Jared Chiarchiaro

Quality of Communication in the ICU and Surrogate's Understanding of Prognosis

Objective:Although misperceptions about prognosis by surrogates in ICUs are common and influence treatment decisions, there is no validated, practical way to measure the effectiveness of prognostic communication. Surrogates’ subjective ratings of quality of communication have been used in other domains as markers of effectiveness of communication. We sought to determine whether surrogates’ subjective ratings of the quality of prognostic communication predict accurate expectation about prognosis by surrogates. Design:We performed a cross-sectional cohort study. Surrogates rated the quality of prognostic communication by survey. Physicians and surrogates gave their percentage estimate of patient survival on ICU day 3 on a 0–100 probability scale. We defined discordance about prognosis as a difference in the physician’s and surrogate’s estimates of greater than or equal to ±20%. We used multilevel logistic regression modeling to account for clustering under physicians and patients and adjust for confounders. Setting:Medical-surgical, trauma, cardiac, and neurologic ICUs of five U.S. academic medical centers located in California, Pennsylvania, Washington, North Carolina, and Massachusetts. Patients:Two hundred seventy-five patients with acute respiratory distress syndrome at high risk of death or severe functional impairment, their 546 surrogate decision makers, and their 150 physicians. Interventions:None. Measurements and Main Results:There was no predictive utility of surrogates’ ratings of the quality of communication about prognosis to identify inaccurate expectations about prognosis (odds ratio, 1.04 ± 0.07; p = 0.54). Surrogates’ subjective ratings of the quality of communication about prognosis were high, as assessed with a variety of questions. Discordant prognostic estimates were present in 63.5% (95% CI, 59.0–67.9) of physician-surrogate pairs. Conclusions:Although most surrogates rate the quality of prognostic communication high, inaccurate expectations about prognosis are common among surrogates. Surrogates’ ratings of the quality of prognostic communication do not reliably predict an accurate expectation about prognosis.

Reengineering Advance Care Planning to Create Scalable, Patient- and Family-Centered Interventions

The Institute of Medicine (IOM) report Dying in America concluded that patients near the end of life often receive undesired, burdensome treatments and called for improvements in advance care planning to ensure that patients’ values guide medical care.1 There is no clear path to accomplish this because there are major shortcomings to existing advance care planning. First, traditional advance directives are often narrowly focused on treatment preferences that are difficult to apply in many clinical situations. The second approach, facilitated advance care planning, is resource intensive and thus difficult to scale up to meet increasing demand. In this Viewpoint, we propose 2 interrelated strategies to create the next generation of advance care planning tools: (1) leveraging web-based technologies to create online interventions and (2) using the science of user-centered design to ensure that advance care planning meets the needs of patients, families, and clinicians.

Developing a Simulation to Study Conflict in Intensive Care Units

RATIONALE Although medical simulation is increasingly being used in healthcare education, there are few examples of how to rigorously design a simulation to evaluate and study important communication skills of intensive care unit (ICU) clinicians. OBJECTIVES To use existing best practice recommendations to develop a medical simulation to study conflict management in ICUs, then assess the feasibility, acceptability, and realism of the simulation among ICU clinicians. METHODS The setting was a medical ICU of a tertiary care, university hospital. Participants were 36 physicians who treat critically ill patients: intensivists, palliative medicine specialists, and trainees. Using best-practice guidelines and an iterative, multidisciplinary approach, we developed and refined a simulation involving a critically ill patient, in which the patient had a clear advance directive specifying no use of life support, and a surrogate who was unwilling to follow the patients preferences. ICU clinicians participated in the simulation and completed surveys and semistructured interviews to assess the feasibility, acceptability, and realism of the simulation. MEASUREMENTS AND MAIN RESULTS All participants successfully completed the simulation, and all perceived conflict with the surrogate (mean conflict score, 4.2 on a 0-10 scale [SD, 2.5; range, 1-10]). Participants reported high realism of the simulation across a range of criteria, with mean ratings of greater than 8 on a 0 to 10 scale for all domains assessed. During semistructured interviews, participants confirmed a high degree of realism and offered several suggestions for improvements. CONCLUSIONS We used existing best practice recommendations to develop a simulation model to study physician-family conflict in ICUs that is feasible, acceptable, and realistic.

New molecular targets for the treatment of sarcoidosis.

Purpose of review Sarcoidosis is a chronic granulomatous disease typically affecting the lung, lymph nodes, and other organ systems. Evidence suggests that the morbidity and mortality rates for sarcoidosis in the USA are rising, despite widespread use of anti-inflammatory therapies. In this review, we survey new therapies that target specific inflammatory pathways in other diseases (such as rheumatoid arthritis, Crohns disease, and psoriasis) that are similar to pathways relevant to sarcoidosis immunopathogenesis, and therefore, represent potentially new sarcoidosis therapies. Recent findings Immunopathogenesis of sarcoidosis has been well elucidated over the past few years. There is abundant evidence for T-cell activation in sarcoidosis leading to activation of both Th1 and Th17 inflammatory cascades. Therapies targeting T-cell activation, Th1 pathways (such as the interleukin-6 inhibitors), Th17 pathway mediators, and others have been Food and Drug Administration approved or under investigation to treat a variety of autoimmune inflammatory diseases, but have not been studied in sarcoidosis. Targeting the p38 mitogen-activated protein kinases and the ubiquitine proteasome system with new agents may also represent a novel therapeutic option for patients with sarcoidosis. Summary Rising morbidity and mortality rates for patients with sarcoidosis strongly support the need to develop more effective anti-inflammatory therapies to treat chronic disease.

Admission to the Intensive Care Unit and Well-being in Patients With Advanced Chronic Illness

PURPOSE To describe the association of intensive care with trajectories of functional, emotional, social, and physical well-being in patients with 3 common advanced illnesses. METHODS Cross-sectional cohort study of 42 patients admitted to the intensive care unit selected from 210 patients with stage IV breast, prostate, or colon cancer or stage IIIb or IV lung cancer; New York Heart Association class III or IV congestive heart failure; and chronic obstructive pulmonary disease with hypercapnea (Pco2 > 46 mm Hg). Scores on subscales of the Functional Assessment of Chronic Illness Therapy-General survey were measured monthly for 6 months before and after admission to the intensive care unit and were analyzed by using the unit admission date as a point of discontinuous change to illustrate trajectories before and after the admission. RESULTS Overall, trajectories of well-being declined sharply after admission to the intensive care unit. Declines in physical, functional, and emotional well-being were statistically significant. During the 6 months after admission, physical, functional, and emotional well-being scores trended back up to baseline while social well-being scores continued to decline. CONCLUSIONS Well-being trajectories declined sharply after admission to the intensive care unit, with recovery in the subsequent 6 months, and may be characterized by common patterns. These results help to better describe intensive care as a marker for advancing illness in patients with advanced chronic illness.

Conflict Management Strategies in the ICU Differ Between Palliative Care Specialists and Intensivists.

Objectives:Conflict is common between physicians and surrogate decision makers around end-of-life care in ICU. Involving experts in conflict management improve outcomes, but little is known about what differences in conflict management styles may explain the benefit. We used simulation to examine potential differences in how palliative care specialists manage conflict with surrogates about end-of-life treatment decisions in ICUs compared with intensivists. Design:Subjects participated in a high-fidelity simulation of conflict with a surrogate in an ICU. In this simulation, a medical actor portrayed a surrogate decision maker during an ICU family meeting who refuses to follow an advance directive that clearly declines advanced life-sustaining therapies. We audiorecorded the simulation encounters and applied a coding framework to quantify conflict management behaviors, which was organized into two categories: task-focused communication and relationship building. We used negative binomial modeling to determine whether there were differences between palliative care specialists’ and intensivists’ use of task-focused communication and relationship building. Setting:Single academic medical center ICU. Subjects:Palliative care specialists and intensivists. Interventions:None. Measurements and Main Results:We enrolled 11 palliative care specialists and 25 intensivists. The palliative care specialists were all attending physicians. The intensivist group consisted of 11 attending physicians, 9 pulmonary and critical care fellows, and 5 internal medicine residents rotating in the ICU. We excluded five residents from the primary analysis in order to reduce confounding due to training level. Physicians’ mean age was 37 years with a mean of 8 years in practice. Palliative care specialists used 55% fewer task-focused communication statements (incidence rate ratio, 0.55; 95% CI, 0.36–0.83; p = 0.005) and 48% more relationship-building statements (incidence rate ratio, 1.48; 95% CI, 0.89–2.46; p = 0.13) compared with intensivists. Conclusions:We found that palliative care specialists engage in less task-focused communication when managing conflict with surrogates compared with intensivists. These differences may help explain the benefit of palliative care involvement in conflict and could be the focus of interventions to improve clinicians’ conflict resolution skills.

A case series describing common radiographic and pathologic patterns of hard metal pneumoconiosis

Introduction Hard metal pneumoconiosis is a rare but serious disease of the lungs associated with inhalational exposure to tungsten or cobalt dust. Little is known about the radiologic and pathologic characteristics of this disease and the efficacy of treating with immunosuppression. Objective We describe the largest cohort of patients with hard metal pneumoconiosis in the literature, including radiographic and pathologic patterns as well as treatment options. Methods We retrospectively identified patients from the University of Pittsburgh pathology registry between the years of 1985 and 2016. Experts in chest radiology and pulmonary pathology reviewed the cases for radiologic and pathologic patterns. Results We identified 23 patients with a pathologic pattern of hard metal pneumoconiosis. The most common radiographic findings were ground glass opacities (93%) and small nodules (64%). Of 20 surgical biopsies, 17 (85%) showed features of giant cell interstitial pneumonia. Most patients received systemic corticosteroids and/or steroid-sparing immunosuppression. Conclusions Hard metal pneumoconiosis is characterized predominately by radiographic ground glass opacities and giant cell interstitial pneumonia on histopathology. Systemic corticosteroids and steroid-sparing immunosuppression are common treatment options.