Questions remain as to how this approach could be replicated at other institutions, including the nature of formal training and credentialing needed for nonsurgeons. Anecdotal and preliminary reports from other centers providing intensivist-driven cannulation, however, have also suggested efficacy, including a pediatric center (9). At the authors’ institution, Conrad et al (7) developed the approach and was able to train his colleagues. At institutions with no current intensivist performing the procedure, would surgeons be willing to provide oversight and proctoring? One could make an analogy to managing the transition in examining the evolution over time in performance of percutaneous coronary intervention (PCI) from direct performance/supervision of surgeons, to use with surgical backup, to common performance of PCI by cardiologists in the absence even of center surgical backup (10). The study has several limitations, including its retrospective nature. Although the study is a large case series, making definitive recommendations on safety cannot be achieved with only 100 patients. The study did not provide direct comparison to results from a center with performance of cannulation by surgeons. However, the authors provided reference to previous single-center studies in centers with surgical performance, and complications were similar in the range of 88–98% (8, 11) in adults and 92% in pediatric patients (12). The authors also emphasize the potential availability of surgical backup as needed. Publication of experience from other institutions would be beneficial to support the broader applicability of their approach. Nevertheless, Conrad et al (7) have provided unique experience to help define a broader pool of capable cannulators for the growing field of pediatric and adult ECMO. Yes we can.
1. Brodie D, Bacchetta M: Extracorporeal membrane oxygenation for ARDS in adults. N Engl J Med 2011; 365:1905–1914 2. Peek GJ, Mugford M, Tiruvoipati R, et al; CESAR trial collaboration: Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): A multicentre randomised controlled trial. Lancet 2009; 374:1351–1363 3. Noah MA, Peek GJ, Finney SJ, et al: Referral to an extracorporeal membrane oxygenation center and mortality among patients with severe 2009 influenza A(H1N1). JAMA 2011; 306:1659–1668 4. Paden ML, Conrad SA, Rycus PT, et al; ELSO Registry: Extracorporeal Life Support Organization Registry Report 2012. ASAIO J 2013; 59:202–210 5. Pellegrino V, Hockings LE, Davies A: Veno-arterial extracorporeal membrane oxygenation for adult cardiovascular failure. Curr Opin Crit Care 2014; 20:484–492 6. Turner DA, Cheifetz IM: Extracorporeal membrane oxygenation for adult respiratory failure. Respir Care 2013; 58:1038–1052 7. Conrad SA, Grier LR, Scott LK, et al: Percutaneous Cannulation for Extracorporeal Membrane Oxygenation by Intensivists: A Retrospective Single-Institution Case Series. Crit Care Med 2015; 43:1010–1015 8. Ganslmeier P, Philipp A, Rupprecht L, et al: Percutaneous cannulation for extracorporeal life support. Thorac Cardiovasc Surg 2011; 59:103–107 9. Gelvez J, Wolf RM, Olarte J, et al: Pediatric intensivist placed percutaneous Avalon catheters. Presented at 30th Annual Children’s National Health System Symposium: ECMO and the Advanced Therapies for Respiratory Failure, Keystone, CO, February 2014 10. Dehmer GJ, Blankenship JC, Cilingiroglu M, et al: SCAI/ACC/AHA Expert Consensus Document: 2014 update on percutaneous coronary intervention without on-site surgical backup. J Am Coll Cardiol 2014; 63:2624–2641 11. Pranikoff T, Hirschl RB, Remenapp R, et al: Venovenous extracorporeal life support via percutaneous cannulation in 94 patients. Chest 1999; 115:818–822 12. Foley DS, Swaniker F, Pranikoff T, et al: Percutaneous cannulation for pediatric venovenous extracorporeal life support. J Pediatr Surg 2000; 35:943–947
Quantifying the Value of Palliative Care and Advance Care Planning* Wendy G. Anderson, MD, MS Division of Hospital Medicine & Palliative Care Program University of California, San Francisco San Francisco, CA
*See also p. 1102. Key Words: advance care planning; critical care; end of life; intensive care unit utilization; palliative care Dr. Anderson’s institution received grant support from the National Institutes of Health (for research about communication in the ICU), the University of California Center for Health Quality and Innovation (for research about communication and palliative care), and the Gordon and Betty Moore Foundation (for research about communication in the ICU). Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000000895
Critical Care Medicine
he use of ICUs near the end of life, along with the burden this use places on patients, families, and the healthcare system, is well documented. One in five Americans die after receiving ICU care, a similar number to those who die of cancer (1). Patients in ICUs and their families have a number of unmet needs for palliative care, including for management of physical symptoms, emotional support of families during and after ICU stays, and clear communication about prognosis and goals of care (2–5). Unclear communication about prognosis and goals of care results in many patients receiving very expensive care near the end-of-life that is not consistent with their wishes. ICU treatments are a significant burden to our healthcare system, where increasing costs are spent on critical care. For example, in the United States, critical care beds and occupancy rates increased between 2000 and 2005, whereas the total www.ccmjournal.org
number of hospital beds decreased. In 2005, costs of critical care totaled 13.4% of U.S. hospital cost, 4.1% of national health expenditures, and 0.66% of gross domestic product (6). Previous work including randomized controlled trials and systematic reviews has demonstrated that palliative care and advance care planning interventions decrease healthcare costs, ICU admission rates, and ICU length of stay (LOS) (7–9). Research has also demonstrated that these interventions improve family satisfaction with care and decrease distress (10–12). Yet, the magnitude of the effect of advance care planning and palliative care interventions on ICU admission and LOS has not been quantified. In this issue of Critical Care Medicine, Khandelwal et al (13) describe the results of a systematic review that aimed to determine whether the magnitude of the effect of advance care planning and palliative care on ICU utilization could be estimated. They included interventions that were conducted in outpatient, acute care, and ICU settings that aimed to clarify patient’s goals and values and ensure that they received care that was consistent with those. Interventions consisted of both consultative models, where palliative care or ethics consult services consulted on patients in hospital or ICUs, and generalist interventions, aimed at training ICU staff or other frontline providers to provide advance care planning or palliative care. Outcomes included ICU admission rates and ICU LOS. Khandelwal et al (13) identified nine randomized controlled trials and 13 nonrandomized controlled trials. Heterogeneity in interventions, study design, and patient populations precluded a quantitative meta-analysis. However, they were able to estimate the magnitude of the effect of advance care planning and palliative care interventions on ICU utilization. They did this by calculating the mean relative risk reduction of ICU admission and ICU LOS for each study and then aggregating these values to determine the mean relative risk reduction in ICU admission and ICU LOS. Nineteen studies were used to estimate the magnitude of effect of palliative care interventions and advance care planning on ICU admission and LOS. Khandelwal et al (13) found that palliative care interventions reduced the risk of ICU admission, with a relative risk reduction of 37%. Palliative care interventions also reduced ICU LOS, with a relative risk reduction of 26%. This review is an important step forward in our understanding of the value of palliative care and advance care planning interventions. The results can be practically applied to designing programs that curtail rising healthcare costs while improving patient and family support and experience of care. By clearly articulating the reductions in ICU utilization, and thus savings associated with these interventions, these results can be used to estimate the return on investment of training and hiring providers and implementing systems to improve palliative care and advance care planning. Despite heterogeneity in individual studies, the authors found a strong and significant decrease in both ICU admissions and ICU LOS as a result of these interventions. This is clear and compelling evidence that we need to systematically implement such programs across our health systems. 1148
Why do advance care planning and palliative care interventions decrease ICU admissions and LOS? As the authors describe, the mechanism of action of these interventions is conceived as decreasing the provision of treatments that are unlikely to help patients to reach a goal that is consistent with their values and preferences. The primary mechanism of action for reducing ICU LOS is likely to be earlier decisions to limit life-sustaining therapies for patients who will ultimately die in the ICU, irrespective of the duration of life-sustaining therapy they receive. The primary limitations of this review relate to limitations in the evidence base the authors reviewed. Although evidence mounts supporting the effectiveness of palliative care, we still need to better understand the specific ways that these interventions result in different care being provided to patients. Heterogeneity of results is in part, as the authors cite, related to differences in patient populations and locations. Yet, we also need to understand which elements of palliative care and advance care planning interventions are critical to their success. For example, communication training for providers is essential, but it may not be enough to improve outcomes without the concomitant implementation of systems to support communication with families (14, 15). This understanding will be essential as we aim to disseminate such interventions systematically across our health systems. We need to know more about the mechanism of how these interventions are effective and how different intervention elements might interact with different environments to produce different results. In summary, the study by Khandelwal et al (13) is concretely relevant to insurers, health systems, hospitals, critical care, and palliative care programs, and it helps us to understand the value of palliative care to patients, families, and our health system. It provides further evidence that these interventions are a core step in achieving the triple aim for critically ill patients: by improving patient symptom management and support, by improving family support and satisfaction, and by decreasing healthcare costs by minimizing provision of treatments that are unlikely to achieve patients’ goals.
1. Angus DC, Barnato AE, Linde-Zwirble WT, et al; Robert Wood Johnson Foundation ICU End-Of-Life Peer Group: Use of intensive care at the end of life in the United States: An epidemiologic study. Crit Care Med 2004; 32:638–643 2. McAdam JL, Fontaine DK, White DB, et al: Psychological symptoms of family members of high-risk intensive care unit patients. Am J Crit Care 2012; 21:386–393; quiz 394 3. McAdam JL, Puntillo K: Symptoms experienced by family members of patients in intensive care units. Am J Crit Care 2009; 18:200–209; quiz 210 4. Nelson JE, Angus DC, Weissfeld LA, et al; Critical Care Peer Workgroup of the Promoting Excellence in End-of-Life Care Project: End-of-life care for the critically ill: A national intensive care unit survey. Crit Care Med 2006; 34:2547–2553 5. Nelson JE, Puntillo KA, Pronovost PJ, et al: In their own words: Patients and families define high-quality palliative care in the intensive care unit. Crit Care Med 2010; 38:808–818 6. Halpern NA, Pastores SM: Critical care medicine in the United States 2000-2005: An analysis of bed numbers, occupancy rates, payer mix, and costs. Crit Care Med 2010; 38:65–71 May 2015 • Volume 43 • Number 5
Editorials 7. Aslakson R, Cheng J, Vollenweider D, et al: Evidence-based palliative care in the intensive care unit: A systematic review of interventions. J Palliat Med 2014; 17:219–235 8. Khandelwal N, Curtis JR: Economic implications of end-of-life care in the ICU. Curr Opin Crit Care 2014; 20:656–661 9. Morrison RS, Dietrich J, Ladwig S, et al: Palliative care consultation teams cut hospital costs for Medicaid beneficiaries. Health Aff (Millwood) 2011; 30:454–463 10. Shaw DJ, Davidson JE, Smilde RI, et al: Multidisciplinary team training to enhance family communication in the ICU. Crit Care Med 2014; 42:265–271 11. Lautrette A, Darmon M, Megarbane B, et al: A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med 2007; 356:469–478
12. Temel JS, Greer JA, Muzikansky A, et al: Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010; 363:733–742 13. Khandelwal N, Kross EK, Engelberg RA, et al: Estimating the Effect of Palliative Care Interventions and Advance Care Planning on ICU Utilization: A Systematic Review. Crit Care Med 2015; 43:1102–1111 14. Curtis JR, Back AL, Ford DW, et al: Effect of communication skills training for residents and nurse practitioners on quality of communication with patients with serious illness: A randomized trial. JAMA 2013; 310:2271–2281 15. Howell AA, Nielsen EL, Turner AM, et al: Clinicians’ perceptions of the usefulness of a communication facilitator in the intensive care unit. Am J Crit Care 2014; 23:380–386
The Importance of Caregiver Outcomes After Critical Illness* Erin K. Kross, MD Division of Pulmonary and Critical Care Medicine Department of Medicine University of Washington Harborview Medical Center Seattle, WA
amily members of critically ill patients are at risk for a number of adverse psychologic outcomes, including posttraumatic stress disorder, depression, anxiety, and complicated grief. In 2010, a task force of the Society of Critical Care Medicine proposed a new term for this cluster of complications—post–intensive care syndrome-family (1). Family caregivers are integral to the care of patients who survive critical illness. Providing this care can be detrimental to the caregiver, and caregiving has been shown to increase stress and even mortality (2–4). Recently, there has been increasing awareness of the importance of improving outcomes for caregivers, the value that family-centered care may add to improving patient outcomes, and the responsibility clinicians have to recognize caregiver burden (5, 6). Recognition of the importance of caregiver outcomes after critical illness is growing. Although some of the initial descriptions focused on bereaved family members (7–9), more recent studies have explored the burden of symptoms for family members who survive critical illness. Our understanding of the emotional toll of critical illness on caregivers of patients who survive critical illness is essential. These family members are often called *See also p. 1112. Key Words: caregivers; critical illness; depression; posttraumatic stress; psychologic outcomes Dr. Kross’s institution received grant support from a National Heart, Lung and Blood Institute K23 award and an American Lung Association award. Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000000910
Critical Care Medicine
upon to provide post-ICU care and support for the surviving patient, a role that may be compromised if the burden is too great. In this issue of Critical Care Medicine, Haines et al (10) add to the growing body of literature with an informative systematic review of the prevalence, risk factors, and trajectory of psychosocial morbidity in informal caregivers of critical care survivors. The authors identified 14 articles that met their criteria for inclusion. They conclude that adverse psychological symptoms are experienced by a substantial portion of ICU caregivers and that these symptoms persist for some time after discharge. Depression was both the most commonly reported symptom in these articles and also the most prevalent adverse psychological symptom among caregivers. Depressive symptoms were highest during the acute phase of the patient’s illness and demonstrated some improvement over time. However, significant depressive symptoms were still present in approximately 25% of caregivers at 1 year, which is higher than what is seen in the general population (11). The authors provide a thorough exploration of risk factors for adverse psychologic outcomes, providing insights to nonmodifiable characteristics that may identify individuals at risk including sex, age, and patient characteristics, as well as modifiable characteristics that may be amenable to intervention, including social support, fatigue, burden, and health risk behaviors. Other important adverse psychologic symptoms that were less often reported include caregiver burden, activity restriction, health-related quality of life, and posttraumatic stress disorder. The authors provide a concise summary of the prevalence, time course, and risk factors for each, as best they are able from the current literature. Although the authors initially sought to include anxiety and stress, none of the studies included in the review reported on these outcomes. The authors acknowledge a number of weaknesses of their review, including the limited number of studies meeting criteria for inclusion, the generally low methodologic quality of the studies which are mostly observational in nature, and a lack of www.ccmjournal.org
Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.