A Multidisciplinary Team-Based Approach to Improve Communication With Surrogates of Patients With Chronic Critical Illness.

BACKGROUND: Clinicians need to deliver prognostic information to surrogates of nondecisional, critically ill patients so that surrogates can make informed medical decisions that reflect the patient's values. Our objective was to implement a new approach for communicating with surrogates of patients with chronic critical illness. METHODS: Surrogate decision makers of patients who were difficult to liberate from mechanical ventilation were prospectively enrolled. Surrogates met with different members of the intensive care unit treatment team for sequential 15-minute appointments to receive patient-specific assessments and education on chronic critical illness. The feasibility and acceptability of this approach were determined. A 24-question comprehension instrument was developed to assess a participant's understanding that a family member was displaying features of chronic critical illness. Each question was scored from 1 to 5, with larger scores indicating greater comprehension. RESULTS: Over a 15-week period, educational sessions for 9 mechanically ventilated patients were conducted. On average, 2 surrogates per patient (range: 1-4) and 6 members of the interdisciplinary team (range: 4-6) were at each meeting. Surrogates and clinicians had very positive impressions of the communication intervention. The average preintervention comprehension score was 85 of 120 (standard deviation [SD]: 8, range: 71-101). The postintervention comprehension score was greater by 5 points on average (SD: 9, range: -11 to +20 points, P = .04). CONCLUSIONS: Surrogates of critically ill patients approved of this novel communication approach and had a greater understanding of the patient's medical condition after the intervention.

Patients with Type 2 diabetes mellitus have a worse functional outcome post knee arthroplasty: a matched cohort study.

Knee arthroplasty provides not only pain relief but also an improvement in function and range of movement. Limited joint mobility is a common complication of diabetes mellitus. We therefore examined functional outcome post total knee arthroplasty in a cohort of subjects with (n=367) and a cohort matched for age, sex, BMI and functional movement at baseline, without diabetes mellitus (n=367). Participants were examined at baseline (pre-operatively), 1, 5 and 10 years post TKA. There was no significant difference in fixed flexion, maximal flexion or total range of movement between the two groups at baseline. By 1 year the group with diabetes had a significantly lower maximal flexion (p<0.001), total range of movement (p<0.001) and Knee Society Score (p=0.034). Similar results were observed at years 5 (except for the KSS) and 10 post procedure. At 5 years post arthroplasty a significant increase was observed in fixed flexion (p=0.026) in the diabetic group. Ten years post arthroplasty yielded similar results. This study demonstrates that the pre-operative presence of diabetes mellitus leads to a worse outcome post knee arthroplasty, although no significant difference was demonstrable in KSS at 5 years (p=0.35) suggesting patient satisfaction remains high during this period.

Prevalence of impaired awareness of hypoglycaemia and frequency of hypoglycaemia in insulin-treated type 2 diabetes.

AIMS: The present study sought to ascertain the prevalence of impaired awareness of hypoglycaemia (IAH) in people with insulin-treated Type 2 diabetes (T2DM) and its effect on risk of hypoglycaemia. METHODS: Data were obtained from 122 people with insulin-treated T2DM (63 male; mean (SD) HbA1c 8.4% (1.5); median (inter quartile range, IQR) age, 67 (58-72) years; duration of T2DM 15 (10-20) years; duration of insulin therapy, 6 (4-9) years). A questionnaire was used to evaluate hypoglycaemia awareness status and estimate the frequency of severe hypoglycaemia (SH) in the preceding year. Capillary blood glucose was monitored prospectively over a 4-week period to document biochemical hypoglycaemia. RESULTS: The prevalence of IAH was 9.8%. In the subgroup with IAH the incidence of SH in the preceding year was 17-fold higher than those with normal hypoglycaemia awareness (0.83 (1.12) vs. 0.05 (0.28) episodes per patient; p<0.001 (n=122)) and had a five-fold higher incidence of biochemical hypoglycaemia (2.43 (4.39) vs. 0.46 (1.21) episodes; p<0.001 (n=63)). CONCLUSION: The prevalence of IAH in insulin-treated T2DM was associated with higher frequencies of SH and biochemical hypoglycaemia. Therefore the presence of IAH in those with insulin-treated T2DM should be evaluated at clinical review.

Modeling the effects of hypoglycemia on a two-choice task in adult humans.

OBJECTIVE: Previous research has demonstrated that hypoglycemia causes reaction times to be slower and more variable. Reaction time tests, however, use multiple cognitive and noncognitive processes. This study is the first to use a validated sequential sampling model (diffusion model) applied to results obtained from a simple 2-choice task in adult humans to assess the effects of hypoglycemia on the basic parameters of decision making. METHOD: Fourteen adult volunteers were tested on a numerosity discrimination task with and without reduced blood glucose concentrations. The results were analyzed with a model that dissects the components of processing that underlie decisions: the quality of the information on which a decision is based (drift rate), the critical amount of evidence that must be accumulated before a decision is made (boundary separation), and the time taken by nondecision processes. RESULTS: Hypoglycemia resulted in a reduction of mean drift rate from 0.290 to 0.211, t(13) = 4.10, p < .05. No effect of experimental state was observed on the amount of evidence required to make a decision or peripheral and motor processes. CONCLUSION: This study locates the precise processing deficit associated with hypoglycemia and provides further understanding of the precise cognitive effect of hypoglycemia. Further research into the amelioration of these effects is required.