Tuesday, March 20, 2007

Ethics in the ICU; Prognosis; Computers to tell us what patients believe


Many, many items in brief....

1)
Critical Care Medicine had a supplement in February about ethics in the ICU. Many articles here, including one on end of life ethics in the unit. It opens with this rather remarkable salvo:

"Originally conceived and operated as short-term, life-saving vehicles for acutely ill or injured patients, modern intensive care units (ICUs) have expanded into entities that care also for chronically, although seriously, ill people; in fact, ICUs often become repositories for patients who have little or no chance for survival. Sophisticated technology frequently takes on a life of its own; the sheer momentum of processes inherent to ICUs may prevent healthcare providers from taking a step back to make well-considered decisions, especially at the end of a human life."

The rest of it is not quite so colorful but a good read; covers the ethics basics, illustrates them with some real cases, and talks quite frankly about the culture of the ICU, power relationships between medical people & patients/families & between physicians and non-physicians. The article, which is written by a single person, benefits from straightforward, idiosyncratic, and at times informal language--none of this formal, committee-written prose. I guess what I liked most about the article is that rather than being a dispassionate discussion of end of life ethics in the ICU, it is a passionate, personal (but well-researched and -informed) reflection on the vagaries & missteps of ethics, informed-consent, decision-making, autonomy, etc. as they apply to very real & really suffering people & families in our ICUs. Stuff like this:

"Healthcare providers are human beings. Patients are human beings. The provision of health care takes place in an elaborate, intricate, imperfect, and unpredictable human society. Medical clinics, hospitals, and, especially, ICUs are bewildering, frightening, and incomprehensible to the vast majority of people. The essential workings of the ICU—all the participants, the hierarchies, the machines, the medical code, the severity of illness—are completely foreign to lay people; they have nothing in their experience, educational or otherwise, to use as an anchor for making sense of their surroundings."

2)
Archives of Gerontology and Geriatrics has a report on mortality in elderly adults with bedsores. It's observational data from an Italian cohort of frail, community dwelling older adults; 18% of these patients had bedsores & 29% of these patients had died within the year. It's a relatively small study, and likely not very generalizable, but there's not too much out there on the natural history/prognosis of bedsores in the elderly so any information is notable.

3)
A recent Archives of Internal Medicine has an outcomes article about the Oncotalk program (it's an educational program aimed mostly at oncology fellows about communication skills surrounding breaking bad news, discussing goals of care, etc.). It was effective & it's gratifying to see these outcomes presented in a major general medicine journal: it furthers the message that these skills, and projects to improve these skills in medical trainees, are of interest to the general medicine audience--at least internal medicine.

4)
The same issue also has an article on shared decision making in the ICU. It comes from a project where physician-family conferences in the ICU were recorded and evaluated. It found that 'more complete' shared decision making was slightly predictive of improved family satisfaction, and that 'less complete' shared decision making occured with lower educational levels of the family. For those of you wondering what shared decision making is, there is not, actually, a consensus on what it really means: the authors define it as including "(1) discussing the nature of the decision to be made, (2) exchanging relevant medical information and information about a patient's values, (3) checking for understanding of information, (4) discussing preferred roles in decision making, and (5) achieving consensus about the treatment course most consistent with the patient's values and preferences" (i.e. it's good decision making).

5)
The same issue has another article about CHF mortality and prognosis: in a cohort of patients in Massachusetts hospitalized with CHF (average age 76 years) 1 year mortality was 38% and 5 year was nearly 80%. This is what people mean when they CHF has a worse prognosis than many cancers....

6)
PLOS Medicine has an article about using computer-based decision-support to determine what incapacitated persons' medical decisions would be . (PLOS Med is an online open-access journal.) The article is mostly a hypothetical exploration of the idea that, based on the previously published research, one could create a program that (after entering patient demographic data) would tell you pretty accurately if the patient would want treatment X (like CPR if they were in a permanent coma). Part of the reason this could be successful is, of course, that family members do a pretty poor job of identifying patients' treatment preferences. Yes, this idea sounds batty and dangerous, and the authors aren't endorsing going out and implementing such a decision-aide currently (the science just isn't there among many reasons why this couldn't work now) but they are proposing, in principle, that it could be done and, in principle, be more accurate than family members. My counter-proposal to this would be a time-machine--going back in time and just asking the patient would be most reliable.

7)
Well I'm not even done with the list I had accumulated but that's enough for tonight. Happy Spring--Drew.

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