Este es un blog medico que nunca podrá sustituir el buen juicio médico en la toma de decisiones.Intentamos compartir con los profesionales nuestras experiencias, conocimientos,lecturas,etc con la finalidad de mejorar la practica clinica.No es un blog para pacientes aunque no rechazamos sus comentarios
We examine him each day — the elderly patient, intubated, sedated, with a bewildered wife at his bedside. We should sit down with his wife before we ask her to make hard decisions about her husband's care, but the unit is so busy that we find ourselves scurrying by, pausing only to offer rushed updates that do not allow for the exchange of meaningful information.
This is a familiar scenario. Approximately one in five people in the United States dies in the intensive care unit (ICU) or shortly after an ICU discharge.1 ICU patients who do not die might face long-term ventilator dependence, with its associated symptoms and care needs, or they might return home with cognitive and physical debility.2 Surrogates are often asked to weigh suffering against the uncertain benefits of life-prolonging technologies.3 Yet, in contrast to the protocols we follow for much of critical care, our approach to communication with surrogate decision makers, though well intentioned, is often haphazard and unsupportive.4,5 Persistent psychological symptoms are common among surrogates, and improving their experience is a critical need.6 In the Journal, White et al. now report results that cannot be interpreted as clinically directive but begin to offer us a way forward.7
Using a stepped-wedge, cluster-randomized trial design, White and colleagues tested a communication pathway that was based on decision theory and on the best practices for communication with families of patients who have a serious illness. The trial involved a cohort of more than 1400 patients who had a high risk of death or poor functional outcomes, but the trial design most likely led to substantial imbalances between the intervention group and the control group. The main intervention of the trial harnessed the competencies and expanded the role of critical care nurses, who received a 12-hour training and then were charged with the following responsibilities: preparing surrogates for physician-led family meetings, attending meetings to make sure essential content was discussed, debriefing with the family after the meetings, and checking in with the family on a daily basis.
Despite these efforts, the results for the primary outcome — the surrogates' burden of anxiety and depression at 6 months — were similar with the intervention and with usual care. The reasons for these results are not clear and deserve further investigation. However, the intervention led to improvements in more proximal outcomes related to communication, specifically enhanced surrogate satisfaction with the quality of clinician–family communication and with the patient- and family-centeredness of care.
What, then, are the patient outcomes that result from improved communication? In this very ill cohort, the intervention group had a shorter mean ICU stay and higher in-hospital mortality than the control group, with the two groups having similar mortality at 6 months after discharge. These findings suggest that the intervention did not lead to the premature death of patients who would have otherwise done well — instead, the intervention was associated with a shorter dying process for those who faced a dismal prognosis. We cannot, of course, ask the patients who died whether their outcomes aligned with their wishes, but we know that people have priorities other than extending life as long as possible.8
The results of the trial by White et al. reflect a profound shift for critical care, which has historically measured its victories in terms of the number of patients who are living, regardless of what that life looks like. These new findings offer a harsh reality that complicates the definition of success — it may be possible that providing better care for the most seriously ill patients means that those patients do not live as long. As we increasingly look beyond mortality as the primary outcome that matters, seeking to maximize quality of life and minimize suffering, this work represents an "end of the beginning" by suggesting the next steps in moving closer to achieving these goals.
Disclosure forms provided by the author are available with the full text of this editorial at NEJM.org.
This editorial was published on May 23, 2018, at NEJM.org.