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1.
Crit Care Med ; 47(3): 369-376, 2019 03.
Artículo en Inglés | MEDLINE | ID: mdl-30585833

RESUMEN

OBJECTIVES: To explore how nonphysicians and physicians interpret the word "treatable" in the context of critical illness. DESIGN: Qualitative study using in-depth interviews. SETTING: One academic medical center. SUBJECTS: Twenty-four nonphysicians (patients and community members) purposively sampled for variation in demographic characteristics and 24 physicians (attending physicians and trainees) purposively sampled from four specialties (critical care, palliative care, oncology, and surgery). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We identified two distinct concepts that participants used to interpret the word "treatable": 1) a "good news" concept, in which the word "treatable" conveys a positive message about a patient's future, thereby inspiring hope and encouraging further treatment and 2) an "action-oriented" concept, in which the word "treatable" conveys that physicians have an action or intervention available, but does not necessarily imply an improved prognosis or quality of life. The overwhelming majority of nonphysicians adopted the "good news" concept, whereas physicians almost exclusively adopted the "action-oriented" concept. For some nonphysicians, the word "treatable" conveyed a positive message about prognosis and/or further treatment, even when this contradicted previously stated negative information. CONCLUSIONS: Physician use of the word "treatable" may lead patients or surrogates to derive unwarranted good news and false encouragement to pursue treatment, even when physicians have explicitly stated information to the contrary. Further work is needed to determine the extent to which the word "treatable" and its cognates contribute to widespread decision-making and communication challenges in critical care, including discordance about prognosis, misconceptions that palliative treatments are curative, and disputes about potentially inappropriate or futile treatment.


Asunto(s)
Toma de Decisiones Clínicas , Comunicación , Enfermedad Crítica/terapia , Terminología como Asunto , Adulto , Anciano , Toma de Decisiones Clínicas/métodos , Femenino , Humanos , Entrevistas como Asunto , Masculino , Persona de Mediana Edad , Médicos/psicología
2.
Pediatr Crit Care Med ; 18(5): 429-433, 2017 May.
Artículo en Inglés | MEDLINE | ID: mdl-28277376

RESUMEN

OBJECTIVES: To determine the 1) incidence of subglottic stenosis in infants and children following cardiac surgery with cardiopulmonary bypass and 2) risk factors associated with its development. DESIGN: Retrospective cohort study. SETTING: Tertiary children's hospital in California. PATIENTS: Infants and children who underwent cardiac surgery with cardiopulmonary bypass. INTERVENTIONS: Diagnosis of subglottic stenosis by tracheoscopy. MEASUREMENTS AND MAIN RESULTS: The incidence of subglottic stenosis at our institution during the study period was 0.7%. Young age (p = 0.014), prolonged cardiopulmonary bypass (p = 0.03), and prolonged mechanical ventilation (p < 0.01) were associated with the development of subglottic stenosis. Gender, chromosomal anomaly, presence of a cuffed endotracheal tube, and lowest core temperature during cardiopulmonary bypass were not associated with the development of subglottic stenosis. CONCLUSIONS: The incidence of subglottic stenosis was less than that previously reported in this population. Although the incidence is relatively low, subglottic stenosis is a serious complication of tracheal intubation and all measures to prevent subglottic stenosis should be undertaken.


Asunto(s)
Procedimientos Quirúrgicos Cardíacos , Puente Cardiopulmonar , Laringoestenosis/epidemiología , Laringoestenosis/etiología , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Adolescente , Niño , Preescolar , Femenino , Humanos , Incidencia , Lactante , Recién Nacido , Laringoestenosis/diagnóstico por imagen , Masculino , Evaluación de Resultado en la Atención de Salud , Complicaciones Posoperatorias/diagnóstico por imagen , Estudios Retrospectivos , Factores de Riesgo
3.
Camb Q Healthc Ethics ; 26(4): 628-639, 2017 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-28937345

RESUMEN

This article addresses questions surrounding the minimally conscious state (MCS) from the perspective of adult clinical ethics. It describes the background of the MCS diagnosis, analyzes phenomenological ambiguities inherent in the nature of MCS, and raises epistemological concerns surrounding its diagnosis. It argues that in many cases, the burdens of prolonging treatment for people who have sustained certain severe brain injuries (SBI) outweigh the benefits, even if they are in or have the prospect of entering into MCS. It also argues that often such long-term measures are problematic from the perspective of patient preferences and stewardship of resources. Consequently, it suggests that the delineation of MCS as a distinct neurological state, along with research that seeks to expand how MCS is diagnosed, poses ethical difficulties for families and providers making decisions for affected patients.


Asunto(s)
Lesiones Encefálicas/terapia , Ética Clínica , Estado Vegetativo Persistente/diagnóstico , Adulto , Discusiones Bioéticas , Humanos
4.
Pediatr Crit Care Med ; 15(5): 401-8, 2014 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-24583503

RESUMEN

OBJECTIVES: Secondary hemophagocytic lymphohistiocytosis, macrophage activating syndrome, and sepsis share the same inflammatory phenotype leading often to multiple organ dysfunction syndrome needing intensive care. The goal of this article is to describe our experience with anakinra (Kineret), a recombinant interleukin-1 receptor antagonist, in decreasing the systemic inflammation. DESIGN: Retrospective case series. SETTING: The PICU at the Helen DeVos Children's Hospital (Grand Rapids, MI). PATIENTS: The records of eight critically ill children presumed to have secondary hemophagocytic lymphohistiocytosis at our institution between January 1, 2011, and July 31, 2012, were reviewed. INTERVENTIONS: All of the patients were treated with anakinra (Kineret) and in some cases systemic corticosteroids as first-line therapy for secondary hemophagocytic lymphohistiocytosis. MEASUREMENTS AND MAIN RESULTS: Patients had a median age of 14 years and a median Pediatric Risk of Mortality score of 11.5. Four were previously healthy and four had underlying diseases that could have made them susceptible to secondary hemophagocytic lymphohistiocytosis. Indications for PICU transfer were respiratory distress 50% (4 of 8), cardiovascular instability 37.5% (3 of 8), and chest pain (1 of 8). Five of the patients (62.5%) were mechanically ventilated and 62.5% (5 of 8) received vasoactive infusions. Inflammatory markers were assessed linearly at the start of therapy and 7 days later. Baseline C-reactive protein was 206 ± 50 mg/L (mean ± SEM) at the start of anakinra and decreased by 67.1% to 68 ± 36 mg/L (p = 0.03). Ferritin decreased by 63.8% to 3,210 ± 1,178 ng/mL (p = 0.30), and fibrinogen decreased by 42% to 158 ± 41 mg/dL (p = 0.03). Absolute neutrophil count (p = 0.38) and absolute lymphocyte count (p = 0.69) did not change significantly. No infections were attributed to anakinra therapy. One patient died long after treatment with anakinra while receiving pre-hematopoietic stem cell transplant chemotherapy. CONCLUSIONS: Anakinra could represent a promising therapeutic approach in these life-threatening disorders that are likely underdiagnosed and often difficult to treat.


Asunto(s)
Antirreumáticos/uso terapéutico , Proteína Antagonista del Receptor de Interleucina 1/uso terapéutico , Linfohistiocitosis Hemofagocítica/tratamiento farmacológico , Adolescente , Antiinflamatorios/uso terapéutico , Proteína C-Reactiva/metabolismo , Niño , Cuidados Críticos , Femenino , Ferritinas/sangre , Fibrinógeno/metabolismo , Humanos , Inmunoglobulinas Intravenosas/uso terapéutico , Factores Inmunológicos/uso terapéutico , Recuento de Linfocitos , Linfocitos , Linfohistiocitosis Hemofagocítica/sangre , Síndrome de Activación Macrofágica/tratamiento farmacológico , Masculino , Insuficiencia Multiorgánica/tratamiento farmacológico , Neutrófilos , Estudios Retrospectivos , Sepsis/tratamiento farmacológico , Esteroides/uso terapéutico , Adulto Joven
5.
Chest ; 163(1): 192-201, 2023 01.
Artículo en Inglés | MEDLINE | ID: mdl-36007596

RESUMEN

BACKGROUND: No Escalation of Treatment (NoET) designations are used in ICUs internationally to limit treatment for critically ill patients. However, they are the subject of debate in the literature and have not been qualitatively studied. RESEARCH QUESTION: How do physicians understand and perceive NoET designations, especially regarding their usefulness and associated challenges? What mechanisms do hospitals provide to facilitate the use of NoET designations? STUDY DESIGN AND METHODS: Qualitative study at seven US hospitals, employing semistructured interviews with 30 physicians and review of relevant institutional records (eg, hospital policies, screenshots of ordering menus in the electronic health record). RESULTS: At all hospitals, participants reported the use of NoET designations, which were understood to mean that providers should withhold new or higher-intensity interventions ("escalations") but not withdraw ongoing interventions. Three hospitals provided a specific mechanism for designating a patient as NoET (eg, a DNR/Do Not Escalate code status order); at the remaining hospitals, a variety of informal methods (eg, verbal hand-offs) were used. We identified five functions of NoET designations: (1) Defining an intermediate point of treatment limitation, (2) helping physicians navigate prearrest clinical decompensations, (3) helping surrogate decision-makers transition toward comfort care, (4) preventing patient harm from invasive measures, and (5) conserving critical care resources. Across hospitals, participants reported implementation challenges related to the ambiguity in meaning of NoET designations. INTERPRETATION: Despite ongoing debate, NoET designations are used in a varied sample of hospitals and are perceived as having multiple functions, suggesting they may fulfill an important need in the care of critically ill patients, especially at the end of life. The use of NoET designations can be improved through the implementation of a formal mechanism that encourages consistency across providers and clarifies the meaning of "escalation" for each patient.


Asunto(s)
Enfermedad Crítica , Médicos , Humanos , Enfermedad Crítica/terapia , Unidades de Cuidados Intensivos , Cuidados Críticos
7.
PLoS One ; 12(11): e0187375, 2017.
Artículo en Inglés | MEDLINE | ID: mdl-29095938

RESUMEN

OBJECTIVES: In the context of serious or life-limiting illness, pediatric patients and their families are faced with difficult decisions surrounding appropriate resuscitation efforts in the event of a cardiopulmonary arrest. Code status orders are one way to inform end-of-life medical decision making. The objectives of this study are to evaluate the extent to which pediatric providers have knowledge of code status options and explore the association of provider role with (1) knowledge of code status options, (2) perception of timing of code status discussions, (3) perception of family receptivity to code status discussions, and (4) comfort carrying out code status discussions. DESIGN: Nurses, trainees (residents and fellows), and attending physicians from pediatric units where code status discussions typically occur completed a short survey questionnaire regarding their knowledge of code status options and perceptions surrounding code status discussions. SETTING: Single center, quaternary care children's hospital. MEASUREMENTS AND MAIN RESULTS: 203 nurses, 31 trainees, and 29 attending physicians in 4 high-acuity pediatric units responded to the survey (N = 263, 90% response rate). Based on an objective knowledge measure, providers demonstrate poor understanding of available code status options, with only 22% of providers able to enumerate more than two of four available code status options. In contrast, provider groups self-report high levels of familiarity with available code status options, with attending physicians reporting significantly higher levels than nurses and trainees (p = 0.0125). Nurses and attending physicians show significantly different perception of code status discussion timing, with majority of nurses (63.4%) perceiving discussions as occurring "too late" or "much too late" and majority of attending physicians (55.6%) perceiving the timing as "about right" (p<0.0001). Attending physicians report significantly higher comfort having code status discussions with families than do nurses or trainees (p≤0.0001). Attending physicians and trainees perceive families as more receptive to code status discussions than nurses (p<0.0001 and p = 0.0018, respectively). CONCLUSIONS: Providers have poor understanding of code status options and differ significantly in their comfort having code status discussions and their perceptions of these discussions. These findings may reflect inherent differences among providers, but may also reflect discordant visions of appropriate care and function as a potential source of moral distress. Lack of knowledge of code status options and differences in provider perceptions are likely barriers to quality communication surrounding end-of-life options.


Asunto(s)
Reanimación Cardiopulmonar , Niño , Humanos
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