Emerging Ethical Challenges in Critical Care for the 21st Century: A Case-Based Discussion.

Ethical challenges for doctors and other health care professionals have existed since the practice of medicine began. Many of the oldest challenges live on to this day, such as who has more authority to make key decisions (autonomy vs. paternalism) and what are the boundaries of life at the beginning and at the end. Two powerful driving forces are new technologies and an ever-changing culture and society. The practice of medicine in intensive care units (ICUs) has been the source of many ethical challenges. Once firmly fixed concepts, such as death or "brain death" are now coming under increasing debate. In other areas, the concept of patient autonomy has been used to request life-prolonging therapies, once thought "futile." New technologies for procreation have necessitated new ethical challenges as well. In this paper, we will use a series of cases, based on experiences from our hospital ethics committee, that occurred over the course of several years and illustrate ethical challenges which are either new to us or not new but growing in frequency due to technological or societal changes. Each one of these topics is complex and worthy of its own large review but for this overview, we will briefly discuss the key points of each dilemma.

Critical Care Beds and Resource Utilization: Current Trends and Controversies.

Recent studies have shown a dramatic increase in the number of intensive care unit (ICU) beds in recent decades. As technologies have become more complex, ICUs continue to grow in size and in specialization. The driving forces behind ICU bed expansion include not only the incorporation of advanced technologies but also other factors such as the increased utilization of ICU beds for patients who previously were not offered ICU care--those who may be terminally ill and those who are not critically ill. This expansion of ICU care in the United States sets it apart from other industrialized nations with comparably fewer ICU beds in relation to other hospital beds. The consequences of this expansion are now being felt in the form of unused beds, workforce shortages, and overuse of ICUs for patients who previously were not cared for in ICUs. ICUs are also now commonly used in the care of dying patients. In coming decades it is likely that changes will need to take place to forestall exorbitant costs and labor shortages. In addition to bringing in new forms of medical staff such as hospitalists and physician assistants, recent opinion papers have suggested that a de-escalation of ICU growth and a new tiered system of ICU care will be necessary in the United States.

Intensivist-to-patient ratios in ICUs: is there a number?

PURPOSE OF REVIEW: Growth in critical care services has led to a dramatic increase in the need for ICU physicians. The supply of intensivists is not easily increased and there is pressure to solve this problem by increasing the number of patients per intensivist. There is a scarcity of published data addressing this issue, and until recently, there were no guidelines on appropriate ratios of intensivists to patients. RECENT FINDINGS: In 2013, the Society of Critical Care Medicine formed a task force to address this issue and published written guidelines to aid hospitals in determining their intensivist staffing. This study reviews the published data which can aid these decisions and summarize the SCCM Taskforce's recommendations. SUMMARY: The complex nature of critical care patients and ICUs make it difficult to provide one specific maximum intensivist-to-patient ratio, but common-sense rules can be applied. These recommendations are predicated on the principles that staffing can impact patient care as well as staff well-being and workforce stability. Also, that worsening patient outcomes, teaching, and workforce issues can be markers of inappropriate staffing. Finally, if the predicted daily workload of an intensivist exceeds the time of a work shift, then adjustments need to be made.

The functional neuroimaging correlates of psychogenic versus organic dystonia.

The neurobiological basis of psychogenic movement disorders remains poorly understood and the management of these conditions difficult. Functional neuroimaging studies have provided some insight into the pathophysiology of disorders implicating particularly the prefrontal cortex, but there are no studies on psychogenic dystonia, and comparisons with findings in organic counterparts are rare. To understand the pathophysiology of these disorders better, we compared the similarities and differences in functional neuroimaging of patients with psychogenic dystonia and genetically determined dystonia, and tested hypotheses on the role of the prefrontal cortex in functional neurological disorders. Patients with psychogenic (n = 6) or organic (n = 5, DYT1 gene mutation positive) dystonia of the right leg, and matched healthy control subjects (n = 6) underwent positron emission tomography of regional cerebral blood flow. Participants were studied during rest, during fixed posturing of the right leg and during paced ankle movements. Continuous surface electromyography and footplate manometry monitored task performance. Averaging regional cerebral blood flow across all tasks, the organic dystonia group showed abnormal increases in the primary motor cortex and thalamus compared with controls, with decreases in the cerebellum. In contrast, the psychogenic dystonia group showed the opposite pattern, with abnormally increased blood flow in the cerebellum and basal ganglia, with decreases in the primary motor cortex. Comparing organic dystonia with psychogenic dystonia revealed significantly greater regional blood flow in the primary motor cortex, whereas psychogenic dystonia was associated with significantly greater blood flow in the cerebellum and basal ganglia (all P < 0.05, family-wise whole-brain corrected). Group × task interactions were also examined. During movement, compared with rest, there was abnormal activation in the right dorsolateral prefrontal cortex that was common to both organic and psychogenic dystonia groups (compared with control subjects, P < 0.05, family-wise small-volume correction). These data show a cortical-subcortical differentiation between organic and psychogenic dystonia in terms of regional blood flow, both at rest and during active motor tasks. The pathological prefrontal cortical activation was confirmed in, but was not specific to, psychogenic dystonia. This suggests that psychogenic and organic dystonia have different cortical and subcortical pathophysiology, while a derangement in mechanisms of motor attention may be a feature of both conditions.

Intensivist/patient ratios in closed ICUs: a statement from the Society of Critical Care Medicine Taskforce on ICU Staffing.

OBJECTIVES: Increases in the number, size, and occupancy rates of ICUs have not been accompanied by a commensurate growth in the number of critical care physicians leading to a workforce shortage. Due to concern that understaffing may exist, the Society of Critical Care Medicine created a taskforce to generate guidelines on maximum intensivists/patient ratios. DATA SOURCES: A multidisciplinary taskforce conducted a review of published literature on intensivist staffing and related topics, a survey of pulmonary/Critical Care physicians, and held an expert roundtable conference. DATA EXTRACTION: A statement was generated and revised by the taskforce members using an iterative consensus process and submitted for review to the leadership council of the Society of Critical Care Medicine. For the purposes of this statement, the taskforce limited its recommendations to ICUs that use a "closed" model where the intensivists control triage and patient care. DATA SYNTHESIS AND CONCLUSIONS: The taskforce concluded that while advocating a specific maximum number of patients cared for is unrealistic, an approach that uses the following principles is essential: 1) proper staffing impacts patient care; 2) large caseloads should not preclude rounding in a timely fashion; 3) staffing decisions should factor surge capacity and nondirect patient care activities; 4) institutions should regularly reassess their staffing; 5) high staff turnover or decreases in quality-of-care indicators in an ICU may be markers of overload; 6) telemedicine, advanced practice professionals, or nonintensivist medical staff may be useful to alleviate overburdening the intensivist, but should be evaluated using rigorous methods; 7) in teaching institutions, feedback from faculty and trainees should be sought to understand the implications of potential understaffing on medical education; and 8) in academic medical ICUs, there is evidence that intensivist/patient ratios less favorable than 1:14 negatively impact education, staff well-being, and patient care.

Perceived effects of attending physician workload in academic medical intensive care units: a national survey of training program directors.

BACKGROUND: Increases in the size and number of American intensive care units have not been accompanied by a comparable increase in the critical care physician workforce, raising concerns that intensivists are becoming overburdened by workload. This is especially concerning in academic intensive care units where attending physicians must couple teaching duties with patient care. METHODS: We performed an in-person and electronic survey of the membership of the Association of Pulmonary and Critical Care Medicine Program Directors, soliciting information about patient workload, other hospital and medical education duties, and perceptions of the workplace and teaching environment of their intensive care units. RESULTS: Eighty-four out of a total 121 possible responses were received from program directors or their delegates, resulting in a response rate of 69%. The average daily (SD) census (as perceived by the respondents) was 18.8 ± 8.9 patients, and average (SD) maximum service size recalled was 24.1 ± 9.9 patients. Twenty-seven percent reported no policy setting an upper limit for the daily census. Twenty-eight percent of respondents felt the average census was "too many" and 71% felt the maximum size was "too many." The median (interquartile range) patient-to-attending physician ratio was 13 (10-16). When categorized according to this median, respondents from intensive care units with high patient/physician ratios (n = 31) perceived significantly more time constraints, more stress, and difficulties with teaching trainees than respondents with low patient/physician ratios (n = 40). The total number of non-nursing healthcare workers per patient was similar in both groups, suggesting that having more nonattending physician staff does not alleviate perceptions of overwork and stress in the attending physician. CONCLUSIONS: Academic intensive care unit physicians that direct fellowship programs frequently perceived being overburdened in the intensive care unit. Understaffing intensive care units with attending physicians may have a negative impact on teaching, patient care, and workforce stability.

Implementing a collaborative protocol in a sepsis intervention program: lessons learned.

The objective of this prospective cohort study was to see the effect of the implementation of a Sepsis Intervention Program on the standard processes of patient care using a collaborative approach between the Emergency Department (ED) and Medical Intensive Care Unit (MICU). This was performed in a large urban tertiary-care hospital, with no previous experience utilizing a specific intervention program as routine care for septic shock and which has services and resources commonly available in most hospitals. The study included 106 patients who presented to the ED with severe sepsis or septic shock. Eighty-seven of those patients met the inclusion criteria for complete data analysis. The ED and MICU staff underwent a 3-month training period followed by implementation of a protocol for sepsis intervention program over 6 months. In the first 6 months of the program's implementation, 106 patients were admitted to the ED with severe sepsis and septic shock. During this time, the ED attempted to initiate the sepsis intervention protocol in 76% of the 87 septic patients who met the inclusion criteria. This was assessed by documentation of a central venous catheter insertion for continuous SvO(2) monitoring in a patient with sepsis or septic shock. However, only 48% of the eligible patients completed the early goal-directed therapy (EGDT) protocol. Our data showed that the in-hospital mortality rate was 30.5% for the 87 septic shock patients with a mean APACHE II score of 29. This was very similar to a landmark study of EGDT (30.5% mortality with mean APACHE II of 21.5). Data collected on processes of care showed improvements in time to fluid administration, central venous access insertion, antibiotic administration, vasopressor administration, and time to MICU transfer from ED arrival in our patients enrolled in the protocol versus those who were not. Further review of our performance data showed that processes of care improved steadily the longer the protocol was in effect, although this was not statistically significant. There was no improvement in secondary outcomes, including total length of hospital stay, MICU days, and mortality. Implementation of a sepsis intervention program as a standard of care in a typical hospital protocol leads to improvements in processes of care. However, despite a collaborative approach, the sepsis intervention program was underutilized with only 48% of the patients completing the sepsis intervention protocol.

Biomarkers of Immunosuppression.

It is now recognized that sepsis is not a uniformly proinflammatory state. There is a well-recognized counter anti-inflammatory response that occurs in many patients. The timing and magnitude of this response varies considerably and thus makes its identification and manipulation more difficult. Studies in animals and humans have now identified a small number of biologic responses that characterize this immunosuppressed state, such as lymphocyte death, HLA receptor downregulation, and monocyte exhaustion. Researchers are now trying to use these as markers of individual immunosuppression to predict outcomes and identify patients who would and would not benefit from new immune stimulatory therapies.

Using serial severity scores to predict death in ICU patients: a validation study and review of the literature.

PURPOSE OF REVIEW: The present study describes the use of serial severity scores to predict death in ICU patients and compares the results with previously published literature on this topic. RECENT FINDINGS: Predicting mortality in critically ill patients has tremendous significance and methods to do so accurately have been studied for decades. The ability to accurately predict death impacts medical therapies, triaging, end-of-life care, and many other aspects of ICU care. There are many methods in existence to help physicians predict mortality, but most are not very accurate on an individual basis. The main tools available are severity scores, published outcomes data, and personal experience and all of them have significant limitations. One strategy that has been shown to be effective in accurately predicting death is to use serial severity scoring during the patient's ICU admission. Recently, a retrospective study done on a large cohort of ICU patients at a single institution showed very high specificity in predicting death by using serial acute physiology, age, and chronic health evaluation (APACHE III) scores on days 1 and 3. The authors of this article sought to validate this study in a different institution using a slightly different model that was easier to use and might increase sensitivity. The results of this small study are presented with a review of the literature on the use of serial scores to predict death in ICU patients. SUMMARY: Over the years multiple studies have shown that systems using serial severity scores can predict death in ICU patients with very high but not perfect accuracy. The clinical use of these systems remains low however and ultimately their main utility may be in research.

Clinical concise review: Mechanical ventilation of patients with chronic obstructive pulmonary disease.

OBJECTIVE: To summarize the current literature on mechanical ventilation of patients with chronic obstructive pulmonary disease (COPD) using published data to augment commonly accepted principles of clinical practice. DATA SOURCE: A MEDLINE/PubMed search from 1966 to November 2006 using the search terms mechanical ventilation, respiratory failure, noninvasive positive pressure ventilation (NIPPV), and COPD, and weaning. Subsequent searches were done on more specific issues such as heliox. Additionally, prominent researchers in this field were interviewed for knowledge of ongoing or unpublished data and their clinical practice. DATA EXTRACTION AND SYNTHESIS: COPD is very common cause of respiratory failure and admission to the intensive care unit. Mechanical ventilation of patients with COPD presents a unique set of challenges compared with other patients. Care must be taken to avoid augmenting dynamic hyperinflation and acid/base disturbances resulting from chronic hypercapnic respiratory failure. Modalities such as NIPPV and helium/oxygen gas mixtures are increasingly being recognized for their ability to help prevent invasive ventilation and aid in getting patients off invasive ventilation. CONCLUSIONS: Despite decades of study, most of the principles of safe mechanical ventilation for patients with COPD such as low respiratory rates that maximize expiratory time and careful attention to air-trapping still hold true to this day. NIPPV appears to be the most important new modality in reducing the mortality, morbidity and incidence of invasive mechanical ventilation.

Perceptions of cost constraints, resource limitations, and rationing in United States intensive care units: results of a national survey.

OBJECTIVE: To examine cost constraints, resource limitations, and rationing within U.S. intensive care units (ICUs) as perceived by ICU clinicians and the roles of ICU physician and nurse directors in resource allocation decisions. DESIGN: A national survey of hospitals with ICUs. SETTING: The study included 447 U.S. hospitals with ICUs. SUBJECTS: ICU nurse and physician directors. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We randomly selected 447 U.S. hospitals stratified for location and ICU size and contacted them for this survey. The institutional response rate was 63%. When asked to characterize their involvement in budgetary decisions, 55% of nurse directors vs. 3% (p < .001) of physician directors answered "heavy" involvement. Additionally, 91% of nurse vs. 38% of physician directors were given feedback on expenditures (p < .001). Responses to questions about specific situations or practices that may be associated with rationing showed that a substantial minority respondents perceived these practices "sometimes" (occurring 25% to 74% of the time) but the majority perceived it "rarely" (occurring <25% of the time) or not at all. Few perceived rationing as occurring "frequently" (occurring >75% of the time) because of costs or availability. When asked if any rationing occurs in their ICUs (using a prestated definition), only 11% of physician and 6% of nurse directors responded yes. Only 6% of nurses and 5% of physicians said that cost constraints have a significant effect on care. In contrast, when asked how often patients receive "too much" care, 46% of respondents said "sometimes or frequently." CONCLUSIONS: Nurse managers have a larger role in managing ICU costs than physicians. Furthermore, both groups perceive that rationing and other cost-related practices sometimes occur in their ICU, but they more commonly perceived excessive care in ICUs. These data may be helpful for policy makers and administrators and may serve as a benchmark for future studies in critical care or other realms of health care.

Nonconsented human immunodeficiency virus testing among critically ill patients: intensivists' practices and the influence of state laws.

BACKGROUND: Human immunodeficiency virus (HIV) testing can improve care for many critically ill patients, but state laws and institutional policies may impede such testing when patients cannot provide consent. METHODS: We electronically surveyed all US academic intensivists in 2006 to determine how state laws influence intensivists' decisions to perform nonconsented HIV testing and to assess intensivists' reliance on surrogate markers of HIV infection when unable to obtain HIV tests. We used multivariate logistic regression, clustered by state, to identify factors associated with intensivists' decisions to pursue nonconsented HIV testing. RESULTS: Of 1,026 responding intensivists, 765 (74.6%) had encountered decisionally incapacitated patients for whom HIV testing was wanted. Of these intensivists, 168 pursued testing without consent and 476 first obtained surrogate consent to testing. Intensivists who believed nonconsented HIV testing was ethical (odds ratio, 3.8; 95% confidence interval, 2.2-6.5) and those who believed their states allowed nonconsented testing when medically necessary (odds ratio, 2.3; 95% confidence interval, 1.6-3.4) were more likely to pursue nonconsented HIV tests; actual state laws were unrelated to testing practices. Of the intensivists, 72.7% had ordered tests for perceived surrogate markers of HIV infection in lieu of HIV tests; more than 90% believed these tests were sufficiently valid to base clinical decisions on. CONCLUSIONS: Most US intensivists have encountered decisionally incapacitated patients for whom HIV testing may improve care. Intensivists' decisions to pursue nonconsented testing are associated with their personal ethics and often erroneous perceptions of state laws, but not with the laws themselves. Uniform standards enabling nonconsented HIV testing may minimize inappropriate influences on intensivists' decisions and reduce intensivists' reliance on perceived surrogate markers of immunodeficiency.

Development of an e-mail database of US intensive care physicians.

PURPOSE: Although surveying critical care physicians regarding their behaviors and attitudes may usefully inform clinical, ethical, and policy questions, few resources exist for surveying intensivists electronically. We sought to develop an e-mail database for all intensivists associated with US training programs in critical care medicine (academic intensivists) and to determine the feasibility of using this database to survey intensivists. MATERIALS AND METHODS: We obtained e-mail addresses for academic intensivists by consulting each training program's institutional Web site or contacting program directors directly. We sent presumed intensivists up to 3 e-mail invitations to participate in an initial survey. RESULTS: We identified 2858 potential intensivists and obtained operative e-mail addresses for 2494 (87%). Only 31 (9%) of the remaining intensivists were members of the Society of Critical Care Medicine, suggesting that most of those without identified addresses were not intensivists. During the conduct of an initial survey, 161 physicians self-identified themselves as nonintensivists; of the remaining 2333 presumed intensivists, 1026 (44%) responded and 44 (2%) opted out. The response rate of 44% is based on the conservative assumptions that the remaining 1263 physicians were intensivists and saw the e-mail invitation. CONCLUSIONS: This database provides a unique resource for investigators wishing to efficiently identify the views and practice patterns of US academic intensivists and provides a benchmark response rate of approximately 44% for electronic surveys of intensivists.

Enterovirus D68 Infection in an Adult.

The first confirmed US case of severe respiratory tract infection caused by enterovirus D68 in an adult occurred in a pregnant woman with no history of asthma in August 2014. Before she came to the hospital, she had a productive cough, headache, and increasing dyspnea. At the hospital, she was hypoxic and required admittance to the intensive care unit and management with noninvasive bilevel positive pressure assistance. Analysis of a nasopharyngeal swab sent to the Centers for Disease Control and Prevention for a viral respiratory panel of tests confirmed enterovirus D68 infection. She eventually had an uneventful vaginal delivery, was discharged without oxygen supplementation, and has resumed normal activities. This case suggests that pregnant women may be a sentinel group infected with this pathogen, similar to what has been described for influenza virus infection.

Provider to patient ratios for nurse practitioners and physician assistants in critical care units.

BACKGROUND: Nurse practitioners and physician assistants are being increasingly integrated into intensive care unit and hospital-based care teams, yet limited information is available on provider to patient ratios. OBJECTIVE: To determine current provider to patient ratios for nurse practitioners and physician assistants working in intensive and acute care units and to assess factors that affect the ratios. METHODS: A descriptive study design was used with a Web-based survey of members of the American Association of Nurse Practitioners, American Academy of Physician Assistants, and the Society of Critical Care Medicine. RESULTS: Responses were received from 222 nurse practitioners and 211 physician assistants from all but 8 of the 50 United States and from Canada. Mean provider to patient ratios in intensive care were 1 to 5 (range, 1 to 3 - 1 to 8). In pediatric intensive care, the mean ratio of nurse practitioners to patients was 1 to 4 (range, 1 to 3 - 1 to 8). Factors that affected nurse practitioner and physician assistant provider to patient ratios included patients' severity of illness, number of patients in the unit, number of providers in the unit, patient diagnosis, number of physicians in the unit, time of day, and number of fellows and medical residents on service. CONCLUSIONS: Additional information on factors influencing provider to patient ratios and specific components of the roles of nurse practitioners and physician assistants will be important to ensure the best utilization of these providers to enable optimal patient care outcomes.

The accuracy of clinical information systems.

The clinical information system (CIS) is becoming more common in intensive care units. These systems have the ability to record, store, and retrieve large amounts of clinical patient data with great ease. This should greatly facilitate outcomes research and quality assurance. Unfortunately, there is not much information available about the accuracy of the data coming from these systems. True accuracy of a patient record requires both completeness of data and correctness of data as well as legibility. Automated systems are clearly superior to human entered data in terms of completeness and legibility but the correctness of entered data remains unclear. There are aspects of automated data entry that facilitate erroneous data entry. This article reviews the existing literature on accuracy of CISs with special attention to the qualities of automated data entry that can lead to false data. Additionally, data are presented from a newly published study by the author evaluating the validity of data from a commercially available CIS.