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Psychological Outcomes of Critical Illness


Psychological Outcomes of Critical Illness Erin K. Kross, MD Senior Fellow Pulmonary & Critical Care Medicine February 23, 2008 * * * * Small study of 32 patients ... – PowerPoint PPT presentation

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Title: Psychological Outcomes of Critical Illness

Psychological Outcomes of Critical Illness
  • Erin K. Kross, MD
  • Senior Fellow
  • Pulmonary Critical Care Medicine
  • February 23, 2008

  • Highlight the patient experience of critical
  • Review psychological sequelae of critical illness
  • Post-traumatic stress disorder (PTSD)
  • What is PTSD?
  • Why does it happen after critical illness?
  • Discuss post-traumatic stress disorder among
  • How common is it?
  • What are the risk factors for it?
  • What can we do about it?
  • Discuss post-traumatic stress disorder among
    family members
  • How common is it?
  • What can we do about it?

(No Transcript)
Experiences of Critical Care
  • What happens in the ICU can have long-term
    consequences for patients and families
  • What we do for patients and their families in the
    ICU has long-term consequences

Psychological Outcomes of Critical Illness
  • Major Depressive Disorder
  • Generalized Anxiety Disorder
  • Panic Disorder
  • Post-traumatic Stress Disorder
  • For family members
  • All of the above
  • Complicated Grief Disorder

Post-traumatic Stress Disorder (PTSD)
  • PTSD is common after traumatic events
  • General population lifetime prevalence
  • 5-6 men
  • 10-14 women
  • War veterans (2-15)
  • Rape or assault victims (14-80)

Yehuda. NEJM 2002346(2)108-114. Jackson et al.
Crit Care 200711(1)R27.
  • Traumatic events provoke fear, helplessness or
    horror in response to an event that threatens
    ones life or safety
  • Exposure to traumatic events increase risk of
    other psychological morbidity
  • Depression
  • Panic disorder
  • Generalized anxiety disorder
  • Substance abuse

Why Does PTSD Matter?
  • Burden of symptoms can be high
  • Psychological stress, interruption of daily life
  • Inability to work
  • Inability to return to prior levels of
  • Increased cost to society, secondary to increased
    health care costs

Diagnostic Criteria
  • Exposure to a traumatic event
  • Perceived or actual threat to ones life or
    physical integrity, or that of another
  • 3 domains
  • Symptoms of re-experiencing
  • Symptoms of avoidance and emotional numbing
  • Symptoms of increased arousal
  • 2 criteria
  • Significant impairment in social, occupational or
    other functional domains
  • Symptoms present for at least 1 month after event

PTSD in the ICU
  • ICU treatment for critical illness exposes
    patients and families to enormous stress
  • Experience of life-threatening illness
  • Need for intensive, often invasive medical
  • Meets DSM-IV criteria for traumatic event
  • Both patients and family members

Three Groups at Risk for PTSD
  • Patients who survive critical illness and are
    discharged following ICU care
  • Family members of individuals who survive
    critical illness
  • Family members of individuals who die during or
    shortly after their ICU stay

1) Survivors of Critical Illness
Survivors of Critical Illness
  • About 20 studies currently in the literature
  • Variation in study population
  • Number of subjects in the studies ranged 20 to
    143 patients
  • Rates of follow-up ranged 30-84
  • Variation in study design
  • Prospective vs. retrospective
  • Survey instruments used vs. diagnostic tools
  • Live interview vs. phone interview

Jackson et al. Crit Care 200711(1)R27.
Survivors of Critical Illness
  • Review article
  • Medical ICU patients only
  • Excluded surgical or trauma patients
  • Some restricted to acute lung injury or septic
  • Most excluded patients with prior psychiatric
    illness, neurologic trauma or disease

Jackson et al. Crit Care 200711(1)R27.
Survivors of Critical Illness
  • Evaluated for symptoms at different time points
  • Some studies looked at patients over time
  • Range from 2 months to 8 years following
  • Other studies only looked at one point in time
  • Range from 3 months to 13 years following

PTSD Among Survivors
  • Prevalence rates ranged from as low as 5 to as
    high as 63 in survivors of critical illness
  • Prevalence seems to vary over time
  • Highest prevalence when assessed close to the
    time of discharge
  • Prevalence decreases over time
  • Stabilizes around 6 months following traumatic

Risk Factors for PTSD
  • Things we cant change
  • Younger age
  • Female gender
  • Prior mental health history
  • Things we might be able to change
  • Increased length of stay
  • Increased duration of mechanical ventilation
  • Things we certainly can change
  • Greater levels of sedation and/or neuromuscular
  • Greater perceived social support appears to be

Jackson et al. Crit Care 200711(1)R27.
Sedation in the ICU
  • Sedative drug infusions
  • Prolonged periods of altered mental status
  • Delay in regaining consciousness once stopped
  • Patients report pain and anxiety
  • Does sedation help or hurt the long-term
    psychological effects of being in the ICU?
  • Helps blunt the experience
  • But causes prolonged periods of amnesia

Girard et al. Crit Care 200711(1)R28. Kress et
al. AJRCCM 2003168(12)1457-61. Nelson et al.
Crit Care Med 2000283626-30.
Sedation Vacations
  • Daily sedative interruption
  • Often combined with spontaneous breathing trials
  • Known short-term benefits in patients requiring
    mechanical ventilation
  • Shorter durations of mechanical ventilation
  • Shorter ICU lengths of stay

Kress et al. NEJM 20003421471-7.
Sedation and PTSD
  • Daily sedation vacations vs. continuous
  • Compared long-term psychological outcomes
  • Lower IES scores with sedation vacations
  • Trend towards lower PTSD (0 vs. 36) with
    sedation vacations

Kress et al. AJRCCM 2003168(12)1457-61.
Social Support and PTSD
  • Long-term survivors of ARDS
  • Health-Related Quality of Life
  • PTSD
  • The more social support, the less PTSD
  • More PTSD among those with high anxiety and pain
  • More anxiety among those who remembered
    difficulty breathing and nightmares

Deja et al. Crit Care 200610(5)R147.
2) Family Members of Survivors of Critical Illness
Family Members
  • Critical illness affects not only the patient who
    is sick, but also their family and friends
  • ICU can be a traumatic environment for these
  • Alarms, machines, monitors, invasive devices

Why are Families at Risk for PTSD?
  • Traumatic experience
  • DSM-IV criteria
  • Family members are often asked to assume the role
    of surrogate decision-maker
  • Participate in decision making in the ICU
  • ICU patients often not able to participate in
    decisions about withholding or withdrawing life

PTSD among Family Members
  • Far fewer studies about how the ICU experience
    affects family members
  • Largest study from France
  • Conducted in 21 medical-surgical ICUs in 2003
  • Family members eligible if came to visit within
    48 hours of admission
  • Closest family member was identified
  • Phone interviews conducted 90 days after ICU
    discharge (or death)

Azoulay et al. AJRCCM 2005171987-994.
PTSD among Family Members
  • 228 family members of patients who survived their
    critical illness participated
  • 28.9 screened positive for significant levels of
    PTSD symptoms
  • Risk factors identified
  • Things we cant change
  • Female gender
  • Children of the ICU patient
  • Things we can change
  • Feeling information is incomplete
  • Sharing decisions in the ICU

Azoulay et al. AJRCCM 2005171987-994.
Smaller Studies of Family Members
  • Only a handful of other studies
  • PTSD as high as 49
  • 6 months after discharge
  • Acute symptoms very common
  • Prevalence of PTSD of 81
  • One week after admission to the ICU
  • Doesnt meet criteria for PTSD
  • High burden of psychological symptoms

3) Family Members of Those Who Die in the ICU
Family Members of Those Who Die
  • Death is a stressful event for families
  • Studies of PTSD following bereavement
  • Deaths outside the ICU
  • Interviews with spouses 2 months after death of
    their spouse
  • 10 met criteria for PTSD
  • No difference between types of death
  • Chronic illness vs. sudden, unexpected death
  • Did not discuss hospitalization or ICU admission

PTSD among Family Members
  • Primary study is from France
  • 56 family members of patients who died were
    interviewed 90 days after death
  • Prevalence of PTSD for this group was 50

Azoulay et al. AJRCCM 2005171987-994.
Some Families are at Higher Risk
  • Among all patients that died 50
  • Family members of patients who died in the ICU
    after end-of-life decisions (60)
  • Family members who were involved in end-of-life
    decisions (80)

How Do We Decrease PTSD?
  • French group followed up with an interventional
  • Goal Lessening the effects of bereavement among
    family members whose loved one dies in the ICU
  • Enrolled 126 family members of patients who died
    in the ICU

Laurtrette et al. NEJM 2007356469-78.
Intervention to Decrease PTSD
  • Intervention Structured end-of-life care family
    conference and a brochure for the family
  • Control Usual care
  • Interviews conducted 90 days following the death

Laurtrette et al. NEJM 2007356469-78.
Intervention to Decrease PTSD
  • Prevalence of PTSD
  • Control group 67
  • Intervention group 45
  • Primary differences between the 2 groups was
    attributed to physician-family communication
  • Intervention group spent more time in family
  • Spent more of the conference time talking than
    the control group

Are the U.S. and France the Same?
  • Differences in regional, racial, religious and
    cultural influences affect families preferences
    for care and clinicians delivery of care
  • Decision making is different in France
  • More than half of family members did not want to
    participate in end-of-life decision making
  • 39 of physicians preferred to involve family
    members in end-of-life decisions

Laurtrette et al. NEJM 2007356469-78. Vincent
et al. Crit Care Med 200129(2S)N52-5.
Are the U.S. and France the Same?
  • In North America, patient autonomy is key
  • Extended to family members
  • Physicians involve family members in decision
    making for end-of-life care 70-80 of the time
  • Family members more satisfied with care when they
    are involved in decision-making at the
  • Participation in end-of-life decision-making may
    result in differing burdens of psychological

Laurtrette et al. NEJM 2007356469-78. Vincent
et al. Crit Care Med 200129(2S)N52-5.
Preliminary Data from U.S.
  • End-of-Life Care Research Program at HMC
  • Group at Yale
  • Both finding lower prevalence of PTSD and
    depression than in France
  • Still higher than the general population

Gries et al. In preparation. Seigel et al. Crit
Care Med, in press.
Challenges to Studying PTSD in the ICU
  • Diagnosis of PTSD requires symptoms of distress,
    and a precipitating traumatic event
  • Difficult to know other history
  • Significant co-morbidity with PTSD and other
    psychiatric illnesses
  • Difficult to decipher the cause of PTSD symptoms,
    as well as the relative contribution of PTSD to
    an individuals overall level of distress

Challenges to Studying PTSD in the ICU
  • Difficult to separate the experience of the ICU
    from other aspects of health care and illness
  • Difficult to separate this experience from other
    traumatic events that may have been experienced
    in the past
  • Clearly this is an important problem for both
    patients and family members of critically ill

What Can We Do?
  • For patients
  • Everything they experience in the ICU may have
    long-term consequences
  • Regardless of sedation, there may be memories of
    their ICU stay
  • Decrease sedation as much as possible
  • Daily interruption of sedation
  • Provide social support

What Can We Do?
  • For families
  • The ICU experience is traumatic for families too
  • Provide social support
  • Participation in decision-making

  • Video courtesy of the IPACC study
  • Harborview End-of-Life Care Research Team
  • J. Randall Curtis
  • Ruth Engelberg
  • Patsy Treece
  • Elizabeth Nielsen
  • Many, many more