Quality of life-related and non-quality of life-related issues in ICU survivors and non-ICU-treated controls: a multi-group exploratory factor analysis.

BACKGROUND: Quality of life (QoL) is a key outcome measure in healthcare. However, the heterogeneity in its definitions presents challenges in the objective evaluation of improvement. Universal questionnaires, tailored for a broad demographic group, inadequately represent the unique experiences of intensive care unit (ICU) survivors, including a lack of ability to discriminate issues related to QoL from issues that do not. METHODS: Using a 218-item, 13-domain provisional questionnaire, we assessed 395 adult ICU survivors, with a minimum 72-h stay at one of three Swedish university hospital ICUs, at 6 months to three years post-discharge. Their responses were compared to those of 195 controls, matched for age and sex and randomly recruited from the Swedish Population Registry. By multi-group exploratory factor analysis, we compared dimensionality in QoL perceptions between the two groups, emphasising patterns of correlation to 13 domain-specific QoL questions. Model fit was assessed using information criteria. Internal consistency reliability for each scale was determined using McDonald's omega or Cronbach's alpha. All analyses were conducted using Mplus, applying full information maximum likelihood to handle missing data. RESULTS: All domains except Cognition had a subset of questions correlating to the domain-specific QoL question in at least the ICU survivor group. The similarity between the two groups varied, with Physical health, Sexual health and Gastrointestinal (GI) functions mainly correlating the same issues to QoL in the two groups. In contrast, Fatigue, Pain, Mental health, activities of daily living, Sleep, Sensory functions and Work life showed considerable differences. In all, about one-fourth of the issues correlated to QoL in the ICU survivor group and about one-tenth of the issues in the control group. CONCLUSIONS: We found most issues experienced by ICU survivors to be unrelated to quality of life. Our findings indicate that the consequences of post-ICU issues may play a more significant role in affecting QoL than the issues themselves; issues restricting and affecting social life and work life were more related to QoL in ICU survivors than in non-ICU-treated controls. Caution is advised before associating all post-ICU problems with an effect on quality of life. TRIAL REGISTRATION: ClinicalTrials.gov Ref# NCT02767180; Registered 28 April 2016.

The relationship between ICU survivorship, comorbidity and educational level in quality of life after intensive care.

BACKGROUND: ICU survivors have lower quality of life (QoL) compared to a non-ICU-treated population. The reason for this is not fully understood, but differences in baseline characteristics may be an important factor. This study evaluates the roles of comorbidity and educational level as possible explanatory factors for differences in QoL in ICU survivors compared to a non-ICU-treated population. METHODS: Using a provisional questionnaire with 218 questions in 13 domains on QoL after intensive care, we compared the responses from 395 adult ICU survivors and 195 non-ICU-treated controls. An initial bivariable linear correlation analysis compared the responses from the two groups. Two secondary multivariable regression analyses tested for effect modification by comorbidity and educational level, respectively, on the effect on QoL from belonging to the ICU survivor group compared to the control group. RESULTS: There was a significant difference in QoL between the two groups in 170 of 218 (78%) questions. In the multivariable analyses, associations between group belonging and QoL remained in 139 questions. In 59 of these, both belonging to the ICU survivor group and comorbidity was associated to QoL, in parallel to each other. Comorbidity moderated the association between group belonging and QoL in six questions, with the highest proportion of questions within the domains of cognition and urinary functions, and the lowest proportion within appetite and alcohol, physical health, and fatigue. In 26 questions, both belonging to the ICU survivor group and educational level were associated to QoL, in parallel to each other. Educational level moderated the association between group belonging and QoL in 34 questions, with the highest proportion of questions within the domains of urinary functions, ADL and physical health, and the lowest proportion within the domains of cognition, appetite and alcohol, pain, sensory functions, and fatigue. CONCLUSIONS: Lower QoL seen in ICU survivors compared to non-ICU-treated controls, as measured by our provisional questionnaire, cannot be explained only by a higher burden of comorbidity, and rarely by only educational level. In issues where comorbidity or educational level was associated to QoL, it often was so in parallel to an association from belonging to the ICU survivor group. Comparing QoL in ICU survivors to that of a non-ICU-treated population may be adequate despite differences in baseline characteristics.

Reasons for physician-related variability in end-of-life decision-making in intensive care.

BACKGROUND: There is increasing evidence that the individual physician is the main factor influencing variability in end-of-life decision-making in intensive care units. End-of-life decisions are complex and should be adapted to each patient. Physician-related variability is problematic as it may result in unequal assessments that affect patient outcomes. The primary aim of this study was to investigate factors contributing to physician-related variability in end-of-life decision-making. METHOD: This is a qualitative substudy of a previously conducted study. In-depth thematic analysis of semistructured interviews with 19 critical care specialists from five different Swedish intensive care units was performed. Interviews took place between 1 February 2017 and 31 May 2017. RESULTS: Factors influencing physician-related variability consisted of different assessment of patient preferences, as well as intensivists' personality and values. Personality was expressed mainly through pace and determination in the decision-making process. Personal prejudices appeared in decisions, but few respondents had personally witnessed this. Avoidance of criticism and conflicts as well as individual strategies for emotional coping were other factors that influenced physician-related variability. Many respondents feared criticism for making their assessments, and the challenging nature of end-of-life decision-making lead to avoidance as well as emotional stress. CONCLUSION: Variability in end-of-life decision-making is an important topic that needs further investigation. It is imperative that such variability be acknowledged and addressed in a more formal and transparent manner. The ethical issues faced by intensivists have recently been compounded by the devastating impact of the COVID-19 pandemic, demonstrating in profound terms the importance of the topic.

Long-term health-related quality of life and burden of disease after intensive care: development of a patient-reported outcome measure.

BACKGROUND: ICU survivorship includes a diverse burden of disease. Current questionnaires used for collecting information about health-related problems and their relation to quality of life lack detailed questions in several areas relevant to ICU survivors. Our aim was to construct a provisional questionnaire on health-related issues based on interviews with ICU survivors and to test if this questionnaire was able to show differences between ICU survivors and a control group. METHODS: Thirty-two ICU survivors were identified at a post-ICU clinic and interviewed at least six months after ICU discharge. Using an established qualitative methodology from oncology, all dysfunctions and disabilities were extracted, rephrased as questions and compiled into a provisional questionnaire. In a second part, this questionnaire was tested on ICU survivors and controls. Inclusion criteria for the ICU survivors were ICU stay at least 72 h with ICU discharge six months to three years prior to the study. A non-ICU-treated control group was obtained from the Swedish Population Register, matched for age and sex. Eligible participants received an invitation letter and were contacted by phone. If willing to participate, they were sent the questionnaire. Descriptive statistics were applied. RESULTS: Analysis of the interviews yielded 238 questions in 13 domains: cognition, fatigue, physical health, pain, psychological health, activities of daily living, sleep, appetite and alcohol, sexual health, sensory functions, gastrointestinal functions, urinary functions and work life. In the second part, 395 of 518 ICU survivors and 197 of 231 controls returned a completed questionnaire, the response rates being 76.2% and 85.3%, respectively. The two groups differed significantly in 13 of 22 comorbidities. ICU survivors differed in a majority of questions (p ≤ 0.05) distributed over all 13 domains compared with controls. CONCLUSIONS: This study describes the development of a provisional questionnaire to identify health-related quality of life issues and long-term burden of disease after intensive care. The questionnaire was answered by 395 ICU survivors. The questionnaire could identify that they experience severe difficulties in a wide range of domains compared with a control group. Trial registry ClinicalTrials.gov Ref# NCT02767180.

Ethical decision-making climate in the ICU: theoretical framework and validation of a self-assessment tool.

BACKGROUND: Literature depicts differences in ethical decision-making (EDM) between countries and intensive care units (ICU). OBJECTIVES: To better conceptualise EDM climate in the ICU and to validate a tool to assess EDM climates. METHODS: Using a modified Delphi method, we built a theoretical framework and a self-assessment instrument consisting of 35 statements. This Ethical Decision-Making Climate Questionnaire (EDMCQ) was developed to capture three EDM domains in healthcare: interdisciplinary collaboration and communication; leadership by physicians; and ethical environment. This instrument was subsequently validated among clinicians working in 68 adult ICUs in 13 European countries and the USA. Exploratory and confirmatory factor analysis was used to determine the structure of the EDM climate as perceived by clinicians. Measurement invariance was tested to make sure that variables used in the analysis were comparable constructs across different groups. RESULTS: Of 3610 nurses and 1137 physicians providing ICU bedside care, 2275 (63.1%) and 717 (62.9%) participated respectively. Statistical analyses revealed that a shortened 32-item version of the EDMCQ scale provides a factorial valid measurement of seven facets of the extent to which clinicians perceive an EDM climate: self-reflective and empowering leadership by physicians; practice and culture of open interdisciplinary reflection; culture of not avoiding end-of-life decisions; culture of mutual respect within the interdisciplinary team; active involvement of nurses in end-of-life care and decision-making; active decision-making by physicians; and practice and culture of ethical awareness. Measurement invariance of the EDMCQ across occupational groups was shown, reflecting that nurses and physicians interpret the EDMCQ items in a similar manner. CONCLUSIONS: The 32-item version of the EDMCQ might enrich the EDM climate measurement, clinicians' behaviour and the performance of healthcare organisations. This instrument offers opportunities to develop tailored ICU team interventions.

Parallel haemodialysis and surgery saves a life after massive overdose of potassium pills.

Severe poisoning with potassium pills is rare but patients may present with serious cardiovascular symptoms requiring immediate and effective treatment. A 30-year-old healthy woman presented to the emergency department after ingestion of 300 slow-release pills of potassium-chloride with serum potassium of 9.5 mmol/l, and poor cardiovascular function. Gastric lavage was performed with poor outcome. Despite intensive medical treatment serum potassium remained very high around 9 mmol/l. Haemodialysis was initiated but despite ongoing dialysis, potassium increased to 10.3 mmol/l. Hence, a parallel dialysis was started and after 4 h of parallel dialysis, serum potassium decreased to 6.4 mmol/l. An x-ray revealed large amounts of pills remaining in the stomach and the surgeon was able to remove about 200 pills through an acute laparotomy. The patient recovered slowly thereafter, but later developed a gastric stricture and pulmonary embolism.

Global differences in causes, management, and survival after severe trauma: the recombinant activated factor VII phase 3 trauma trial.

BACKGROUND: Little is known about international variation in mortality after severe trauma. This study examines variation in mortality, injury severity, and case management among countries from a recent prospective multinational trauma trial. METHODS: This trauma trial was a prospective, randomized, double-blinded, multicenter comparison of recombinant activated factor VII versus placebo in severely injured bleeding trauma patients. Differences in baseline patient characteristics, case management, and clinical outcomes were examined for the 11 countries recruiting most patients. Between-country differences in mortality were examined using regression analysis adjusting for case mix and case management differences. Global predictors of mortality were also identified using multivariate regression analysis. RESULTS: Significant differences were observed between countries in unadjusted mortality rates at 24 hours (p = 0.025) and 90 days (p < 0.0001). When adjusting for differences in case mix and case management, the between country differences in mortality at 24 hours and 90 days remained significant. Consistent independent predictors of 24-hour, 24-hour to 90-day, and 90-day mortality were admission lactate >or=5 mmol/L (odds ratio: 9.06, 3.56, and 5.39, respectively) and adherence to clinical management guidelines (odds ratio: 4.92, 5.90, and 3.26, respectively). On average, the damage control surgery guideline was less well adhered to than the RBC transfusion and ventilator guidelines. There was statistically significant variation between countries with respect to adherence to the RBC transfusion guideline. CONCLUSIONS: Considering international variation in mortality when designing or interpreting results from multinational trauma studies is important. Significant differences in mortality persisted between patients from different countries after case mix and case management adjustment. Adherence to clinical guidelines was associated with improved survival. Stratification, case mix adjustment, and use of guidelines on damage control surgery, transfusion, and ventilation may mitigate country-driven variation in mortality.