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Psychological Outcomes of Critical Illness

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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


1
Psychological Outcomes of Critical Illness
  • Erin K. Kross, MD
  • Senior Fellow
  • Pulmonary Critical Care Medicine
  • February 23, 2008

2
Objectives
  • Highlight the patient experience of critical
    illness
  • 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
    patients
  • 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?

3
(No Transcript)
4
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

5
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

6
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.
7
PTSD
  • 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

8
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
    functioning
  • Increased cost to society, secondary to increased
    health care costs

9
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

10
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
    procedures
  • Meets DSM-IV criteria for traumatic event
  • Both patients and family members

11
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

12
1) Survivors of Critical Illness
13
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.
14
Survivors of Critical Illness
  • Review article
  • Medical ICU patients only
  • Excluded surgical or trauma patients
  • Some restricted to acute lung injury or septic
    shock
  • Most excluded patients with prior psychiatric
    illness, neurologic trauma or disease

Jackson et al. Crit Care 200711(1)R27.
15
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
    discharge
  • Other studies only looked at one point in time
  • Range from 3 months to 13 years following
    discharge

16
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
    event

17
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
    blockade
  • Greater perceived social support appears to be
    protective

Jackson et al. Crit Care 200711(1)R27.
18
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.
19
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.
20
Sedation and PTSD
  • Daily sedation vacations vs. continuous
    sedation
  • 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.
21
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.
22
2) Family Members of Survivors of Critical Illness
23
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
    individuals
  • Alarms, machines, monitors, invasive devices

24
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
    support

25
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.
26
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.
27
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

28
3) Family Members of Those Who Die in the ICU
29
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

30
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.
31
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)

32
How Do We Decrease PTSD?
  • French group followed up with an interventional
    study
  • 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.
33
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.
34
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
    conferences
  • Spent more of the conference time talking than
    the control group

35
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.
36
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
    end-of-life
  • Participation in end-of-life decision-making may
    result in differing burdens of psychological
    disease

Laurtrette et al. NEJM 2007356469-78. Vincent
et al. Crit Care Med 200129(2S)N52-5.
37
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.
38
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

39
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
    patients

40
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
  • COMMUNICATION

41
What Can We Do?
  • For families
  • The ICU experience is traumatic for families too
  • Provide social support
  • Participation in decision-making
  • COMMUNICATION

42
Acknowledgements
  • 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
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