Michael E. Wilson

Perspectives of physicians and nurses regarding end-of-life care in the intensive care unit.

Context: The delivery of end-of-life care (EOLC) in the intensive care unit (ICU) varies widely among medical care providers. The differing opinions of nurses and physicians regarding EOLC may help identify areas of improvement. Objective: To explore the differences of physicians and nurses on EOLC in the ICU and how these differences vary according to self-reported proficiency level and primary work unit. Design: Cross-sectional survey of 69 ICU physicians and 629 ICU nurses. Setting: Single tertiary care academic medical institution. Results: A total of 50 physicians (72%) and 331 nurses (53%) participated in the survey. Significant differences between physicians and nurses were noted in the following areas: ability to safely raise concerns, do not resuscitate (DNR) decision making, discussion of health care directives, timely hospice referral, spiritual assessment documentation, utilization of social services, and the availability of EOLC education. In every domain of EOLC, physicians reported a more positive perception than nurses. Additional differences were noted among physicians based on experience, as well as among nurses based on their primary work unit and self-reported proficiency level. Conclusions: Even with an increased focus on improving EOLC, significant differences continue to exist between the perspectives of nurses and physicians, as well as physicians among themselves and nurses among themselves. These differences may represent significant barriers toward providing comprehensive, consistent, and coordinated EOLC in the ICU.

Pretransplant frailty is associated with decreased survival after lung transplantation

BACKGROUND Frailty is a condition of increased vulnerability to adverse health outcomes. Although frailty is an important prognostic factor for many conditions, the effect of frailty on mortality in lung transplantation is unknown. Our objective was to assess the association of frailty with survival after lung transplantation. METHODS We performed a retrospective cohort analysis of all adult lung transplant recipients at our institution between 2002 and 2013. Frailty was assessed using the frailty deficit index, a validated instrument that assesses cumulative deficits for up to 32 impairments and measures the proportion of deficits present (with frailty defined as >0.25). We examined the association between frailty and survival, adjusting for age, sex, and bilateral (vs single) lung transplant using Cox proportional hazard regression models. RESULTS Among 144 lung transplant patients, 102 (71%) completed self-reported questionnaires necessary to assess the frailty deficit index within 1 year before lung transplantation. Frail patients (n = 46) had an increased risk of death, with an adjusted hazard ratio (HR) of 2.24 (95% confidence interval [CI], 1.22-4.19; p = 0.0089). Frailty was not associated with an increased duration of mechanical ventilation (median, 2 vs 2 days; p = 0.26), intensive care unit length of stay (median, 7.5 vs 6 days; p = 0.36) or hospital length of stay after transplantation (median, 14 vs 10.5 days; p = 0.26). CONCLUSIONS Pre-transplant frailty was independently associated with decreased survival after lung transplantation. Pre-transplant frailty may represent an important area for intervention to improve candidate selection and lung transplant outcomes.

A video to improve patient and surrogate understanding of cardiopulmonary resuscitation choices in the ICU: a randomized controlled trial.

Objective:To determine if a video depicting cardiopulmonary resuscitation and resuscitation preference options would improve knowledge and decision making among patients and surrogates in the ICU. Design:Randomized, unblinded trial. Setting:Single medical ICU. Patients:Patients and surrogate decision makers in the ICU. Interventions:The usual care group received a standard pamphlet about cardiopulmonary resuscitation and cardiopulmonary resuscitation preference options plus routine code status discussions with clinicians. The video group received usual care plus an 8-minute video that depicted cardiopulmonary resuscitation, showed a simulated hospital code, and explained resuscitation preference options. Measurements and Main Results:One hundred three patients and surrogates were randomized to usual care. One hundred five patients and surrogates were randomized to video plus usual care. Median total knowledge scores (0–15 points possible for correct answers) in the video group were 13 compared with 10 in the usual care group, p value of less than 0.0001. Video group participants had higher rates of understanding the purpose of cardiopulmonary resuscitation and resuscitation options and terminology and could correctly name components of cardiopulmonary resuscitation. No statistically significant differences in documented resuscitation preferences following the interventions were found between the two groups, although the trial was underpowered to detect such differences. A majority of participants felt that the video was helpful in cardiopulmonary resuscitation decision making (98%) and would recommend the video to others (99%). Conclusions:A video depicting cardiopulmonary resuscitation and explaining resuscitation preference options was associated with improved knowledge of in-hospital cardiopulmonary resuscitation options and cardiopulmonary resuscitation terminology among patients and surrogate decision makers in the ICU, compared with receiving a pamphlet on cardiopulmonary resuscitation. Patients and surrogates found the video helpful in decision making and would recommend the video to others.

Physician Staffing Models Impact the Timing of Decisions to Limit Life Support in the ICU

BACKGROUND A growing trend is the implementation of 24-h attending physician coverage in the ICU. Our aim was to measure the impact of 24-h, in-house, attending intensivist coverage on the quality of end-of-life care and the timing of end-of-life decision-making. METHODS A retrospective cohort study was conducted of all ICU deaths 6 months before and 6 months after the implementation of mandatory 24-h attending intensivist coverage in a medical ICU. Data relevant to end-of-life care per established consensus recommendations were abstracted from the medical record. RESULTS The following changes were observed after implementation of 24-h intensivist coverage: Time from ICU admission to decision to withdraw mechanical ventilation and time to decision to change to do-not-resuscitate code status both were shortened by 2 days (both P = .03). Quality measures, such as increased family presence around time of death ( P = .01) also improved. Other findings, which did not reach statistical significance, included the following: Time to family conference was shortened by 2 days ( P = .09), time to decision to limit any life support was shortened by 1 day ( P = .08), time to death was shortened by 2 days ( P = .08), and intubations against patient wishes decreased (from three to none; P = .12). CONCLUSIONS The implementation of mandatory 24-h, in-house, attending intensivist coverage was associated with earlier decision-making across a number of domains related to end-of-life care. Positive trends were noted in quality of end-of-life care as reflected in the presence of family at the time of death.

Klinefelter’s syndrome

A 29 year old man presented to primary care with anxiety and depression that had worsened since childhood. Further questioning revealed a history of poor school performance, poor body image, and poor self esteem. On physical examination, the patient’s height was 189 cm and he had narrow shoulders, wide hips, sparse facial hair (which he shaved once every two months), and small, firm testicles. He was found to have elevated luteinising hormone and follicular stimulating hormone concentrations, low serum concentrations of testosterone, absent sperm on semen analysis, and a karyotype of 47,XXY. Klinefelter’s syndrome is the clinical result of an additional X chromosome in males (47,XXY), although other chromosome abnormalities (such as 46,XY/47,XXY mosaicism; 48,XXXY; 49,XXXXY) account for 10-20% of cases.1 2 Classic clinical findings include infertility, small testes, hypergonadotropic hypogonadism (elevated luteinising hormone and follicular stimulating hormone concentrations with low or low to normal testosterone concentrations), decreased facial and body hair, gynecomastia, tall stature with eunuchoid features, and psychosocial morbidity.1 3 #### How common is Klinefelter’s syndrome?

Development, validation, and results of a survey to measure understanding of cardiopulmonary resuscitation choices among ICU patients and their surrogate decision makers

BackgroundShared-decision-making about resuscitation goals of care for intensive care unit (ICU) patients depends on a basic understanding of cardiopulmonary resuscitation (CPR). Our objective was to develop and validate a survey to assess comprehension of CPR among ICU patients and surrogate decision-makers.MethodsWe developed a 12-item verbally-administered survey incorporating input from patients, clinicians, and expert focus groups.ResultsWe administered the survey to 32 ICU patients and 37 surrogates, as well as to 20 resident physicians to test discriminative validity. Median (interquartile range) total knowledge scores were 7 (5-10) for patients, 9 (7-12) for surrogates, and 14.5 (14-15) for physicians (p <.001). Forty-four percent of patients and 24% of surrogates could not explain the purpose of CPR. Eighty-eight percent of patients and 73% of surrogates could not name chest compressions and breathing assistance as two components of CPR in the hospital. Forty-one percent of patients and 24% of surrogates could not name a single possible complication of CPR. Forty-three percent of participants could not specify that CPR would be performed with a full code order and 25% of participants could not specify that CPR would not be performed with a do-not-resuscitate order. Internal consistency (Cronbach’s alpha = 0.97) and test-retest reliability (Pearson correlation = 0.96, p < .001) were high.ConclusionsThis easily administered survey, developed to measure knowledge of CPR and resuscitation preference options among ICU patients and surrogates, showed strong face validity, content validity, internal consistency, test-retest reliability, and discriminative validity. A substantial proportion of ICU patients and surrogates decision-makers have poor knowledge of CPR and basic resuscitation options.

Central Anticholinergic Syndrome Following Dobutamine–Atropine Stress Echocardiography

We present a case of central anticholinergic syndrome following dobutamine–atropine stress echocardiography in an elderly female. Although atropine toxicity is a recognized complication of stress echocardiography, no case reports are currently available. The central nervous system side effects of atropine are varied in severity (mild cognitive impairment to severe coma) and spectrum (agitation or somnolence), and thus are often overlooked. Management includes prompt recognition, stopping the offending agent, providing supportive care, and consideration of physiostigmine. Atropine is used in up to 60% of dobutamine stress echocardiograms, and has the potential to cause morbidity. (Echocardiography 2011;28:E205‐E206)

Long-Term Return to Functional Baseline After Mechanical Ventilation in the ICU

Objective: Predictors of long-term functional impairment in acute respiratory failure of all causes are poorly understood. Our objective was to assess the frequency and predictors of long-term functional impairment or death after invasive mechanical ventilation for acute respiratory failure of all causes. Design: Population-based, observational cohort study. Setting: Eight adult ICUs of a single center. Patients: All adult patients from Olmsted County, Minnesota, without baseline functional impairment who received mechanical ventilation in ICUs for acute respiratory failure of all causes from 2005 through 2009. Interventions: None. Measurements and Main Results: In total, 743 patients without baseline functional impairment received mechanical ventilation in the ICU. At 1- and 5-year follow-up, the rates of survival with return to baseline functional ability were 61% (366/597) and 53% (356/669). Among 71 patients with new functional impairment at 1 year, 55% (39/71) had recovered and were alive without functional impairment at 5 years. Factors predictive of new functional impairment or death at 1 year were age, comorbidities, discharge to other than home, mechanical ventilation of 7 days or longer, and stroke. Of factors known at the time of intubation, the following are predictive of new functional impairment or death: age, comorbidities, nonsurgical condition, Acute Physiology and Chronic Health Evaluation III score, stroke, and sepsis. Post hoc sensitivity analyses revealed no significant change in predictor variables in patient populations when stroke was excluded or who received more than 48 hours of mechanical ventilation. Conclusions: At 1- and 5-year follow-up, many patients who received mechanical ventilation for acute respiratory failure from all causes are no longer alive or have new moderate-to-severe functional impairment. Functional recovery between year 1 and year 5 is possible and common. Sepsis, stroke, illness severity, age, and comorbidities predict long-term functional outcome at intubation.

Normal carboxyhaemoglobin level in carbon monoxide poisoning treated with hyperbaric oxygen therapy

Throughout the world both intentional and inadvertent exposure to carbon monoxide (CO) remains an important public health issue. While CO poisoning can be lethal, the morbidity is predominantly due to nervous system injury. A previously healthy 22-year-old woman was found unconscious at home by her sister. Her parents were found dead in the house with a recent history of a dysfunctional furnace. She was presumed to have CO poisoning despite an initial carboxyhaemoglobin level of 2.5%. Patient had both clinical and radiological evidence of neurological damage. However, with multiple sessions of hyperbaric oxygen (HBO) therapy she recovered to a near normal functional status. There is no consensus that exists among treating physicians about the role of hyperbaric oxygen in management of neurological injury. The case described here has significant neurological damage related to CO exposure but improved after HBO therapy.

The importance of frailty in lung transplantation and chronic lung disease

Frailty is a state of functional decline and increased vulnerability to adverse health outcomes, associated with increased inflammation and dysregulated immune and physiological systems. Frailty plays an important role in morbidity and mortality in elderly patients and is emerging as an important risk factor in chronic diseases and solid organ transplant patients. There is no consensus as to the best frailty measure, and a multitude of options are available to researchers and clinicians. The prevalence in chronic lung disease and solid organ transplant varies by organ and frailty measurement type but appears higher than in elderly community populations. Frailty has been linked to removal from the transplant waiting list, mortality, delayed graft function, and length of stay in transplant populations. Much work remains to discover methods to prevent or reverse frailty. Encouragingly, studies suggest that frailty is not a permanent state and may be responsive to exercise training.