Gayle R. Spill

Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference.

Background: Millions of patients are discharged from intensive care units annually. These intensive care survivors and their families frequently report a wide range of impairments in their health status which may last for months and years after hospital discharge. Objectives: To report on a 2-day Society of Critical Care Medicine conference aimed at improving the long-term outcomes after critical illness for patients and their families. Participants: Thirty-one invited stakeholders participated in the conference. Stakeholders represented key professional organizations and groups, predominantly from North America, which are involved in the care of intensive care survivors after hospital discharge. Design: Invited experts and Society of Critical Care Medicine members presented a summary of existing data regarding the potential long-term physical, cognitive and mental health problems after intensive care and the results from studies of postintensive care unit interventions to address these problems. Stakeholders provided reactions, perspectives, concerns and strategies aimed at improving care and mitigating these long-term health problems. Measurements and Main Results: Three major themes emerged from the conference regarding: (1) raising awareness and education, (2) understanding and addressing barriers to practice, and (3) identifying research gaps and resources. Postintensive care syndrome was agreed upon as the recommended term to describe new or worsening problems in physical, cognitive, or mental health status arising after a critical illness and persisting beyond acute care hospitalization. The term could be applied to either a survivor or family member. Conclusions: Improving care for intensive care survivors and their families requires collaboration between practitioners and researchers in both the inpatient and outpatient settings. Strategies were developed to address the major themes arising from the conference to improve outcomes for survivors and families.

Functional outcome following rehabilitation of the cancer patient

OBJECTIVE To identify impairments resulting from cancer or its treatment in patients undergoing inpatient rehabilitation, to assess the extent of functional gains, and to determine if cancer type, ongoing radiation treatment, or the presence of metastatic disease influences functional improvement. DESIGN AND SETTING A retrospective, case series of cancer patients undergoing inpatient rehabilitation at a free-standing, university-affiliated rehabilitation hospital. PARTICIPANTS A referred sample of 159 patients admitted because of functional impairments resulting from cancer or its treatment during a 2-year time period. INTERVENTION Comprehensive inpatient rehabilitation. MAIN OUTCOME MEASURE Functional status as measured by the motor score of the Functional Independence Measure. RESULTS Significant functional gains were made between admission (mean = 42.9) and discharge (mean = 56.0; p < .001), with all cancer subgroups making similar gains. The presence of metastatic disease did not influence functional outcome, and those patients receiving radiation actually made larger functional improvements (p = .025). CONCLUSION Individuals impaired by cancer or its treatment benefit from inpatient rehabilitation. The presence of metastatic disease or ongoing radiation should not preclude participation.

Exploring the scope of post-intensive care syndrome therapy and care: engagement of non-critical care providers and survivors in a second stakeholders meeting.

Background:Increasing numbers of survivors of critical illness are at risk for physical, cognitive, and/or mental health impairments that may persist for months or years after hospital discharge. The post–intensive care syndrome framework encompassing these multidimensional morbidities was developed at the 2010 Society of Critical Care Medicine conference on improving long-term outcomes after critical illness for survivors and their families. Objectives:To report on engagement with non–critical care providers and survivors during the 2012 Society of Critical Care Medicine post–intensive care syndrome stakeholder conference. Task groups developed strategies and resources required for raising awareness and education, understanding and addressing barriers to clinical practice, and identifying research gaps and resources, aimed at improving patient and family outcomes. Participants:Representatives from 21 professional associations or health systems involved in the provision of both critical care and rehabilitation of ICU survivors in the United States and ICU survivors and family members. Design:Stakeholder consensus meeting. Researchers presented summaries on morbidities for survivors and their families, whereas survivors presented their own experiences. Meeting Outcomes:Future steps were planned regarding 1) recognizing, preventing, and treating post–intensive care syndrome, 2) building strategies for institutional capacity to support and partner with survivors and families, and 3) understanding and addressing barriers to practice. There was recognition of the need for systematic and frequent assessment for post–intensive care syndrome across the continuum of care, including explicit “functional reconciliation” (assessing gaps between a patient’s pre-ICU and current functional ability at all intra- and interinstitutional transitions of care). Future post–intensive care syndrome research topic areas were identified across the continuum of recovery: characterization of at-risk patients (including recognizing risk factors, mechanisms of injury, and optimal screening instruments), prevention and treatment interventions, and outcomes research for patients and families. Conclusions:Raising awareness of post–intensive care syndrome for the public and both critical care and non–critical care clinicians will inform a more coordinated approach to treatment and support during recovery after critical illness. Continued conceptual development and engagement with additional stakeholders is required.

Cancer Rehabilitation: Do Functional Gains Relate to 60 Percent Rule Classification or to the Presence of Metastasis?

Literature supporting the benefits of inpatient rehabilitation for cancer patients is increasing. Many cancer patients, however, do not qualify for inclusion in the Centers for Medicare and Medicaid 60% rule and consequently may not receive services. The benefit of inpatient rehabilitation in this specific cancer group has not been investigated and is the focus of this study.

Perceived Quality of Life With Spinal Cord Injury: A Comparison Between Emergency Medicine and Physical Medicine and Rehabilitation Physicians

To explore the attitudes of health care providers who treat patients with spinal cord injury (SCI) and examine whether Emergency Medicine (EM) and Physical Medicine and Rehabilitation (PM&R) physicians differ in their judgments about quality of life (QOL) after SCI.

Prognosis Disclosure in Spinal Cord Injury

No one likes to deliver bad news, including doctors, who often have to discuss a poor prognosis with patients and their families. The subject of prognosis disclosure has been well-studied in the oncology literature [1-3], but less so in rehabilitation. For many life-limiting diagnoses, cancer and dementia, for example, prognosis disclosure is confounded by the uncertainties of disease course and response to treatment. Spinal cord injury (SCI), on the other hand, is a life-changing diagnosis with more certainty about outcomes and prognoses based on a patient’s American Spinal Injury Association Impairment Scale [4]. In theory, this should make prognosis disclosure easier, but it is not necessarily so. In all cases of disclosing a “poor” prognosis, the goal is to maintain hope, promote shared decision-making, and engender trust. It is important to pay attention to what question thepatient is asking andattend to their emotional and cognitive needs [5]. The questions “when will I walk again?” and “will I ever walk again?” are very different and require the physician to first acknowledge where the patient is in his/her understanding of diagnosis and proceed with expertise, honesty and compassion. In the face of a patient and family experiencing the emotional after effects of a trauma, this is often easier said than done. For this column, I have asked several experts to give their perspectives and reflect on their experiences of prognosis disclosure in SCI. Dr. Joyce Fichtenbaum, psychologist at Kessler Institute for Rehabilitation, and Dr. Steven Kirshblum, Director of Spinal Cord Injury Services, Kessler Institute for Rehabilitation and Professor, Rutgers New Jersey Medical School, have published on this topic and offer us some general guidelines and a case study in prognosis disclosure. Dr. Lisa Ruppert, Assistant Attending of Rehabilitation Medicine Services at Memorial Sloan Kettering Cancer Center and Assistant Professor of Rehabilitation Medicine at Weill Cornell Medical College, has dual specialization in Cancer Rehabilitation and SCI medicine, and has unique experience and insights on the difficulties of prognosis disclosure in patients with metastatic SCI. Finally, Ms. Thea Flaum, president of the Hill Foundation and founder of the FacingDisability.com website and an advocate for people with SCI, shares some personal reflections about how prognosis disclosure affected people with SCI.

The Team Physician: Ethical and Legal Issues

I have asked Gayle Spill, MD, to guest edit this Ethical Legal column. Dr Spill is a physiatrist and clinical ethicist who has been in practice for more than 20 years and has written on topics including cancer prognosis disclosure and quality of life considerations. She and I invited 3 experts to respond to a general query about the ethical and legal issues surrounding the team physician. Our first columnist, Cheri Blauwet, MD, is a physiatrist at Spaulding Rehabilitation Hospital and the Brigham and Women’s Hospital in Boston, a Paralympic gold medallist, and chairperson of the Medical Committee of the International Paralympic Committee. Our second

When Teams Fumble: Cancer Rehabilitation and the Problem of the “Handoff”

Who is the patient’s “team captain?” Who is responsible for defining the goals of treatment and the plan of care? And, ultimately, who is responsible for discussing prognosis and treatment options, particularly if a patient has a life-limiting condition? In the last 50 years we have witnessed a marked increase in medical specialization with concomitant fragmentation of health care. In a single episode of acute inpatient cancer care, a patient may have an inpatient hospitalist, a medical oncologist, a surgeon, a radiation oncologist, an intensivist, and other specialists as needed, not to mention the accompanying house staff—all of whom may rotate on and off service at regular intervals. It is possible that the patient may have no contact with any of these physicians beyond the episode of care. Indeed, if he or she has a primary care physician, that physician may not even be in the loop regarding decision-making until the patient is discharged from the hospital back to the primary care physician’s care. Physiatrists are increasingly finding themselves as another episodic provider in the cancer patient’s care. It’s not surprising. Patients with complex cancers increasingly are surviving, often with associated temporary or permanent disability. The 5-year relative survival for female breast cancer patients alone, for example, has improved from 63% in the early 1960s to a remarkable 90% today [1]. Some of these patients will undoubtedly have disabilities. Recognizing the need to care for cancer patients with disabilities, the National Cancer Act of 1971 “declared cancer rehabilitation as an objective and directed funds to the development of training programs and research projects.” Indeed, the National Cancer Institute sponsored a National Cancer Rehabilitation Planning Conference in 1972 and identified 4 objectives in the rehabilitation care of patients with cancer: (1) Psychosocial support, (2) optimization of physical functioning, (3) vocational counseling, and (4) optimization of social functioning [2]. Indeed, cancer rehabilitation has grown as a subspecialty area of interest in PM&R, although it still lacks formal certification. I am grateful that Dr. Sarah Eickmeyer suggested we tackle some of the ethics issues with which she and her colleagues struggle in the care of cancer patients in rehabilitation. Dr. Eickmeyer is an attending physician at Froedtert Hospital and the Zablocki VA in Milwaukee, Wisconsin. She notes that patients with cancer in acute inpatient rehabilitation often have medically complex cases, require close monitoring of multiple medical issues, and are known to have a greater rate of acute care transfers and readmissions during their inpatient rehabilitation stays. Physiatrists may have to balance poor prognosis with appropriate goal setting and discharge planning. Not uncommonly, rehabilitation teams also may find that the understanding of the patient and family about prognosis can be contradictory to that of oncology providers and the rehabilitation team, creating multiple opportunities for misunderstanding as well as difficulties in setting appropriate rehabilitation goals. Thus, the issue of clinical handoffs becomes even more critical to affect a high-quality plan of care in rehabilitation. Dr. Eickmeyer posed the following case for consideration:

Iliac Fracture After a Bone Marrow Biopsy

Rehabilitation care and consultations for oncology patients are expanding as both patients and physicians determine which ongoing therapies may be appropriate, and consultations for these patients will continue to increase as quality-of-life expectations and optimal post-treatment function are addressed. Physiatrists are consulted to facilitate the diagnosis and treatment of multiple issues that may be contributing to a patient’s failure to progress in therapy or recover from an illness, as well as to aid in the patient’s transition to the next level of care. It is important to realize that iatrogenic complications are a consideration for this population, given the variety of treatments and invasive procedures to which they are subjected. Along with bone marrow aspiration, a bone marrow trephine biopsy (ie, the removal of a small core of bone marrow) may be indicated in persons with hematopoietic malignancies to evaluate bone marrow cellularity and involvement and to search for evidence of infiltration [1]. Although these procedures are not without risk, complications are rare and include bleeding with reports of retroperitoneal hemorrhage, infection, tumor seeding, and needle breakage. Sternal aspiration poses special risks because of the relatively thin layer of bone at the site of evaluation, which may lead to penetration of the sternum, with potentially fatal cardiovascular complications. Performing a sternal biopsy is contraindicated for this reason [2,3]. The most typical bone marrow biopsy site is the posterior iliac crest. Postprocedure pain at this site is common. Very rare complications have been reported in the literature, such as gluteal compartment syndrome with transient neuropathy caused by bleeding after the biopsy [4], osteomyelitis, and fracture thought to be a result of osteoporosis [5]. We report an iatrogenic fracture that occurred at the biopsy site and was diagnosed while the patient was in acute care, preparing for his course of rehabilitation.

Soft tissue sarcoma affecting the right shoulder of a man with paraplegia from a remote traumatic spinal cord injury: a case report

IntroductionPeople with spinal cord injury (SCI) are getting older due to a combination of increased life expectancy and older age at the time of injury. This trend makes it more likely for these patients to have other chronic health conditions including cancer. Inevitably relatively rare cancers such as soft tissue sarcomas (STS), which are more common with advancing age, will occur in some SCI patients. The present case represents the first report of a limb STS in a patient with chronic paraplegia from a traumatic SCI.Case presentationWe report a case of a 50-year-old right handed male with a T6 chronic, complete SCI (American Spinal Injury Association Impairment Scale A) who presented with a large mass involving his right shoulder musculature that was determined to be a high grade spindle cell sarcoma. The patient was followed closely by Physiatry over an approximately 6-month time course including prior to his tumor diagnosis, during the pre-radiation and pre-surgical planning phase, and then post-operatively for his acute inpatient rehabilitation. He was successfully discharged home to live alone in his accessible apartment complex.DiscussionThis case is the first ever reported case of a person living with a traumatic SCI who subsequently developed a limb STS. In addition to its novelty, this case illustrates how health conditions such as rare cancers are presenting more often as the chronic SCI population is getting older, which creates both unique diagnostic and management challenges for cancer rehabilitation specialists.