2012 AAHPM & HPNA Annual Assembly

Transcription

1 Chronic Critical Illness: Opportunities and Challenges Patient RG Zara Cooper, MD, MSc Department of Surgery Harvard Medical School Brigham and Women s Hospital Rachelle Bernacki, MD, MS Department of Psychosocial Oncology and Palliative Care Harvard Medical School Brigham and Women s Hospital Chronic Critical Illness: Triumph of technology or failure of communication? Intensive Care Background Metabolic Syndrome Outcomes Ethics Future directions Chronically Critically Ill 1. Defined by tracheotomy 2. DRG 483 (541/542) MV > 96 hours 3. Consensus group recommends >21 days >21 days is a unique group Tracheotomy Ventilator > 21 >96h days In hospital cost $140,409 $143,389 One year 48% 58% mortality Functional Weekly care Severely limited status giving One Year cost $266,105 $423,596 National Association for the Medical Direction of Respiratory Care Consensus Statement 2008 Cox. Crit Care 2007;11:R9 1

2 CAMBRIDGE, MA Population 101,355 CAMBRIDGE, MA Population 101,355 We know the American population is getting older S.S. Carson / Crit Care Clin 19 (2003) Black and Hispanic Populations are growing Hanchate. Arch Intern Med. 2009;169: Zilberberg. BMC Health Services Research 2008;8:242 2

3 The LTAC business is booming ,732 admissions $484 million 38.1/100M after critical illness One year mortality 50.7% ,353 admissions $1.325 billion 99.7/100M after critical illness One year mortality 52.2% Distinct Metabolic Syndrome Khan JM, et al, JAMA 2010;303 (22): The spectrum of critical illness We were never prepared for this Angus. Intensive Care Med 2003;29: Mechanick. Curr Opin Clin Nut and Met Care 2005;8:33 We are left with Muscle wasting and Protein Calorie Malnutrition Impaired immune-neuroendocrine neuroendocrine axis Hyperglycemia Bone disease Neuromuscular abnormalities Clinical manifestations Prolonged respiratory failure Wasting GI Failure Skin breakdown Multiple infections Cognitive failure 3

4 Endocrine Changes Adrenal Exhaustion Syndrome X Thyroid regulation X Metabolic Bone Disease Bone hyperreadsorption Prolonged immobilization and Cytokine-related inflammation Vitamin D deficiency Lack of sun, renal failure, malnutrition and malabsorption Hypophosphatemia Immune Exhaustion Hyperglycemia and malnutrition Exposure to resistant hospital acquired organisms Multiple courses of antibiotics Indwelling lines and catheters Neuromuscular dysfunction The neuromuscular component of MODS Myopathies, acute neuropathies, cognitive dysfunction Prognosis 37% mortality 18% incomplete recovery 45% complete recovery (mean 4.5 months) Op de Coul. Clin Neurol Neurosurg 1991:93;

5 Outcomes 40 will survive 22 will be institutionalized 9 will be homebound 9 will have good physical functioning Carson. Am J Respir Crit Care Med 159: Nelson. Crit Care Med. 2004;32:1527 Survival is similar to some malignancies Brain Dysfunction One-year Survival* Nelson. Arch Intern Med. 2006;166: Pancreatic cancer PMV >21 days Invasive Esophageal cancer MV > 96h Cancer of the colon and rectum Invasive Breast cancer % SEER

6 The Symptom Burden Can we predict who is at risk? Prevalence of physical and psychological symptoms among chronically critically ill patients Nelson. Crit Care Med. 2004;32:1527 Who are these patients? 10-15% 15% of all ICU patients The majority are elderly, and were functionally independent before their ICU stay An acute insult, added to other co morbidities leads to a catastrophic illness with ventilator dependency An infection usually precipitates PMV 40% are surgical patients Organ System Failure Impacts Survival D Amico. Chest 2003;124: Scheinhorn DJ. Chest 2007;131:76 Ethics Autonomy Death used to be inevitable now it s a choice Shocks Chest Compression Vasopressors CMO 6

7 Distributive Justice: Rationing or rational Beneficence and non-beneficial care Hospitalization >$100,000 with survival <100 days 22% of DRG 541/542 41% of patients ventilated > 21 days 1 in 5 are readmitted in 30 days Cox. Critical Care. 2007, 11: R9 The futility gap [Medical] care can be considered futile if the best an ICU stay can accomplish is an outcome that patients find unacceptable or even worse than death A Good Save Surgeons pride themselves on total care of the patient and the total outcome The surgeon is ideally trained to organize and sustain the rescue attempt the surgeon is poorly positioned to abort the rescue attempt when it has failed. Buchman et al. JACS 154, 2002 Civetta. Crit Care Med 1996;24: Non-malfeasance Do not do harm through acts of omission or comission Communications challenges Surgical buy-in We are not the best communicators Don t have enough information to prognosticate Never want to take away hope We are only human For surgeons it is difficult to accept poor outcomes Keenan SP. Critical Care Med 1997;25:

8 Do we provide false hope? What we do tell them Why mechanical ventilation needed 97% Why tracheotomy needed 99% Tracheotomy and ability to speak 84% Tracheotomy and ability to eat 75% Nelson. Arch Int Med. 2007;167:2509 What we don t tell them What do patients want to hear? Symptoms during continued treatment 66% Financial burden for the family 25% Expected functional status 20% Alternatives 17% Expected One Year Mortality 7% We don t take away hope by sharing the truth Physician explanations strongly influence the interventions patients will accept Nelson. Arch Int Med. 2007;167:2509 Mazur. Med Decis Making 1997;17: What we can tell them? One year mortality is very high A large proportion will remain dependent on life- sustaining therapy If they don t get home in 6 months it is unlikely they will ever e get home Less than 10% are oriented, ambulatory and independent at 1 year Patients with a GCS <8 are 6.5 times more likely to fail weaning Carson. Am J Respir Crit Care Med 159: MacIntyre. Chest 2005;128:3937 Decision making at the transition from acute to chronic 1. Nature of the patient s illness 2. Prognosis including ventilator dependence, function and quality of life 3. Symptom burden 4. Potential complications 5. Level of care after hospitalization 6. Alternatives to continuation of treatment Nelson. J Crit Care. 2005;20:

9 Strategies to Improve communication Surgical Buy-in Family meetings within 72 hours Distribution of printed materials for families about what to expect in the ICU Ethics consultations when conflicts arise Lilly. Am J Med.2000;109; Palliative Care Palliative care has a role in the treatment of all patients requiring PMV Palliative care is focused on the relief of pain, dyspnea and anxiety Include early to help the patient and family prepare for the road ahead When restoration of health is no longer possible, comfort should be the primary goal MacIntyre. Chest 2005;128:3937 Palliative care in surgical patients Consensus Panel Members of ACS Palliative Task Force Critical Care Surgeons Palliative Medicine CCI patients require a Multidisciplinary approach Objective: to identify triggers for Palliative Care Consult in the SICU Family request Futility per medical team Conflict among team or with advanced directive Death expected during same SICU stay SICU Stay > 1 mo Diagnosis with median survival < 6 mo Multi organ failure > 3 systems Bradley. Crit Care Med. 2009;37:

10 Figure 3: Multidisciplinary Patient -Centered Care for the Chronically Critically Ill Multidisciplinary Patient -Centered Care Ventilator Weaning Pulmonologist Respiratory Therapy VENTILATOR WEANING Intensivist Respiratory Therapy Nutrition Registered Dietician Pharmacy Support Managing Physician Patient Social Services/ Support Social work Chaplaincy Family NUTRITION Dietician Pharmacy MANAGING PHYSICIAN PATIENT REHABILITATION Physical Therapy Occ. Therapy Speech Therapy Symptom Management Palliative Care Pharmacy Support Bedside/Primary Nurse Rehabilitation Physiatrist Physical Therapy Occupational Therapy Speech Therapy Psychological Support Psychiatrist /Psychologist Palliative Care SYMPTON MANAGEMENT Pharmacy Palliative Care BEDSIDE NURSE Social Work And Spiritual Support PHYSCOLOGICAL SUPPORT Respiratory Care Unit LTAC Mount Sinai Medical Center RCU 14 bed unit for patients from all ICUs post trach Closed but close Recognition that patients have moved to different phase of care Financials Increases ICU throughput May exceed hospital payment for DRG Were long-term TB hospitals LOS > 25 days Different payment model is more lucrative Acute facilities available with similar ancillary support Most patients do not require PMV Other Locations High Loss Medicare Admissions Were Distributed Across Service Lines; Patients Treated in These Admissions Were High Severity Distribution of High Loss Medicare Admissions, by Service Line Skilled Nursing facilities Patients require advanced directives Not all have pulmonologists on staff Home ventilators Little data on prevalence and outcome Most common for neuromuscular disease All Other, 22% 55% Surgical Other Med, 0% 6% Surgical 0% Surg. Respiratory, 7% 73% 91% Surg. Surg. Vascular, 8% Ortho, 9% 39% Surg. 64% Surgical 53% Surgical GI, 9% Cardiac, 22% Onco, 17% Sub-Population as a Share of High Loss Cases Academic Medical Centers Community Hospitals Patient went to ICU 57% 20% med, 37% surg 49% Death w/in 6 mo 36% 30% HPM 5 & PHS Business Planning 7 10

11 Approaches to High Loss Encounters: Show Potential To Improve Quality and Margin Approaches ICU Process Improvement Inpatient Palliative Care Initiatives Pre-Procedure Discussion Transfer-In Prioritization High Level Description Pronovost check lists Family meetings within 72hrs Expanded inpatient palliative care programs at System hospitals, including consults as a core component. Engage in a comprehensive strategic planning process for palliative care at Partners. Discuss risks of elective procedures with high-risk patients & family Develop discharge plan in case of negative outcome Meet with AMC physicians and surgeons to discuss developing a way to apply more scrutiny to transfers-in Post ICU clinics Train intensivists to think longitudinally and think about patient-centered outcomes Study of post-icu clinics in UK Identify ICU related complications early Improve quality of life, and provide goal-focused care Prevent bounce backs Kahn. Curr Opin Crit Care 13: HPM 5 & PHS Business Planning 9 Medical Orders for Life-Sustaining Treatments (MOLST) Angus, Intensive Care Med 2003;29: It is a universal order form which is accepted by EMS and across multiple facilities Recommended for patients who their PCP would not be surprised if they died within a year Individuals can either encourage or limit life- sustaining treatment Patients are still encouraged to have a proxy MOLST/POLST Surviving Intensive Care CCI is a distinct clinical syndrome Need to better define this population Develop health outcomes and prediction models Improve communication Improve public education MOLST will be piloted in Central MA in

12 Thank You The existence of chronic critical patients is a testament to modern medical technology. Our challenge now is to define an ethical philosophy of care for [these patients] that includes what technology can accomplish and what it cannot. - DM Nierman Selwyn Rogers Suellen Breakey Daryl Owens 12