Storytelling In The Early Bereavement Period To Reduce Emotional Distress Among Surrogates Involved In A Decision To Limit Life Support In The Icu: A Pilot Feasibility Trial
Posttraumatic-stress-disorder; Bereavement; Scale; Posttraumatic-stress-disorder; Depression; Surrogate Decision Making; Intensive-care-unit; Critical Care Medicine; Critically-ill; Terminal Care; Family-members; End; Critical Illness; Self-regulation; Intensive Care; Complicated Grief
OBJECTIVES:
Surrogate decision makers involved in decisions to limit life support for an incapacitated patient in the ICU have high rates of adverse emotional health outcomes distinct from normal processes of grief and bereavement. Narrative self-disclosure (storytelling) reduces emotional distress after other traumatic experiences. We sought to assess the feasibility, acceptability, and tolerability of storytelling among bereaved surrogates involved in a decision to limit life support in the ICU.
DESIGN:
Pilot single-blind trial.
SETTING:
Five ICUs across three hospitals within a single health system between June 2013 and November 2014.
SUBJECTS:
Bereaved surrogates of ICU patients.
INTERVENTIONS:
Storytelling and control conditions involved printed bereavement materials and follow-up assessments. Storytelling involved a single 1- to 2-hour home or telephone visit by a trained interventionist who elicited the surrogate's story.
MEASUREMENTS AND MAIN RESULTS:
The primary outcomes were feasibility (rates of enrollment, intervention receipt, 3- and 6-mo follow-up), acceptability (closed and open-ended end-of-study feedback at 6 mo), and tolerability (acute mental health services referral). Of 53 eligible surrogates, 32 (60%) consented to treatment allocation. Surrogates' mean age was 55.5 (SD, 11.8), and they were making decisions for their parent (47%), spouse (28%), sibling (13%), child (3%), or other relation (8%). We allocated 14 to control and 18 to storytelling, 17 of 18 (94%) received storytelling, 14 of 14 (100%) and 13 of 14 (94%) control subjects and 16 of 18 (89%) and 17 of 18 (94%) storytelling subjects completed their 3- and 6-month telephone assessments. At 6 months, nine of 13 control participants (69%) and 16 of 17 storytelling subjects (94%) reported feeling "better" or "much better," and none felt "much worse." One control subject (8%) and one storytelling subject (6%) said that the study was burdensome, and one control subject (8%) wished they had not participated. No subjects required acute mental health services referral.
CONCLUSION:
A clinical trial of storytelling in this study population is feasible, acceptable, and tolerable.
Barnato AE; Schenker Y; Tiver G; Dew MA; Arnold RM; Nunez ER; Reynolds CF
Critical Care Medicine
2016
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
10.1097/CCM.0000000000002009
The intensity and variation of surgical care at the end of life: a retrospective cohort study
BACKGROUND: Although the extent of hospital and intensive-care use at the end of life is well known, patterns of surgical care during this period are poorly understood. We examined national patterns of surgical care in the USA among elderly fee-for-service Medicare beneficiaries in their last year of life. METHODS: We did a retrospective cohort study of elderly beneficiaries of fee-for-service Medicare in the USA, aged 65 years or older, who died in 2008. We identified claims for inpatient surgical procedures in the year before death and examined the relation between receipt of an inpatient procedure and both age and geographical region. We calculated an end-of-life surgical intensity (EOLSI) score for each hospital referral region defined as proportion of decedents who underwent a surgical procedure during the year before their death, adjusted for age, sex, race, and income. We compared patient characteristics with Rao-Scott chi(2) tests, resource use with generalised estimating equations, regional differences with generalised estimating equations Wald tests, and end-of-life surgical intensity scores with Spearman's partial-rank-order correlation coefficients. FINDINGS: Of 1,802,029 elderly beneficiaries of fee-for-service Medicare who died in 2008, 31.9% (95% CI 31.9-32.0; 575,596 of 1,802,029) underwent an inpatient surgical procedure during the year before death, 18.3% (18.2-18.4; 329,771 of 1,802,029) underwent a procedure in their last month of life, and 8.0% (8.0-8.1; 144,162 of 1,802,029) underwent a procedure during their last week of life. Between the ages of 80 and 90 years, the percentage of decedents undergoing a surgical procedure in the last year of life decreased by 33% (35.3% [95% CI 34.7-35.9; 8858 of 25,094] to 23.6% [22.9-24.3; 3340 of 14,152]). EOLSI score in the highest intensity region (Munster, IN) was 34.4 (95% CI 33.7-35.1) and in the lowest intensity region (Honolulu, HI) was 11.5 (11.3-11.7). Regions with a high number of hospital beds per head had high end-of-life surgical intensity (r=0.37, 95% CI 0.27-0.46; p<0.0001), as did regions with high total Medicare spending (r=0.50, 0.41-0.58; p<0.0001). INTERPRETATION: Many elderly people in the USA undergo surgery in the year before their death. The rate at which they undergo surgery varies substantially with age and region and might suggest discretion in health-care providers' decisions to intervene surgically at the end of life. FUNDING: None.
Kwok AC; Semel ME; Lipsitz SR; Bader AM; Barnato AE; Gawande AA; Jha AK
Lancet
2011
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
Journal Article
<a href="http://doi.org/10.1016/S0140-6736(11)61268-3" target="_blank" rel="noreferrer">10.1016/S0140-6736(11)61268-3</a>
Patterns Of Palliative Care Service Consultation In A Sample Of Critically Ill Icu Patients At High Risk Of Dying
Critical Care; End-of-life Care; Palliative Care; Patient-centered Outcomes; Quality Of Health Care
OBJECTIVE: Describe patterns of palliative care service consultation among a sample of ICU patients at high risk of dying. BACKGROUND: Patients receiving mechanical ventilation (MV) face threats to comfort, social connectedness and dignity due to pain, heavy sedation and physical restraint. Palliative care consultation services may mitigate poor outcomes. METHODS: From a dataset of 1440 ICU patients with ≥2 days of MV and ≥12 h of sustained wakefulness, we identified those at high risk of dying and/or who died and assessed patterns of sub-specialty palliative care consultation. RESULTS: About half (773/1440 [54%]) were at high risk of dying or died, 73 (9.4%) of whom received palliative care consultation. On average, referral occurred after 62% of the ICU stay had elapsed. Primary reason for consult was clarification of goals of care (52/73 [72.2%]). CONCLUSIONS: Among MV ICU patients at high risk of dying, palliative care service consultation occurs late and infrequently, suggesting a role for earlier palliative care.
Seaman JB; Barnato AE; Sereika SM; Happ MB; Erlen JA
PLOS Neglected Tropical Diseases
2016
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).