. These include inflated expectations for critical care therapies, which are shared by many clinicians and many patients and families; preoccupation with an unattainable level of prognostic certainty, delaying attention to palliative needs; and fragmentation of the healthcare team into separate "silos" of disciplines and specialties. The article reviews these barriers and relevant empirical evidence. Specific strategies to improve intensive care unit palliative care, including consultation by palliative care specialists, and palliative care quality measurement are discussed.

Decision Making↗

PubMed2006

End-of-life care for the critically ill: A national intensive care unit survey.

OBJECTIVE: One in five Americans dies following treatment in an intensive care unit (ICU), and evidence indicates the need to improve end-of-life care for ICU patients. We conducted this study to elicit the views and experiences of ICU directors regarding barriers to optimal end-of-life care and to identify the type, availability, and perceived benefit of specific strategies that may improve this care. DESIGN: Self-administered mail survey. SETTING: Six hundred intensive care units. PARTICIPANTS: A random, nationally representative sample of nursing and physician directors of 600 adult ICUs in the United States. INTERVENTIONS: Mail survey. MEASUREMENTS AND MAIN RESULTS: We asked participants about barriers to end-of-life care (1 = huge to 5 = not at all a barrier), perceived benefit of strategies to improve end-of-life care, and availability of these strategies. From 468 ICUs (78.0% of sample), 590 ICU directors participated (406 nurses [65.1% response] and 184 physicians [31.7% response]). Respondents had a mean of 16.6 yrs (sd 7.6 yrs) of ICU experience. Important barriers to better end-of-life care included patient/family factors, including unrealistic patient/family expectations 2.5 (1.0), inability of patients to participate in discussions 2.7 (0.9), and lack of advance directives 2.9 (1.0); clinician factors, which included insufficient physician training in communication 2.9 (1.1) and competing demands on physicians' time 3.0 (1.1); and institution/ICU factors, such as suboptimal space for family meetings 3.5 (1.2) and lack of a palliative care service 3.4 (1.2). More than 80% of respondents rated 14 of 14 strategies as likely to improve end-of-life care, including trainee role modeling by experienced clinicians, clinician training in communication and symptom management, regular meetings of senior clinicians with families, bereavement programs, and end-of-life care quality monitoring. However, few of these strategies were widely available. CONCLUSIONS: Intensive care unit directors perceive important barriers to optimal end-of-life care but also universally endorse many practical strategies for quality improvement.

Attitude of Health Personnel↗

PubMed2005

When critical illness becomes chronic: informational needs of patients and families.

PURPOSE: A large and growing group of intensive care unit survivors are "chronically critically ill," with ongoing respiratory failure and poor outcomes for postdischarge survival and functional recovery. In this qualitative study, we investigated what information is relevant and important for clinician-patient/family communication when critical illness becomes chronic, as indicated by tracheotomy for prolonged mechanical ventilation. METHODS: We conducted focus groups and structured interviews of patients who survived chronic critical illness, of surrogates of such patients and of nonsurvivors, and of clinicians with relevant experience. Discussions were audiotaped, transcribed, and analyzed using grounded theory. RESULTS: Twenty-five subjects participated (4 survivors, 7 survivors' surrogates, 4 nonsurvivors' surrogates, 10 clinicians). We found broad agreement on 6 major domains of information that are relevant and important: (1) nature of illness/treatments, (2) prognosis, (3) impact of treatment, (4) potential complications, (5) expected care needs after hospitalization, and (6) alternatives to continuation of treatment. Participants endorsed the multidisciplinary family meeting as an effective communication strategy. CONCLUSIONS: Given poor outcomes for most patients and high costs and burdens of treatment, effective communication is essential when critical illness enters a chronic phase. Our findings provide a framework for such communication and a basis for further research.

Adult↗

PubMed2004

The symptom burden of chronic critical illness.

OBJECTIVE: To assess self-reported symptom burden of chronic critical illness. DESIGN: Prospective cohort study. SETTING: Respiratory care unit for treatment of chronically critically ill patients at an academic, tertiary-care, urban medical center. PATIENTS: Fifty patients who underwent elective tracheotomy and transfer from an adult intensive care unit to the respiratory care unit for weaning from mechanical ventilation. INTERVENTIONS: Assessment of physical and psychological symptoms through patients' self-reports using a modification of the Condensed Form of the Memorial Symptom Assessment Scale. MEASUREMENTS AND MAIN RESULTS: We measured self-reported symptom burden, ventilator outcomes, and vital status and functional status at discharge and 3 and 6 months after discharge. Half of the patients were successfully liberated from mechanical ventilation, but most hospital survivors were discharged to skilled nursing facilities and more than half of the cohort was dead at 3 months after discharge. Seventy-two percent (36 of 50) of patients were able to self-report symptoms during the period of respiratory care unit treatment. Among patients responding to symptom assessment, approximately 90% were symptomatic. Forty-four percent of patients reported pain at the highest levels. More than 60% reported psychological symptoms at these levels, and approximately 90% of patients reported severe distress due to difficulty communicating. CONCLUSIONS: Physical and psychological symptom distress is common and severe among patients receiving treatment for chronic critical illness. The majority of these patients die soon after hospital discharge. Given the level of distress in our study patients and the high mortality rate that we and others have observed, greater attention should be given to relief of pain and other distressing symptoms and to assessment of burdens and benefits of treatment for the chronically critically ill.

APACHE↗

PubMed2003

End-of-life care in patients with lung cancer.

Evidence-based practice guidelines for end-of-life care for patients with lung cancer have been previously available only from the British health-care system. Currently in this setting, there has been increasing concern in attaining control of the physical, psychological, social, and spiritual distress of the patient and family. This American College of Chest Physicians'-sponsored multidisciplinary panel has generated recommendations for improving quality of life after examining the English-language literature for answers to some of the most important questions in end-of-life care. Communication between the doctor, patient, and family is central to the active total care of patients with disease that is not responsive to curative treatment. The advance care directive, which has been slowly evolving and is presently limited in application and often circumstantially ineffective, better protects patient autonomy. The problem-solving capability of the hospital ethics committee has been poorly utilized, often due to a lack of understanding of its composition and function. Cost considerations and a sense of futility have confused caregivers as to the potentially important role of the critical care specialist in this scenario. Symptomatic and supportive care provided in a timely and consistent fashion in the hospice environment, which treats the patient and family at home, has been increasingly used, and at this time is the best model for end-of-life care in the United States.

Advance Directives↗

PubMed2002

Palliative care of the chronically critically ill patient.

Evidence is accumulating that distressing physical and emotional symptoms are prevalent among patients with critical illness, including those requiring prolonged mechanical ventilation, and that suffering is underestimated and undertreated by caregivers. Although patients and their families rank communication as a preeminent concern, it remains deficient in process and content, even when the illness requires weeks of critical care. Strategies are available to improve symptom management and communication about appropriate goals of care. For the CCI, whose risks of death, disability, and suffering are so high, it is essential that excellent palliative care be provided along with restorative treatment in an integrated way.

Analgesics, Opioid↗

PubMed2002

Pressure ulcers in the chronically critically ill patient.

All chronically critically ill patients are at high risk for development and progression of pressure ulcers. Constant surveillance including daily examination of the skin must be part of the care protocol. All pressure ulcers are chronic wounds that have an inherent, physiologic impairment to healing. As soon as a pressure ulcer develops, intervention should begin immediately, and a treatment plan should be determined. We believe that early intervention and appropriate treatment, guided by the paradigm we have described, can retard progression and promote healing [49]. Treatment decisions should be made within the context of the patient's overall care goals.

Chronic Disease↗