Preferences for Mechanical Ventilation Among Survivors
Preferences for Mechanical Ventilation Among Survivors
Background: Among survivors of prolonged mechanical ventilation, preferences for this treatment have rarely been explored.
Objectives: To elicit preferences of survivors of prolonged mechanical ventilation (≥7 days) and factors influencing these preferences.
Methods: A descriptive, cross-sectional survey design was used. Subjects were recruited from intensive care units in a tertiary care hospital and from long-term care facilities. Each subject (n = 30) was asked to reflect on the decision to use mechanical ventilation; rate current health, pain/discomfort in the intensive care unit and from mechanical ventilation, perceived family financial burden, and emotional/ physical stress related to mechanical ventilation; identify changes that would influence preference for mechanical ventilation; and answer questions about quality of life, functional status, depressive symptoms, and communication.
Results: Most subjects (75.9%) would have chosen mechanical ventilation. Median days of mechanical ventilation and tracheostomy were greater for subjects who would have chosen mechanical ventilation (98.5 vs 70), as were median days of tracheostomy (102 vs 64). Patients who would not have chosen mechanical ventilation had more depressive symptoms and were more likely to be insured by Medicare. No other variables differed between groups. Patients who preferred mechanical ventilation would change their preference on the basis of their families' emotional/physical stress and financial burden. Patients who did not prefer mechanical ventilation would change their preference if the family financial burden and emotional/physical stress were reduced and current health improved.
Conclusions: Most patients would have chosen mechanical ventilation. Survivors' preferences were influenced by their current health and families' financial burden and stress.
Care in the intensive care unit (ICU) is associated with significant costs, and critically ill patients who require prolonged mechanical ventilation account for a substantial proportion of these costs. Although most patients who require mechanical ventilation during an acute illness are quickly weaned from ventilatory support, in a minority, an estimated 3% to 6% of all patients admitted to the ICU, weaning is prolonged. The cost of caring for patients who are difficult to wean is related to the time and effort-intensive nature of the weaning process, extended stay in acute and long-term care facilities, and the morbidity associated with increased duration of ventilatory support.
Escalating healthcare costs, concerns about patients' autonomy, and recognition that prolonged ICU stays are often followed by death or disability have prompted evaluation of the benefits and burdens of intensive care and life-sustaining therapies. Mortality is high in patients who require prolonged mechanical ventilation; according to estimates, 33% to 44% of patients who require such treatment die during the first 12 months after discharge from the ICU. Higher mortality is associated with increased age, more comorbid conditions, and poorer functional status before hospitalization. Despite resource-intensive treatment, most patients who require prolonged mechanical ventilation experience profound physical debilitation as a consequence of their extended illness. Consequently, nearly all spend an extended period in a long-term care facility after discharge from the ICU. Although Niskanen et al found that 6 months after ICU discharge most patients who had required prolonged intensive care were independent in activities of daily living, in most studies, similar patients had a significant decline in physical functioning. Nevertheless, long-term survivors of prolonged mechanical ventilation commonly report satisfaction with their quality of life despite moderate to severe limitations in functional ability.
Background: Among survivors of prolonged mechanical ventilation, preferences for this treatment have rarely been explored.
Objectives: To elicit preferences of survivors of prolonged mechanical ventilation (≥7 days) and factors influencing these preferences.
Methods: A descriptive, cross-sectional survey design was used. Subjects were recruited from intensive care units in a tertiary care hospital and from long-term care facilities. Each subject (n = 30) was asked to reflect on the decision to use mechanical ventilation; rate current health, pain/discomfort in the intensive care unit and from mechanical ventilation, perceived family financial burden, and emotional/ physical stress related to mechanical ventilation; identify changes that would influence preference for mechanical ventilation; and answer questions about quality of life, functional status, depressive symptoms, and communication.
Results: Most subjects (75.9%) would have chosen mechanical ventilation. Median days of mechanical ventilation and tracheostomy were greater for subjects who would have chosen mechanical ventilation (98.5 vs 70), as were median days of tracheostomy (102 vs 64). Patients who would not have chosen mechanical ventilation had more depressive symptoms and were more likely to be insured by Medicare. No other variables differed between groups. Patients who preferred mechanical ventilation would change their preference on the basis of their families' emotional/physical stress and financial burden. Patients who did not prefer mechanical ventilation would change their preference if the family financial burden and emotional/physical stress were reduced and current health improved.
Conclusions: Most patients would have chosen mechanical ventilation. Survivors' preferences were influenced by their current health and families' financial burden and stress.
Care in the intensive care unit (ICU) is associated with significant costs, and critically ill patients who require prolonged mechanical ventilation account for a substantial proportion of these costs. Although most patients who require mechanical ventilation during an acute illness are quickly weaned from ventilatory support, in a minority, an estimated 3% to 6% of all patients admitted to the ICU, weaning is prolonged. The cost of caring for patients who are difficult to wean is related to the time and effort-intensive nature of the weaning process, extended stay in acute and long-term care facilities, and the morbidity associated with increased duration of ventilatory support.
Escalating healthcare costs, concerns about patients' autonomy, and recognition that prolonged ICU stays are often followed by death or disability have prompted evaluation of the benefits and burdens of intensive care and life-sustaining therapies. Mortality is high in patients who require prolonged mechanical ventilation; according to estimates, 33% to 44% of patients who require such treatment die during the first 12 months after discharge from the ICU. Higher mortality is associated with increased age, more comorbid conditions, and poorer functional status before hospitalization. Despite resource-intensive treatment, most patients who require prolonged mechanical ventilation experience profound physical debilitation as a consequence of their extended illness. Consequently, nearly all spend an extended period in a long-term care facility after discharge from the ICU. Although Niskanen et al found that 6 months after ICU discharge most patients who had required prolonged intensive care were independent in activities of daily living, in most studies, similar patients had a significant decline in physical functioning. Nevertheless, long-term survivors of prolonged mechanical ventilation commonly report satisfaction with their quality of life despite moderate to severe limitations in functional ability.
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