Wednesday, October 11, 2006

Spirituality & African Americans' end of life experience; Chronic vent prognosis


Journal of General Internal Medicine has a piece about the importance of spirituality in African Americans' end of life experience. It is basically two physicians' & and a chaplains' thoughts about African American spirituality & religious belief as they witnessed it at the bedside. It's really a brief phenomenology of their patients' religious statements. They state they haven't found an increased desire for more aggressive medical care at the end of life in their African American patients compared to their other patients. That is fine but the findings supporting that in general African Americans advocate for more aggressive medical care at the end of life than non-African American patients has been a finding replicated multiple times in quantitative studies, so I'm not sure what they're getting at.

Archives of Internal Medicine has a study of 'brain dysfunction' in the chronically critically ill . It is interesting because it provides a natural history of these patients. (By chronically critically ill they mean patients who require extended mechanical ventilation in an ICU such that they eventually receive a tracheostomy and are sent to a chronic vent facility.) The study looked at ~200 patients at a single institution who were discharged to a chronic vent floor; mean age was 72 & the patients were ventilated for a wide variety of reasons. They found a high burden of 'brain dysfunction' (delirium, coma, etc) not surprisingly. The longer term outcomes were what interested me: over half the patients had died within 6 months of being sent to the chronic vent floor; 30% died in the facility; less than 20% of patients were discharged to home or a rehabilitation facility (the rest died, went to another acute setting, or went to a long-term care facility); ~60% of survivors at 6 months were dependent in all activities of daily living; and 71% of 6 month survivors were so cognitively impaired that they couldn't participate in a telephone mental status examination. Yikes. So, in this institution's cohort: if you went to a chronic vent facility, chances are at 6 months you'd be dead, and if you weren't chances are you'd be significantly cognitively impaired. I don't have much to say about this other than it's valuable prognostic information. I hope a similar multi-institutional study occurs to see how if these dismal prognostic figures are generalizable nation-wide.

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