Intensive communication: Fouryear followup from a clinical practice study

1
Intensive communication Four-year follow-up
from a clinical practice study
Journal Reading

• 
  Ri ???

Lilly Crit Care Med, Volume 31(5) Supplement.May
2003.S394-S399
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Preface

• Fear, air hunger, pain, anxiety of dying
• Hospice care, intensive care ?
• End of life care, option ?
• Ineffective life support moving to a
  comfort-focused care plan

Lilly Crit Care Med, Volume 31(5) Supplement.May
2003.S394-S399
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Introduction

• Purpose moving dying patients from ineffective
  lift support to comfort-focused care plan
• When to decide? Where the decision made? What
  memberships? Why do it? How to do?
• Intensive communication- the bridge between ICU
  support to comfort care

Lilly Crit Care Med, Volume 31(5) Supplement.May
2003.S394-S399
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Intensive communication

• The uniform application of a process of
  communication moving dying patients to
  comfort-focused care
• Noncoercive, patient and family-centered,
  multidisciplinary process
• Primary outcome variables --- length of ICU stay
  and mortality
• Secondary outcome varibles --- agreement among
  providers, team, patient, family

Lilly Crit Care Med, Volume 31(5) Supplement.May
2003.S394-S399
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Methods (1)

• 2891 adult patients admitted to ICU during 4-yr
  period from Oct. 31, 1998, to Sept. 30, 2002
• 10-bed medical ICU
• 1 attending physician, 23 residents, 3 interns,
  and 45 nurses (in shifts).
• Admission decision physician not part of ICU
  team
• Discharge decision critical care physician

Lilly Crit Care Med, Volume 31(5) Supplement.May
2003.S394-S399
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Methods (2)

• Initial meeting within 72 hrs of ICU admission
• Criteria
• 1. Predicted ICU stay gt 5 days
• 2. Predicted mortality of gt 25
• 3. Function status potentially irreversible and
  sufficient to preclude eventual return to home

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Methods (3)

• Memberships attending intensivists, nurse, house
  officer, family, patient ( if possible)
• Other members outside expert, social workers,
  psychiatrist, even security expert
• Initial introductions, open-ended questions and
  patient current status and cure
• Red flags ---- Final interventions

Lilly Crit Care Med, Volume 31(5) Supplement.May
2003.S394-S399
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Methods (4)

• Discussion objects
• 1. Review the medical facts and options for
  treatment
• 2. Patient s perspectives, acceptability of
  risks, and discomfort of critical care
• 3. Agree on a care plan
• 4. Agree on criteria by which the success or
  failure of this care plan would be judged

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Methods (5)

• The comparison of the three group periods
• Pre-intervention period
  134 consecutive pt, consecutive 12-month
  periods from Oct.1, 1996 to Oct. 31, 1998
• Intensive communication period
  396 consecutive pt, consecutive 12-month periods
  from Oct.1, 1996 to Oct. 31, 1998
• 4-yr follow up period
  2361 consecutive pt, from Oct. 31, 1998
  to Oct. 30, 2002

Lilly Crit Care Med, Volume 31(5) Supplement.May
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Results (1)
Lilly Crit Care Med, Volume 31(5) Supplement.May
2003.S394-S399
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Results (2)

• Pre 41 sessions / 134 pt ( 0.3 / pt)
• During 594 sessions / 396 pt ( 1.5 / pt)
• 4 yrs F/U 3679 sessions / 2361 pt ( 1.6 / pt)

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Results (3)

• Median length of stay in the ICU
• 1. Pre 4 days (2-11 days)
• 2. During 3 days (2-6 days)
• 3. 4-yr F/U 3 days (2-6 days)
• Median length of stay was reduced from
  pre-intervention period to during period. But
  during and 4-yr F/U period seems the same

Lilly Crit Care Med, Volume 31(5) Supplement.May
2003.S394-S399
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Results (4)
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2003.S394-S399
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Results (5)

• Effects on mortality
• 1. Pre 31.3 (chi-square p lt .001)
• 2. During 22.7
• 3. 4-yr F/U 18.0
• ICU mortality significantly decreased because of
  the perform of intensive communication

Lilly Crit Care Med, Volume 31(5) Supplement.May
2003.S394-S399
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Results (6)
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Discussion (1)

• Intensive communication
• Three groups of adult critical ill patients with
  different needs for support a group with
  functional recovery, or significant disability,
  or dying
• Prevent significant disability
• Prevent premature inappropriate palliative care
  plan
• Encourage the transition to a comfort-only care
  plan for dying patients

Lilly Crit Care Med, Volume 31(5) Supplement.May
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Discussion (2)

• Intensive communication
• A patient-family meeting note template
• Clinical milestones (care plans and criteria by
  which their success was to be judged)
• The patients value of what we determine
• The surviving ones (patient or family) were
  almost satisfied with the process of the
  intensive communication

Lilly Crit Care Med, Volume 31(5) Supplement.May
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Discussion (3)

• Intensive communication
• The relationships between the intensive care
  providers and non-direct caregivers --- by
  session summary notes to understand how to do and
  why the decision maded
• Continue advanced supportive technology or elect
  a comfort-only focused care as a process rather
  than as an event

Lilly Crit Care Med, Volume 31(5) Supplement.May
2003.S394-S399
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Discussion (4)

• Intensive communication and ICU stay
• Time frame within 72 hrs ICU admission
• The senior physician and direct patient care
  nurse time are critical components of intensive
  communication, non-direct care givers not
  absolutely required

Lilly Crit Care Med, Volume 31(5) Supplement.May
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Discussion (5)

• Intensive communication and mortality
• Approximately 1/3 of the mortality benefit could
  be accounted for by improved asscess to ICU
  admission for patients who were less likely to
  die, based on their lower APACHE scores
• May due to the ability to support critically ill
  patients and to target advanced supportive
  technology to those who can survive

Lilly Crit Care Med, Volume 31(5) Supplement.May
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Discussions (6)

• Significant limitations
• Exportable to other ICUs ?
• Labor intensive communication
• ICU length of stay not been adequately defined
  and may vary among ICUs

Lilly Crit Care Med, Volume 31(5) Supplement.May
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Conclusion

• Intensive communication
• A process-based intervention to determine --- The
  use of supportive technology when it is effective
  for accomplishing patient or --- Facilitates
  acceptance of a comfort-focused care plan for
  dying patients
• A significant, substantial, and durable
  reductions in the length of ICU stay and ICU
  mortality

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• Thank you for listening !