医学课件血液成份及输血疗法

Intensive communication: Four-year follow-up from a clinical practice study,Ri 王信堯,Journal Reading,Lilly: Crit Care Med, Volume 31(5) Supplement.May 2003.S394-S399,Preface,Fear, air hunger, pain, anxiety of dying Hospice care, intensive care ? End of life care, option ? Ineffective life support moving to a comfort-focused care plan,Lilly: Crit Care Med, Volume 31(5) Supplement.May 2003.S394-S399,Introduction,Purpose: moving dying patients from ineffective lift support to comfort-focused care plan When to decide? Where the decision made? What memberships? Why do it? How to do? Intensive communication- the bridge between ICU support to comfort care,Lilly: Crit Care Med, Volume 31(5) Supplement.May 2003.S394-S399,Intensive communication,The uniform application of a process of communication moving dying patients to comfort-focused care Noncoercive, patient and family-centered, multidisciplinary process Primary outcome variables - length of ICU stay and mortality Secondary outcome varibles - agreement among providers, team, patient, family,Lilly: Crit Care Med, Volume 31(5) Supplement.May 2003.S394-S399,Methods (1),2891 adult patients admitted to ICU during 4-yr period from Oct. 31, 1998, to Sept. 30, 2002 10-bed medical ICU 1 attending physician, 23 residents, 3 interns, and 45 nurses (in shifts). Admission decision: physician not part of ICU team Discharge decision: critical care physician,Lilly: Crit Care Med, Volume 31(5) Supplement.May 2003.S394-S399,Methods (2),Initial meeting: within 72 hrs of ICU admission Criteria: 1. Predicted ICU stay = 5 days 2. Predicted mortality of 25 % 3. Function status potentially irreversible and sufficient to preclude eventual return to home,Lilly: Crit Care Med, Volume 31(5) Supplement.May 2003.S394-S399,Methods (3),Memberships: attending intensivists, nurse, house officer, family, patient ( if possible) Other members: outside expert, social workers, psychiatrist, even security expert Initial introductions, open-ended questions and patient current status and cure “ Red flags “ - Final interventions,Lilly: Crit Care Med, Volume 31(5) Supplement.May 2003.S394-S399,Methods (4),Discussion objects: 1. Review the medical facts and options for treatment 2. Patient s perspectives, acceptability of risks, and discomfort of critical care 3. Agree on a care plan 4. Agree on criteria by which the success or failure of this care plan would be judged,Lilly: Crit Care Med, Volume 31(5) Supplement.May 2003.S394-S399,Methods (5),The comparison of the three group periods: Pre-intervention period: 134 consecutive pt, consecutive 12-month periods from Oct.1, 1996 to Oct. 31, 1998 Intensive communication period: 396 consecutive pt, consecutive 12-month periods from Oct.1, 1996 to Oct. 31, 1998 4-yr follow up period: 2361 consecutive pt, from Oct. 31, 1998 to Oct. 30, 2002,Lilly: Crit Care Med, Volume 31(5) Supplement.May 2003.S394-S399,Results (1),Lilly: Crit Care Med, Volume 31(5) Supplement.May 2003.S394-S399,Results (2),Pre: 41 sessions / 134 pt ( 0.3 / pt) During: 594 sessions / 396 pt ( 1.5 / pt) 4 yrs F/U: 3679 sessions / 2361 pt ( 1.6 / pt),Lilly: Crit Care Med, Volume 31(5) Supplement.May 2003.S394-S399,Results (3),Median length of stay in the ICU 1. Pre: 4 days (2-11 days) 2. During: 3 days (2-6 days) 3. 4-yr F/U: 3 days (2-6 days) Median length of stay was reduced from pre-intervention period to during period. But during and 4-yr F/U period seems the same,Lilly: Crit Care Med, Volume 31(5) Supplement.May 2003.S394-S399,Results (4),Lilly: Crit Care Med, Volume 31(5) Supplement.May 2003.S394-S399,Results (5),Effects on mortality: 1. Pre: 31.3 % (chi-square p .001) 2. During: 22.7 % 3. 4-yr F/U: 18.0 % ICU mortality significantly decreased because of the perform of intensive communication,Lilly: Crit Care Med, Volume 31(5) Supplement.May 2003.S394-S399,Results (6),Lilly: Crit Care Med, Volume 31(5) Supplement.May 2003.S394-S399,Discussion (1),Intensive communication: Three groups of adult critical ill patients with different needs for support: a group with functional recovery, or significant disability, or dying Prevent significant disability Prevent premature inappropriate palliative care plan Encourage the transition to a comfort-only care plan for dying patients,Lilly: Crit Care Med, Volume 31(5) Supplement.May 2003.S394-S399,Discussion (2),Intensive communication: A patient-family meeting note template Clinical milestones (care plans and criteria by which their success was to be judged) The patients value of what we determine The surviving ones (patient or family) were almost satisfied with the process of the intensive communication,Lilly: Crit Care Med, Volume 31(5) Supplement.May 2003.S394-S399,Discussion (3),Intensive communication: The relationships between the intensive care providers and non-direct caregivers - by session summary notes to understand how to do and why the decision maded Continue advanced supportive technology or elect a comfort-only focused care as a process rather than as an event,Lilly: Crit Care Med, Volume 31(5) Supplement.May 2003.S394-S399,Discussion (4),Intensive communication and ICU stay: Time frame: within 72 hrs ICU admission The senior physician and direct patient care nurse time are critical components of intensive communication, non-direct care givers not absolutely required,Lilly: Crit Care Med, Volume 31(5) Supplement.May 2003.S394-S399,Discussion (5),Intensive communication and mortality: Approximately 1/3 of the mortality benefit could be accounted for by improved asscess to ICU admission for patients who were less likely to die, based on their lower APACHE scores May due to the ability to support critically ill patients and to target advanced supportive technology to those who can survive,Lilly: Crit Care Med, Volume 31(5) Supplement.May 2003.S394-S399,Discussion