Management of the patient with do not resuscitate status: compassion and cost containment

An interdisciplinary approach to the management of patients with do not resuscitate status on a supportive care team is an alternative to traditional intensive care unit management. This approach focuses on the physical, psychological, and spiritual needs of the patient and family. We describe our experience with 131 patients managed by the supportive care team that resulted in humane care of dying patients and reduced hospital costs as evidenced by reduced Therapeutic Intervention Scoring System values. Although our goal is comprehensive terminal care, financial savings have resulted as well. We describe the elements of care that contribute to compassionate management and to reduced interventions and costs. This approach may have application in other critical care settings that are faced with the same challenges of providing humane care to hopelessly ill patients.     

Intensive care of the patient with cirrhosis

Acute deterioration of patients with cirrhosis manifests as multiple organ failure requiring admission to an intensive care unit. Precipitating events may be viral hepatitis, typically in Asia, and drug or alcoholic hepatitis and variceal hemorrhage in the West. Patients with cirrhosis in the intensive care unit have a high mortality, and each admission is associated with a mean charge of US $116,200. Prognosis is determined by the number of organs failing (sequential organ failure assessment [SOFA] score), the presence of infection, and the degree of liver dysfunction (Child-Turcotte-Pugh or Model for End-Stage Liver Disease scores). The most common organ failing is the kidney; sepsis is associated with further deterioration in liver function by compromise of the microcirculation. Care of these critically ill patients with impending multiple organ failure requires a team approach with expertise in both hepatology and critical care. Treatment is aimed at preventing further deterioration in liver function, reversing precipitating factors, and supporting failing organs. Liver transplantation is required in selected patients to improve survival and quality of life. Treatment is futile in some patients, but it is difficult to identify these patients a priori. Artificial and bioartificial liver support systems have thus far not demonstrated significant survival benefit in these patients.     

高度依赖病房及其在重症肝病患者临床管理中的应用

[摘要]高度依赖病房（high dependency unit, HDU）可为单器官衰竭（呼吸衰竭除外）患者提供介于普通病房与重症监护病房之间的中等水平的护理。重症肝病（severe liver disease, SLD）患者肝功能严重障碍，多表现出急性或慢性单器官衰竭。HDU可满足SLD患者的监护需求，但目前国内仅有少数医院开设HDU。本文通过介绍HDU的概念、类型、作用以及SLD HDU建设与应用的研究进展，表明HDU在SLD患者临床管理中的应用将有助于医疗团队为患者实施更安全高效的救治，同时为推广建设HDU提供了理论及实践依据。     

The critically ill liver patient: fulminant hepatic failure

Fulminant hepatic failure is a challenging medical condition that requires intensive care management to prevent-major complications (cerebral edema, infections, and multi-system organ failure) and assistance from a liver transplant team when it is believed that liver regeneration is unlikely. Unfortunately, there are no specific medical therapies or devices to correct all of the functions of a liver. N-acetylcysteine is used for the treatment of acetaminophen overdose, but for most other causes of fulminant hepatic failure therapy is supportive care. This case illustrates many of the problems that are encountered during medical management of fulminant hepatic failure.     

Hematologic failure

Hematologic factors, in particular platelets and the coagulation system, play an important role in the pathogenesis of organ failure in the intensive care unit. Failure of these hematologic systems is common in intensive care patients and may range from isolated thrombocytopenia or prolonged global clotting tests to complex defects, such as disseminated intravascular coagulation. There are many causes for a deranged coagulation in critically ill patients, and each of these underlying disorders may require specific therapeutic management. Hence, a proper differential diagnosis and initiation of adequate (supportive) treatment strategies are crucial to reduce morbidity and mortality in critically ill patients with coagulation abnormalities.     

Acute lung injury and the acute respiratory distress syndrome: a clinical review

Acute respiratory distress syndrome and acute lung injury are well defined and readily recognised clinical disorders caused by many clinical insults to the lung or because of predispositions to lung injury. That this process is common in intensive care is well established. The mainstay of treatment for this disorder is provision of excellent supportive care since these patients are critically ill and frequently have coexisting conditions including sepsis and multiple organ failure. Refinements in ventilator and fluid management supported by data from prospective randomised trials have increased the methods available to effectively manage this disorder.     

Medical care inconsistent with patients' treatment goals: association with 1-year Medicare resource use and survival

OBJECTIVES: To describe how frequently seriously ill persons perceive that the care they receive is inconsistent with treatment preferences and the effect on 1-year resource utilization. SETTING: Five U.S. teaching hospitals. DESIGN: Secondary analysis of interview data. PARTICIPANTS: Seriously ill Medicare beneficiaries. MEASUREMENTS: Interviews about patients' preferred approaches to care and whether they perceived care was consistent with these preferences. Part A and B costs for up to 1 year, adjusted for cost differences across hospitals and over time and for 1-year survival. RESULTS: Forty percent of the 1,185 study patients expressed a preference for treatment to focus on extending life, whereas 60% expressed a preference for comfort care. Eighty-six percent of the patients who wanted aggressive treatment reported that care was consistent with their preferences, but only 41% of those who preferred comfort care reported that care was consistent with their preferences. More than one-third of those with a preference for comfort care (35%) reported that the medical care that they received was inconsistent with their goals; 24% were unsure of treatment goals. Those who preferred comfort care but believed that their care was inconsistent with their wishes had higher estimated mean 1-year costs than those who believed that their care was consistent with their wishes (92,442 US dollars vs 52,098 US dollars, P < .001). Even after adjusting for differences in disease severity, age, gender, race, functional status, income, and years of education, adjusted costs were 1.4 times (95% confidence interval = 1.2-1.6) higher. However, 1-year survival was lower in these patients who stated that care was consistent with their preference to focus on comfort care than for those who wished to receive comfort care and stated that care was not consistent with their preference (38% vs 55% 1-year survival, P < .001). CONCLUSION: More than one in three seriously ill persons who prefer comfort care believe that their medical care is at odds with their preference that treatment focus on palliation. Such discord was associated with higher 1-year healthcare costs and increased survival.     

Reflections of medical students on visiting chronically ill older patients in the home

The expanding number of Americans living with chronic illness necessitates educating future physicians about chronic illness care. Weill Cornell Medical College's Chronic Illness Care in the Home Setting Program (CIC-HSP), a mandatory part of the primary care clerkship, exposes medical students to persons with chronic illness via a half day of house calls with a geriatrics team. The investigators sought to qualitatively assess the effect of the CIC-HSP on medical students and recent medical graduates. Fifty-two prospective participants were approached, and 50 (96%) with varying training levels and time since completing the program were interviewed. Most respondents (63%) found that the home visits taught them important approaches to caring for the chronically ill, such as individualizing care to meet patients' individual needs and improving quality of life as a goal of care. Students remarked that the experience enhanced their empathy (18%) and sensitivity (20%) toward chronically ill patients and increased their appreciation for chronic illness care (35%). Many participants reported that patients were more empowered in the home (55%) and perceived greater rapport and warmth between the doctor and patient (57%) in the home (vs office) setting. The vast majority of recent medical graduates (84%) related that this educational exposure continued to positively influence their approach to patient care. A home visit experience with a geriatrics team can help foster medical students' understanding of the psychosocial and medical aspects of chronic illness, teach relevant approaches to patient care, and improve students' attitudes toward caring for the chronically ill.     

肝衰竭的重症监护治疗

肝衰竭由于肝脏严重损伤，多系统脏器功能发生障碍，严重危及患者生命，病死率极高。重症监护手段在肝衰竭患者中的应用能够提高患者生存率，并为患者赢得肝移植的宝贵时间。由于肝衰竭的特殊性，如血液动力学、凝血机制以及肝脏代谢等异常，使得肝衰竭的重症监护治疗与其他重症患者的监护治疗不同，必须具有其独特性。本文就肝衰竭的重症监护治疗作一简要介绍。     

Changing concepts in the surgical management of acute pancreatitis.

Most episodes of acute pancreatitis are mild and self-limiting, but severe disease complicated by multiple system organ failure develops in up to 20% of cases. Early detection of those patients who subsequently develop necrotizing pancreatitis allows the start of supportive treatment in the intensive care unit before organ failure occurs. Conservative treatment in the intensive care unit, including the administration of intravenous antibiotics, is the gold standard. Surgery is indicated in patients with infected pancreatic necrosis but not in patients with sterile necrosis in the absence of deteriorating multi-organ failure despite maximal intensive care unit treatment, or other specific surgical complications. At our institution, out of 44 patients with necrotizing pancreatitis 29 (66%) had sterile necrosis and were managed conservatively while 15 (34%) had infected pancreatic necrosis and were treated by necrosectomy and continuous closed retroperitoneal lavage. There were two deaths resulting in an overall mortality of 5% in patients with severe acute pancreatitis.     

The Developmental and Family Services Unit--a model AIDS project serving developmentally disabled children and their families

This paper describes a model program that uses a multidisciplinary team to assess the developmental and psychosocial needs of HIV-infected children and their families. The objective of the program is to assess the needs of the children, in order to provide rehabilitative and psychosocial services; and to improve the quality of life by optimizing developmental functioning. The team includes developmental pediatricians, social workers, psychologists, a medical ethicist, physiatrist, psycho-educational specialist, and occupational, physical, and language therapists, each of whom perform complete evaluations. A weekly conference results in the formation of an individual Family Service Plan for each child and family. Forty children have been evaluated and are in program. Family compositions were varied and non-traditional. The disabilities and rehabilitative needs differed as well. The most frequently required services were occupational therapy and psychosocial intervention, to increase parental coping skills in handling disabled, chronically ill children. Children with HIV infection are living longer and will have serious deficits. The need to develop services to address the unique developmental and psychosocial needs of the children and families iS paramount.     

Palliative care and hematologic oncology: The promise of collaboration

Palliative medicine provides active evaluation and treatment of the physical, psychosocial and spiritual needs of patients and families with serious illnesses, regardless of curability or stage of illness. The hematologic malignancies comprise diverse clinical presentations, evolutions, treatment strategies and clinical and quality of life outcomes with dual potential for rapid clinical decline and ultimate improvement. While recent medical advances have led to cure, remission or long-term disease control for patients with hematologic malignancy, many still portend poor prognoses and all are associated with significant symptom and quality of life burden for patients and families. The gravity of a diagnosis of a hematologic malignancy also weighs heavily on the medical team, who typically develop close and long-term relationships with their patients. Palliative care teams provide an additional layer of support to patients, family caregivers, and the primary medical team through close attention to symptoms and emotional, practical, and spiritual needs. Barriers to routine palliative care co-management in hematologic malignancies include persistent health professional confusion about the role of palliative care and its distinction from hospice; inadequate availability of palliative care provider capacity; and widespread lack of physician training in communicating about achievable goals of care with patients, family caregivers, and colleagues. We herein review the evidence of need for palliative care services in hematologic malignancy patients in the context of a growing body of evidence demonstrating the beneficial outcomes of such care when provided simultaneously with curative or life-prolonging treatment.     

A rational approach to ligation of patent ductus arteriosus in the neonate.

During a 23-month period, 25 premature infants underwent ligation of a patent ductus arteriosus performed in the neonatal intensive care unit utilizing a limited posterolateral muscle-retracting incision. This approach afforded adequate exposure with minimal surgical time and trauma. All infants manifested severe respiratory distress and congestive heart failure. Both standard and contrast echocardiographic studies were used for noninvasive preoperative evaluation. Echocardiographic study proved to be a highly reliable and sensitive indicator of ductal patency. Eight infants (32 percent) died at 8 to 225 days of age. The primary cause of death was progressive pulmonary disease with subsequent failure of multiple organ systems. Seventeen (68 percent) of the 25 infants survived to leave the hospital. Advantages of ligation of a patent ductus arteriosus in the neonatal intensive care unit include the elimination of problems of transportation (thermoregulation, ventilation, and loss of lines) and continuity of ongoing care and monitoring. The standard facilities of the neonatal intensive care unit proved completely satisfactory for ligation of a patent ductus arteriosus. Ligation in the neonatal intensive care unit is suggested to minimize potential complications of care in the operating room and transport of these critically ill infants.     

Mechanical ventilation in cancer patients. Analysis of clinical data and outcome

Between 1984 and 1988, 49 medically treated cancer patients were ventilated in the intensive care unit (ICU) of our hospitals. The charts of these patients were analyzed retrospectively. Sixty-seven percent of patients died during ventilation; 24% were able to leave hospital. The remaining 9% were transferred from the ICU to the ward, but died shortly thereafter in hospital. Assessment of the severity of acute disease prior to intubation by means of the organ failure score or the APACHE-II score was strongly associated with outcome after ventilation.     

Maintaining connections: some thoughts on the value of intensive care unit rounding for general medicine ward teams

When established ward patients are unexpectedly transferred to an intensive care unit (ICU), the ward team should continue to follow them. Although there may be reasons not to do so, the advantages outweigh the obstacles. Great pedagogic value can be gained from following patients after acute decompensation, but a more important reason is that by following patients into the ICU, the ward team can enact for both patients and their families the twin virtues of caring and continuity. Doing so also demonstrates the highest ideals of medicine-that we are focused not on defined areas of turf, but on our patient's well-being. It shows that we are not merely doing narrowly defined "shift work," but that we truly care about our patients. Rounding on established patients who have been transferred into the ICU is the sort of behavior that undergirds the fundamental bases of professionalism. It takes a few minutes from a busy day, but it can be incredibly beneficial for families, patients, and the ideals of medicine.     

Subintensive care unit for the elderly: a new model of care for critically ill frail elderly medical patients

OBJECTIVE: An increasing number of elderly patients are admitted to the hospital for critical diseases and the gap between supply and demand of intensive care resources is a growing problem. To meet this challenge, 4 beds in a 24-bed acute care for the elderly (ACE) medical unit were dedicated to a subintensive care unit (SICU). Severely ill elderly medical patients, requiring a higher level of care than provided in ordinary wards, are admitted. The aim of the study was to describe the characteristics of the setting and to discuss its usefulness based on data obtained after the first period of implementation. METHODS: This article describes the development, management, economics and patient characteristics of the SICU. Patient care combines the ACE model with a highly specialised medical care. Patients admitted to the SICU are compared with patients treated in the ordinary ACE unit before the SICU opened. All patients received a multidimensional evaluation, including demographics, main diagnosis, number of chronic somatic diseases, Charlson index, APACHE II score, APACHE-APS subscore, number of currently administered drugs, serum albumin, cognitive status (Mini-Mental State Examination), depression (Geriatric Depression Scale) and functional status (basic and instrumental activities of daily living). Ward physicians performed assessment and collection of data. RESULTS: During the first 16 months, 489 patients were admitted, 401 according to the selection criteria (60 +/- years and APACHE II score > or =5 and/or APACHE-APS score > or =3). Mean age was 78.1 years, mean APACHE II score 14.5 (moderate severity) and non-invasive mechanical ventilation was received by 87 (21.7%). The most common diagnoses were respiratory failure, cardiac disease and stroke. Mean length of stay in the SICU was 61.8 h, and 6.0 days in the hospital. Compared with ACE-unit patients admitted during 2002 (n=1380), SICU patients were obviously more seriously ill (APACHE II score 14.5 vs 6.7). When comparing patients of same illness severity (APACHE-APS score > or =3) (n=125), patients treated in the SICU had lower in-hospital mortality than those treated in the ordinary ACE ward (12.5 vs 19.2%). Only a few patients (3.5%) were transferred to the intensive care unit as a consequence of increased severity of illness. CONCLUSIONS: The SICU is an innovative method to treat frail elderly patients with more severe conditions. Low hospital mortality compared with that of severe patients in the ACE unit supports the usefulness of this model. It could be implemented in medical units of large hospitals in order to give optimal care and advanced interventions to the frail elderly and to avoid intensive care unit overcrowding.     

The effect of care of terminally ill patients' families on care of families attending patients' deathbeds in a general ward

AIM: Care of families attending patients' deathbeds is important, leading to care of the bereaved. However, we have no knowledge of a causal relationship between factors of care of terminally ill patients' families and care of families attending patients' deathbeds. The aim of this survey was to find out which factors of care nurses provide to terminally ill patients' families affect care of families attending patients' deathbeds in a general ward where many terminally ill elderly patients spend their time. METHODS: Questionnaire survey of 978 general ward chief nurses working for hospitals with over 100 beds in the Kyushu district. Data were processed through factor analysis and covariance structured analysis. RESULTS: 236 valid responses were analyzed. Four factors regarding chief nurses providing for families of terminally ill patients were identified. These factors were interpreted as first, mediating communication between families and patients; second, providing information; third, promoting cooperation and understanding among families; and fourth alleviating restrictions. The first factor correlates with the third factor. Especially, the first factor strongly affects the provision of care to families attending patients' deathbeds. The relationships of the second and fourth factors with care of families attending patients' deathbeds were not proved. CONCLUSION: Care of terminally ill patients' families in a general ward consists of four factors: mediating communication between families and patients, providing information, promoting cooperation and understanding among families, and alleviating restrictions. It was revealed that the more nurses promote cooperation and understanding among families, the more they can mediate communication between families and patients and provide care to families attending patients' deathbeds. It suggests that nurses are able to have a positive effect on the grief process of the bereaved by intervening between patients and families.