Critical care medicine
-
Critical care medicine · Feb 2001
Review Case ReportsCommunication in intensive care settings: the challenge of futility disputes.
In intensive care settings, suboptimal communication can erode family trust and fuel so-called "futility" disputes. Presenting a teaching case used by >225 hospitals participating in the Decisions Near the End-of-Life program, we identify critical communication challenges and opportunities. We emphasize that good communication requires not only clear and sensitive language but also clinician self-awareness, psychological insight, and an institutional culture that promotes good communication with families. The article concludes with two examples of steps institutions can take to foster good communication between families and healthcare professionals.
-
End-of life care is in need of improvement, yet little is known about the effectiveness or cost of various end-of-life therapies. Economic analyses are used to help make decisions between two or more therapies when resources are constrained. In this chapter, we review the various types of economic analyses, the costs of dying, and how healthcare reform has impacted these costs. ⋯ As the national debate about healthcare costs, access, and quality continues, we will increasingly turn to economic analyses to help make resource allocation decisions. Cost-effectiveness analysis will continue to be the most popular form of economic analysis because it combines the results (effectiveness of treatment) with the costs of achieving the results. We must be aware of the limitations of cost-effectiveness analyses and the need for value judgments when using cost-effectiveness analyses to inform healthcare decisions.
-
Critical care medicine · Feb 2001
Comparative StudyThe hypothalamic-pituitary-adrenal axis of patients with severe sepsis: altered response to corticotropin-releasing hormone.
To investigate the functional integrity of the hypothalamic-pituitary-adrenal (HPA) axis in patients with severe sepsis by stimulating with corticotropin-releasing hormone (CRH). ⋯ We found lower basal plasma cortisol concentrations in nonsurvivors compared with survivors of severe sepsis. In addition, the plasma cortisol response to a single CRH stimulation was impaired in nonsurvivors compared with survivors. Reduced responses to CRH stimulation may reflect a state of endocrinologic organ dysfunction in severe sepsis.
-
Critical care medicine · Feb 2001
Comparative StudyAccuracy and utility of a continuous intra-arterial blood gas monitoring system in pediatric patients.
To determine the accuracy of the Paratrend 7 continuous intra-arterial blood gas monitor (CI-ABGM) in radial and femoral artery catheters placed in children compared with simultaneous measurements of pH, Pa(CO2), and Pa(O2) performed by intermittent blood gas analysis. To determine sensor longevity in pediatric patients at different arterial sites. To determine the utility of CI-ABGM for tracking unanticipated events related to blood gas deterioration. ⋯ The Paratrend 7 CI-ABGM is accurate within the extremes of physiologic gas exchange typically encountered in the pediatric intensive care setting. The device is capable of tracking extreme fluctuations in gas exchange with a response rate suitable for making real-time therapeutic decisions. The sensor can be recommended for insertion into a femoral artery cannula. There is a high incidence of blood pressure waveform dampening encountered in radial artery use.
-
We now have a decade of experience with advance directives since the Patient Self-Determination Act was signed into law in November 1990. With few exceptions, empirical studies have yielded disappointing results. Advance directives are recorded by medical personnel more often but are not completed by patients more frequently. ⋯ Recent research suggests that preferences for care are not fixed but emerge in a clinical context from a process of discussion and feedback within the network of the patient's most important relationships. Clinical trials emphasizing this approach have been successful. The approach that emphasizes communication, building trust over time, and working within the patient's most important relationships offers a hopeful model for clinicians working in intensive care units.