Poor Concordance Between Intensive Care Unit Patients' and Family Members' Patient Dignity Inventory Scores Despite Communication of Dignity-Related Distress.

BACKGROUND: Promptly assessing and treating the distress of intensive care unit (ICU) patients may improve long-term psychological outcomes. One holistic approach to reduce patient distress is through dignity-centered care, traditionally used in palliative care. The 25-item Patient Dignity Inventory has construct validity and reliability for measuring dignity-related distress among ICU patients. Because family members often serve as ICU patients' surrogates and play an integral role in patients' dignity, we examined whether family members reliably recognized ICU patients' sources of distress. METHODS: Two single-center observational studies of adult ICU patients were performed from May to June 2022. Inclusion criteria were ICU length-of-stay >48 hours, awake and alert, intact cognition, and no delirium. Study #1 evaluated concordance between patient and family for dignity-related distress. Both completed the Patient Dignity Inventory independently. The next Study #2 measured how many distressing items that the patient reported discussing with family members. RESULTS: Study #1 of concordance had 33 patient-family dyads complete the Patient Dignity Inventory. The concordance correlation coefficient was small, 0.20 (99% confidence interval -0.21 to 0.55) and less than the inventory's test-retest reliability (r = .85). Study #2 examined sharing of Patient Dignity Inventory-related items between patients and family members. There were 12 of 19 patients who had severe distress based on an average Patient Dignity Inventory item score ≥1.92. The median patient shared multiple items of distress with their family (median 12, 99% 2-sided exact Hodges-Lehmann interval 4.0-17.5). CONCLUSIONS: Although ICU patients often report sharing sources of distress with their loved ones, family members cannot accurately or reliably assess the extent to which patients experience psychosocial, existential, and symptom-related distress during critical illness. Treatments of distress should not be delayed by the absence of family members.

Language in Bioethics: Beyond the Representational View.

Though assumptions about language underlie all bioethical work, the field has rarely partaken of theories of language. This article encourages a more linguistically engaged bioethics. We describe the tacit conception of language that is frequently upheld in bioethics-what we call the representational view, which sees language essentially as a means of description. We examine how this view has routed the field's theories and interventions down certain paths. We present an alternative model of language-the pragmatic view-and explore how it expands and clarifies traditional bioethical concerns. To lend concreteness, we apply the pragmatic view to a pervasive concept in bioethics and adjacent fields: decision making. We suggest that problems of the decision-making approach to bioethical issues are grounded in adherence to the representational view. Drawing on empirical work in surgery and critical care, we show how the pragmatic view productively reframes bioethical questions about how medical treatments are pursued.

Ethical and Professional Issues Encountered by Fourth-Year Medical Students during a Critical Care Clerkship before and during the COVID-19 Pandemic.

OBJECTIVES: The objective of this study was to describe ethical and professional issues encountered and the ethical and professional values cited by medical students during their critical care clerkship, with a comparison of issues encountered before and during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: In this single-center, retrospective mixed-methods study, two investigators at a midwestern US academic medical center performed qualitative content analysis on reflections written by fourth-year medical students about ethical and professional issues encountered during their critical care rotations between March 2016 and September 2021. We also analyzed the ethical/professional values mentioned in their reflections. Descriptive and inferential (χ2) statistics were performed to examine differences in issues and values cited before and during the pandemic. RESULTS: Respondents highlighted several key themes identified in prior studies, including decision making (64.1%), communication between clinicians and families (52.2%), and justice-related issues (32.1%), as well as interdisciplinary communication (25.7%) and issues related to the role of students in the intensive care unit (6.1%). Six novel subthemes were identified in this group, predominantly related to resource availability and end-of-life care. Of 343 reflections, 69% were written before the pandemic. Analysis of ethical and professional issues before and during COVID were notable for several significant differences, including increased discussion of inadequate tools/supplies/equipment (1.3% before vs 17.6% during, P = 0.005) and/or access to care (3.9% before vs 17.6% during, P = 0.03) and increased concerns about the tension between law and ethics (21.2% before vs 41.2% during, P = 0.028). Primacy of patient welfare (49.8% before vs 47.2% during, P = 0.659) and patient autonomy (51.1% before vs 38.9% during, P = 0.036) were the most commonly cited ethical principles in both time frames, often discussed concurrently and in tension. CONCLUSIONS: Although the COVID-19 pandemic was associated with increased reflection by medical students about resources in the intensive care unit, their perception of ethical issues arising in critical illness remained largely focused on enduring challenges in shared decision-making. These findings should be considered when developing ethics curricula for critical care rotations.

Dignity-related distress and recall among alert, non-delirious critically ill patients.

OBJECTIVES: Critical illness is associated with multiple undesired impacts, including residual psychological distress, frequently associated with recollections of critical illness. Dignity-related distress is highly prevalent among the one-fifth of critically ill patients who are alert. The distress may be associated with unpleasant recollections of care. We examined whether patients at risk for dignity-related distress had recall of their reported distress approximately 1 week after assessment and whether this recall differed from another high-risk group, specifically patients undergoing dialysis for end-stage renal disease. METHODS: The prospective cohort study included patients with critical illness and patients with end-stage renal disease enrolled from intensive care units (ICUs) and dialysis units at 1 academic center. Distress was assessed using the Patient Dignity Inventory (PDI). Participants received in-patient or telephonic follow-up 7-10 days after the initial interaction. Follow-up encounters focused on recollection of key aspects of the interpersonal interaction as well as the content of the PDI. RESULTS: A total of 32 critically ill patients participated in initial assessment and follow-up. In total, 26 dialysis patients participated in both phases. The groups' demographics differed. Fifty percent (n = 16) of critically ill patients and 58% (n = 15) of dialysis patients reported a mean score per item of >1.6, corresponding with severe distress on the PDI. Among the ICU patients, the 95% upper 2-sided confidence interval for the median level of recall was commensurate with the participant having had no recall of the initial interview beyond remembering that there was an interview. The end-stage renal disease group did not demonstrate significantly better recall. SIGNIFICANCE OF RESULTS: Dignity-related distress is high in both critically ill patients and those with end-stage renal disease; however, recollection of assessment is poor in both groups. Any intervention designed to mitigate dignity-related distress will need either to be immediately deployable or not to be reliant upon recollection for impact.

Escalation and Withdrawal of Treatment for Patients on Extracorporeal Membrane Oxygenation: A Qualitative Study.

OBJECTIVE: The aim of this study was to describe decisions about the escalation and withdrawal of treatment for patients on extracorporeal membrane oxygenation (ECMO). SUMMARY BACKGROUND DATA: Interventions premised on facilitating patient autonomy have proven problematic in guiding treatment decisions in intensive care units (ICUs). Calls have thus been made to better understand how decisions are made in critical care. ECMO is an important form of cardiac and respiratory support, but care on ECMO is characterized by prognostic uncertainty, varying time course, and high resource use. It remains unclear how decisions about treatment escalation and withdrawal should be made for patients on ECMO and what role families should play in these decisions. METHODS: We performed a focused ethnography in 2 cardiothoracic ICUs in 2 US academic hospitals. We conducted 380 hours of observation, 34 weekly interviews with families of 20 ECMO patients, and 13 interviews with unit clinicians from January to September 2018. Qualitative analysis used an iterative coding process. RESULTS: Following ECMO initiation, treatment was escalated as complications mounted until the patient either could be decannulated or interventional options were exhausted. Families were well-informed about treatment and prognosis but played minimal roles in shaping the trajectory of care. CONCLUSIONS: Discussion between clinicians and families about prognosis and goals was frequent but did not occasion decision-making moments. This study helps explain why communication interventions intended to maintain patient autonomy through facilitating surrogate participation in decisions have had limited impact. A more comprehensive understanding of upstream factors that predispose courses of critical care is needed.

Lack of Useful Predictors of Dignity-Related Distress Among the Critically Ill as Assessed With the Patient Dignity Inventory.

BACKGROUND: Many intensive care unit patients are awake (ie, alert and engaging in conversation), actively experiencing many facets of their critical care. The Patient Dignity Inventory can be used to elicit sources of distress in these patients. We examined the administrative question as to which awake intensive care unit patients should be evaluated and potentially treated (eg, through palliative care consultation) for distress. Should the decision to screen for distress be based on patient demographics or treatment conditions? METHODS: This was a retrospective cohort study of 155 adult patients from 5 intensive care units of one hospital from 2019 to 2020. Each patient had ≥48 hours without delirium, dementia, or sedation. The Patient Dignity Inventory has 25 items to which patients responded on a 1 (not a problem) to 5 (an overwhelming problem) scale. Multiple complete, stepwise forward, and stepwise backward logistic regression models were created among patient and treatment variables for predicting thresholds of the mean among the 25 items. RESULTS: There were 50% (78/155; 95% confidence interval [CI], 42-58) of patients with significant dignity-related distress (mean score ≥1.60). There were 34% (52/155; CI, 26-42) of patients with severe dignity-related distress (mean score ≥1.92; previously associated with often feeling like wanting to die). Models including combinations of vasopressor medication (protective of distress), tracheostomy (greater risk of distress), and female gender (greater risk of distress) had some predictive value. However, all combinations of potential predictors had misclassification rates significantly >20%. CONCLUSIONS: Identification of subsets of patients with little potential benefit to screening for dignity-related distress would have a reduced workload of palliative care team members (eg, nurses or social workers). Our results show that this is impractical. Given that approximately one-third of critical care patients who are alert and without delirium demonstrate severe dignity-related distress, all such patients with prolonged intensive care unit length of stay should probably be evaluated for distress.

Wellness and Coping of Physicians Who Worked in ICUs During the Pandemic: A Multicenter Cross-Sectional North American Survey.

OBJECTIVES: Few surveys have focused on physician moral distress, burnout, and professional fulfilment. We assessed physician wellness and coping during the COVID-19 pandemic. DESIGN: Cross-sectional survey using four validated instruments. SETTING: Sixty-two sites in Canada and the United States. SUBJECTS: Attending physicians (adult, pediatric; intensivist, nonintensivist) who worked in North American ICUs. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: We analysed 431 questionnaires (43.3% response rate) from 25 states and eight provinces. Respondents were predominantly male (229 [55.6%]) and in practice for 11.8 ± 9.8 years. Compared with prepandemic, respondents reported significant intrapandemic increases in days worked/mo, ICU bed occupancy, and self-reported moral distress (240 [56.9%]) and burnout (259 [63.8%]). Of the 10 top-ranked items that incited moral distress, most pertained to regulatory/organizational ( n = 6) or local/institutional ( n = 2) issues or both ( n = 2). Average moral distress (95.6 ± 66.9), professional fulfilment (6.5 ± 2.1), and burnout scores (3.6 ± 2.0) were moderate with 227 physicians (54.6%) meeting burnout criteria. A significant dose-response existed between COVID-19 patient volume and moral distress scores. Physicians who worked more days/mo and more scheduled in-house nightshifts, especially combined with more unscheduled in-house nightshifts, experienced significantly more moral distress. One in five physicians used at least one maladaptive coping strategy. We identified four coping profiles (active/social, avoidant, mixed/ambivalent, infrequent) that were associated with significant differences across all wellness measures. CONCLUSIONS: Despite moderate intrapandemic moral distress and burnout, physicians experienced moderate professional fulfilment. However, one in five physicians used at least one maladaptive coping strategy. We highlight potentially modifiable factors at individual, institutional, and regulatory levels to enhance physician wellness.

The Effect of Sedation on Long-Term Psychological Impairment After Extracorporeal Life Support.

OBJECTIVE: This retrospective study aimed to identify the association between long-term psychological impairment and total sedation received during venovenous extracorporeal life support (VV-ECLS) for acute respiratory failure (ARF). DESIGN: This observational retrospective study compared characteristics between patients with and without long-term psychological morbidity at long-term follow-up after VV-ECLS for ARF. SETTING: A single institutional experience in a quaternary referral academic medical center in the United States. PATIENTS: Patients who received VV-ECLS for ARF between January 1, 2015, and April 1, 2017, were identified for selection. Presence of psychiatric morbidity (anxiety and/or depression) was determined with the Hospital Anxiety and Depression Subscale battery at long-term follow-up. INTERVENTIONS: No interventions were made during this retrospective observational study. MEASUREMENTS AND MAIN RESULTS: A total of 42 patients (21 male, 21 female, median age 49 [interquartile range {IQR} 36-57]) completed a telephone interview a median of 14.6 (IQR 7.7-21.1) months after ECLS decannulation. Cohorts were defined as possessing any psychiatric morbidity (anxiety and/or depression) as defined by the Hospital Anxiety and Depression Subscale battery (n = 22 [52%]) versus no psychiatric morbidity (n = 20 [48%]) at long-term follow-up. Patients who had clinically significant psychiatric morbidity received a median of 15.0 (IQR 11.0-17.0) days of continuous intravenous sedation compared with patients who had no psychiatric morbidity, who received a median of 10.0 (IQR 6.5-13.5) days of intravenous sedation; (p = 0.02). CONCLUSIONS: This retrospective analysis identified a significant association between the presence of long-term post-VV-ECLS psychiatric symptoms and the total number of days of intravenous sedation.

Palliative Care for Patients With Advanced Heart Disease.

Over the past 2 decades, the discipline of palliative care has evolved and expanded such that it is now the standard of care for a variety of acute and chronic processes. Although there are recommendations encouraging incorporation of palliative care into the routine management of patients with chronic cardiac processes, such as congestive heart failure, implementation has been challenging, and nowhere more so than in the cardiac surgical population. However, as the boundaries of surgical care have expanded to include progressively more complex cases, increasing attention has been given to the integration of palliative care into their management. In this review article, the authors describe the existing evidence for palliative care team involvement in patients with non-operative and surgical cardiac diseases and examine future directions for growth in this field.

"Why Would I Choose Death?": A Qualitative Study of Patient Understanding of the Role and Limitations of Cardiac Devices.

BACKGROUND: Although cardiology organizations recommend early introduction of palliative care for patients with heart failure (HF), integration has remained challenging, particularly in patients with cardiac devices such as cardiac implantable electronic devices and left ventricular assist devices. Study authors suggest that patients often have limited and erroneous understanding of these devices and their implications for future care. OBJECTIVE: The aim of this study was to assess perceptions of cardiac devices in patients with HF and how these perceptions impacted advance care planning and future expectations. METHODS: This study used qualitative semistructured interviews with 18 community-dwelling patients with New York Heart Association stage II to IV HF. RESULTS: We interviewed 18 patients (mean ejection fraction, 38%; mean age, 64 years; 33% female; 83% white; 39% New York Heart Association class II, 39% class III, and 22% class IV). All had a cardiac implantable electronic device (6% permanent pacemaker, 56% implantable cardioverter-defibrillator, 28% biventricular implantable cardioverter-defibrillator); 11% had left ventricular assist devices. Patients with devices frequently misunderstood the impact of their device on cardiac function. A majority expressed the belief that the device would forestall further deterioration, regardless of whether this was the case. This anticipation of stability was often accompanied by the expectation that emerging technologies would continue to preempt decline. Citing this faith in technology, these patients frequently saw limited value in advance care planning. CONCLUSIONS: In our sample, patients with cardiac devices overestimated the impact of their devices on preventing disease progression and death and deprioritized advance care planning as a result.

Anesthesia Care Capacity at Health Facilities in 22 Low- and Middle-Income Countries.

BACKGROUND: Globally, an estimated 2 billion people lack access to surgical and anesthesia care. We sought to pool results of anesthesia care capacity assessments in low- and middle-income countries (LMICs) to identify patterns of deficits and provide useful targets for advocacy and intervention. METHODS: A systematic review of PubMed, Cochrane Database of Systematic Reviews, and Google Scholar identified reports that documented anesthesia care capacity from LMICs. When multiple assessments from one country were identified, only the study with the most facilities assessed was included. Patterns of availability or deficit were described. RESULTS: We identified 22 LMICs (15 low- and 8 middle-income countries) with anesthesia care capacity assessments (614 facilities assessed). Anesthesia care resources were often unavailable, including relatively low-cost ones (e.g., oxygen and airway supplies). Capacity varied markedly between and within countries, regardless of the national income. The availability of fundamental resources for safe anesthesia, such as airway supplies and functional pulse oximeters, was often not reported (72 and 36 % of hospitals assessed, respectively). Anesthesia machines and the capability to perform general anesthesia were unavailable in 43 % (132/307 hospitals) and 56 % (202/361) of hospitals, respectively. CONCLUSION: We identified a pattern of critical deficiencies in anesthesia care capacity in LMICs, including some low-cost, high-value added resources. The global health community should advocate for improvements in anesthesia care capacity and the potential benefits of doing so to health system planners. In addition, better quality data on anesthesia care capacity can improve advocacy, as well as the monitoring and evaluation of changes over time and the impact of capacity improvement interventions.

Palliative Care Utilization and Hospital Transfers in Veterans Treated in Telecritical Care-Supported Intensive Care Units Versus Non-Telecritical Care Intensive Care Units.

Background: Although telecritical care (TCC) implementation is associated with reduced mortality and interhospital transfer rates, its impact on goal-concordant care delivery in critical illness is unknown. We hypothesized that implementation of TCC across the Veterans' Health Administration system resulted in increased palliative care consultation and goals of care evaluation, yielding reduced transfer rates. Methods: We included veterans admitted to intensive care units between 2008 and 2022. We compared palliative care consultation and transfer rates before and after TCC implementation with rates in facilities that never implemented TCC. We used generalized linear mixed multivariable models to assess the associations between TCC initiation, palliative care consultation, and transfer and subsequently used mediation analysis to evaluate potential causality in this relationship. Results: Overall, 1,020,901 veterans met inclusion criteria. Demographic characteristics of patients were largely comparable across groups, although TCC facilities served more rural veterans. Palliative care consultation rates increased substantially in both ever-TCC and never-TCC hospitals during the study period (2.3%-4.3%, and 1.6%-4.7%, p < 0.01). Admissions post-TCC implementation were associated with an increased likelihood of palliative care consultation (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.01-1.15). TCC implementation was also associated with a reduction in transfer rates (OR 0.90, 95% CI 0.84-0.95). Mediation analysis did not demonstrate a causal relationship between TCC implementation, palliative care consultation, and reductions in interhospital transfer rate. Conclusions: TCC is associated with increased palliative care engagement, while TCC and palliative care engagement are both independently related to reduced transfers.

Top Ten Tips Palliative Care Clinicians Should Know About Dignity-Conserving Practice.

The acknowledgment and promotion of dignity is commonly viewed as the cornerstone of person-centered care. Although the preservation of dignity is often highlighted as a key tenet of palliative care provision, the concept of dignity and its implications for practice remain nebulous to many clinicians. Dignity in care encompasses a series of theories describing different forms of dignity, the factors that impact them, and strategies to encourage dignity-conserving care. Different modalities and validated instruments of dignity in care have been shown to lessen existential distress at the end of life and promote patient-clinician understanding. It is essential that palliative care clinicians be aware of the impacts of dignity-related distress, how it manifests, and common solutions that can easily be adapted, applied, and integrated into practice settings. Dignity-based constructs can be learned as a component of postgraduate or continuing education. Implemented as a routine component of palliative care, they can provide a means of enhancing patient-clinician relationships, reducing bias, and reinforcing patient agency across the span of serious illness. Palliative care clinicians-often engaging patients, families, and communities in times of serious illness and end of life-wield significant influence on whether dignity is intentionally integrated into the experience of health care delivery. Thus, dignity can be a tangible, actionable, and measurable palliative care goal and outcome. This article, written by a team of palliative care specialists and dignity researchers, offers 10 tips to facilitate the implementation of dignity-centered care in serious illness.

Dangerous Variation or Patient-Centered Care? Palliative Care and Pain Providers' Comfort, Experiences, and Approaches when Treating Cancer Pain With Coexisting Aberrant Behaviors.

BACKGROUND: Patients with cancer-related pain are at high risk for aberrant drug use behaviors (ADB), including self-escalation, diversion and concurrent illicit substance or opioid misuse; however, limited evidence is available to guide opioid prescribing for patients with life-limiting illness and concurrent or suspected ADB. We sought to characterize how specialists evaluate for and manage these high-risk behaviors in patients with cancer-related pain. METHODS: We conducted telephonic semi-structured interviews with palliative care and pain medicine providers. Participants discussed their own comfort and experience level with identifying and managing ADB in patients with life-limiting illness. They were subsequently presented with a series of standardized scenarios and asked to describe their concerns and management strategies. RESULTS: 95 interdisciplinary pain and palliative care specialists were contacted; 37 agreed to participate (38.9%). Analysis of interview contents revealed several central themes: (1) widespread discomfort and anxiety regarding safe and compassionate opioid prescribing for high-risk patients, (2) belief that widely used risk-mitigation tools such as opioid contracts and urine drug screens provided inadequate support for decision-making, and (3) lack of institutional and organizational support and guidance for safe prescribing strategies. Most clinicians reported self-education regarding addiction and alternative prescribing/pain management strategies. Providers varied widely in their willingness to discontinue opioid prescribing in a patient with aberrant behavior and pain associated with life-limiting illness. CONCLUSION: Providers caring for patients demonstrating ADB and cancer-related pain struggle to balance safe prescribing with symptom management. Increased guidance is needed regarding opioid prescribing, monitoring, and discontinuation in high-risk patients.

Top Ten Tips Palliative Care Clinicians Should Know Before Their Patient Undergoes Surgery?

Many seriously ill patients undergo surgical interventions. Palliative care clinicians may not be familiar with the nuances involved in perioperative care, however they can play a valuable role in enabling the delivery of patient-centered and goal-concordant perioperative care. The interval of time surrounding a surgical intervention is fraught with medical, psychosocial, and relational risks, many of which palliative care clinicians may be well-positioned to navigate. A perioperative palliative care consult may involve exploring gaps between clinician and patient expectations, facilitating continuity of symptom management or helping patients to designate a surrogate decision-maker before undergoing anesthesia. Palliative care clinicians may also be called upon to direct discussions around perioperative management of modified code status orders and to engage around the goal-concordance of proposed interventions. This article, written by a team of surgeons and anesthesiologists, many with subspecialty training in palliative medicine and/or ethics, offers ten tips to support palliative care clinicians and facilitate comprehensive discussion as they engage with patients and clinicians considering surgical interventions.

Identifying Barriers and Facilitators to Veterans Affairs Whole Health Integration Using the Updated Consolidated Framework for Implementation Research.

BACKGROUND: Veterans Affairs (VA) implemented the Veteran-centered Whole Health System initiative across VA sites with approaches to implementation varying by site. PURPOSE: Using the Consolidated Framework for Implementation Research (CFIR), we aimed to synthesize systemic barriers and facilitators to Veteran use with the initiative. Relevance to healthcare quality, systematic comparison of implementation procedures across a national healthcare system provides a comprehensive portrait of strengths and opportunities for improvement. METHODS: Advanced fellows from 11 VA Quality Scholars sites performed the initial data collection, and the final report includes CFIR-organized results from six sites. RESULTS: Key innovation findings included cost, complexity, offerings, and accessibility. Inner setting barriers and facilitators included relational connections and communication, compatibility, structure and resources, learning centeredness, and information and knowledge access. Finally, results regarding individuals included innovation deliverers, implementation leaders and team, and individual capability, opportunity, and motivation to implement and deliver whole health care. DISCUSSION AND IMPLICATIONS: Examination of barriers and facilitators suggest that Whole Health coaches are key components of implementation and help to facilitate communication, relationship building, and knowledge access for Veterans and VA employees. Continuous evaluation and improvement of implementation procedures at each site is also recommended.

Forecasting Caseload of Critically Ill Patients Who Are Alert and Without Delirium for at Least Two Consecutive Days for the Assessment of Their Psychological Distress.

INTRODUCTION: One-quarter of alert, non-delirious patients in critical care units report significant psychological distress. Treatment of this distress depends upon identifying these high-risk patients. Our aim was to characterize how many critical care patients remain alert and without delirium for at least two consecutive days and could thus predictably undergo evaluation for distress. METHODS: This retrospective cohort study used data from a large teaching hospital in the United States of America, from October 2014 to March 2022. Patients were included if they were admitted to one of three intensive care units, and for >48 hours all delirium and sedation screenings were negative (Riker sedation-agitation scale four, calm and cooperative, and no delirium based on all Confusion Assessment Method for the Intensive Care Unit scores negative and all Delirium Observation Screening Scale less than three). Means and standard deviations of means for counts and percentages are reported among the most recent six quarters. Means and standard deviations of means for lengths of stay were calculated among all N=30 quarters. The Clopper-Pearson method was used to calculate the lower 99% confidence limit for the percentages of patients who would have had at most one assessment of dignity-related distress before intensive care unit discharge or change in mental status. RESULTS: An average of 3.6 (standard deviation 0.2) new patients met the criteria daily. The percentages of all critical care patients (20%, standard deviation 2%) and hours (18%, standard deviation 2%) meeting criteria decreased slightly over the 7.5 years. Patients spent a mean of 3.8 (standard deviation 0.1) days awake in critical care before their condition or site changed. In the context of assessing distress and potentially treating it before the date of change of condition (e.g., transfer), 66% (6818/10314) of patients would have zero or one assessment, lower 99% confidence limit of 65%. CONCLUSIONS: Approximately one-fifth of critically ill patients are alert and without delirium and thus could be evaluated for distress during their intensive care unit stay, mostly during a single visit. These estimates can be used to guide workforce planning.

Logistic Regression and Machine Learning Models for Predicting Whether Intensive Care Patients Who Are Alert and Without Delirium Remain As Such for at Least Two More Days.

Background Some intensive care unit patients are alert and without delirium for at least two consecutive days. These patients, like other critically ill individuals, are at risk for dignity-related distress. An interval of at least two days would provide for a palliative care multidisciplinary team to be consulted in the late morning or afternoon of day one and visit the next day. An assessment would include the administration of the validated Patient Dignity Inventory in a reflective manner. To determine whether dignity-related distress can be identified and treated during patients' intensive care unit stay, we evaluated whether a substantive fraction of such patients (≥5%) have a substantial (>90%) probability of remaining alert and without delirium in the intensive care unit for at least four consecutive days. Methods The retrospective cohort study used data from one large teaching hospital in the United States of America, from 2012 to June 2022. The inclusion criteria were: a) adults, b) present in an intensive care unit at 12 PM one day and continually so for the next 48 hours, c) during those two days had every Riker sedation-agitation scale score "4, calm and cooperative," and d) during those two days had all Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) scores negative (i.e., no delirium) and all Delirium Observation Screening Scale (DOS) scores less than three (i.e., no delirium). Results Among the 10,314 patients alert and without delirium in an intensive care unit over two-day periods that included three successive 12 PMs, 3,826 (37%) maintained this status for at least two successive 12 PMs. Six patient characteristics (e.g., hemodynamic infusion or ventilatory support) had value in predicting those 37% of patients. However, logistic regression and classification models each predicted a few (≈0.2%) patients with >90% probability of maintaining these criteria. Forecasts were inaccurate for nearly all patients remaining alert and without delirium in the intensive care unit (≈37%) because the models predicted no patient alert, without delirium, and in the intensive care unit for two days would remain so for at least four days. That ≈63% accuracy was improved upon by random forest machine learning, but only with ≈3% improvement. Conclusion Although many intensive care unit patients remain alert and without delirium for several consecutive days, each patient has a high daily probability of intensive care unit discharge or deterioration in medical condition. Therefore, the results of our prediction modeling show that care models for the assessment and treatment of patients with intensive care unit-associated dignity-related distress should not rely solely on the intensive care unit team but instead should be taken from the perspective of the entire hospitalization.