Prolonged respiratory failure: when doctor and family connect, the patient wins.

2012 Critical Care Medicine Prolonged acute respiratory failure is associated with high mortality, poor chronic health, and massive use of healthcare resources (1). Of the approximately 30% of intensive care unit patients that require mechanical ventilation for acute respiratory failure, 5%–10% remain intubated and ventilated for weeks to months (2). A substantial portion (20%–30%) of this population endures multiple admissions to various wards and institutions, is cared for by a number of different teams, and eventually dies, mostly from consensual withdrawal of support (1, 3). Were we to address goals of care for these patients earlier, mortality would not be affected, length of stay would decrease, and patients and families would be spared a great deal of emotional distress and financial losses. Nonetheless, timely planning of care is an elusive goal that requires education and commitment if it is to meet the satisfaction of all involved: surrogates, caregivers, and, most important, patients. The process of decision making (not limited to end-of-life directives) in the care of critically ill patients is multifaceted, involving both physiological and psychosocial considerations. Physicians must also be aware that evidence has become available of effective ways to communicate with families to optimize the chances of success (4). One aspect of this complex process is investigated in the study of Cox et al (5) published in this issue of Critical Care Medicine. The authors hypothesized that “shared decision-making” (6) between caregivers and surrogates facilitates the development of a treatment plan that is most consistent with the patient’s own wishes; furthermore, such plan may facilitate the relationship between physicians and surrogates, and possibly shorten time on the ventilator and decrease costs. The need for developing a decision aid for surrogates is appreciated when one considers the following facts. First, families have incorrect and generally unrealistic expectations of the outcome of their critically ill loved ones (7). Sadly, physicians also have mistakenly optimistic outlooks; in addition, they do not present with clarity the expectations for recovery, and tend to talk more than to listen (8). Finally, physicians and surrogates do not relate well, generating inefficient care planning and distrust (7). Over this background, Cox et al developed and validated, with meticulous methodology, a decision aid designed to educate families on the basics of respiratory failure and ventilatory support, and to foster consensus on a treatment plan based on the patients’ own wishes. The use of the newly developed decision aid enhanced surrogates’ comprehension, improved their concordance with physicians on prognosis, and reduced their conflict with physicians. Furthermore, it was associated with shorter length of stay and lower costs without affecting survival rates. The value of this study is fully appreciated if considered within the larger context of a well refined and executed research plan. For the past several years, these authors have dedicated their research activity to the challenges posed by the patients that remain in the intensive care unit environment for much longer time than predicted. These patients, often rumored to be “less exciting” to care for, are extremely complex because they suffer the persistent failure of multiple organs, requiring highly skilled medical care. In addition, their prolonged illness raises challenges of a different nature, including strain on their families, cost to society, and the task for the intensivist to deal with the beliefs and emotion of patients, families, and fellow caregivers. The authors deserve great praise for their work, but much still needs to be done. First, proper care has to be delivered early in the course of acute respiratory failure, reducing the burden of prolonged respiratory failure in the best possible way, i.e., by not creating it. Using “lung protective ventilation” for acute lung injury/acute respiratory distress syndrome, implementing weaning protocols that consistently use daily spontaneous breathing trials, limiting sedation to specific targets, and avoiding hospital-acquired infections will decrease the number of ventilated patients and increase survival. Second, targeting the decision-making process to predictable timelines. In a dedicated weaning unit (3), 50% of the patients were off the ventilator by the second week of admission, and 60% (of 69% who weaned within 6 months) were off well within 30 days. Beyond the 30th day, the majority of patients who had not weaned went on to die. Although specific times of weaning and dying vary across units due to unique triage criteria and processes of care, the pattern of an early high weaning rate that subsequently tails off occurs in both acute (9) and prolonged respiratory failure (10). When such a time-based pattern can be identified, it may greatly facilitate the physician–surrogate dialogue in setting goals and expectations. Third, care planning is not synonymous to end of life (11). A number of physicians still identify a family meeting with a distressful time where 1) they have to admit failure of their treatment, and 2) they have to obtain a do-not-resuscitate order (i.e., “throwing in the towel,” “pulling the plug”.) (12). On the contrary, in a model of patient-centered care (13), meetings are held primarily to inform the families and educate on what are the possible path of care going forward, according to the patient’s best-known wishes. Oddly, the decision of whether to forgo cardiopulmonary resuscitation (do-not-resuscitate status) is generally a very difficult one for the surrogate, and *See also p. 2327.