Prolonged mechanical ventilation gobbles up a huge proportion of healthcare dollars and still results in persistent, profound disability. Family members or other decision makers should be informed of this when they are considering a course of prolonged life support, researchers write in a new study published in the August 3 issue of the Annals of Internal Medicine.
“Growing numbers of critically ill patients receive prolonged mechanical ventilation,” write Mark Unroe, MD, from Duke University, Durham, North Carolina, and colleagues. “Decision makers’ hope for patient survival coupled with an incomplete understanding of the specific implications for providing prolonged mechanical ventilation may contribute to the increasing incidence.”
The aim of this study was to describe the overall trajectories of care location and costs for patients receiving prolonged mechanical ventilation.
The 1-year, prospective cohort study was conducted in 5 intensive care units (ICUs), including trauma, neurologic, cardiac, cardiothoracic surgery, and medical ICUs, at Duke University Medical Center. The study involved 126 patients who received prolonged mechanical ventilation for 4 days or more with a tracheostomy, or ventilation for 21 days or more without a tracheostomy, as well as 126 of their surrogate decision makers and 54 ICU physicians.
The patients were middle-aged, had health insurance, and were well-educated, with few premorbid conditions before ICU admission.
The patients, surrogate decision makers, and physicians were interviewed within 48 hours of study entry, and then at 3 and 12 months after discharge from hospital. The primary outcomes were 1-year survival, functional status, and healthcare resource utilization. Health outcomes were described as:
- good, or alive with no dependencies in activities of daily living;
- fair, or alive with 1 to 5 dependencies in activities of daily living, or
- poor, or either dead or alive with dependencies in all 6 activities of daily living.
The 103 surviving patients had 457 transitions in care location after discharge from the ICU (median, 4; interquartile range, 3 – 5) and received a total of 14,552 days of inpatient hospital and facility care. There were 150 readmissions in 68 (67%) of the 103 hospital survivors. Most (65%) occurred within 3 months, and nearly half were caused by sepsis.
The study also found that patients spent an average of 74% (95% confidence interval [CI], 68% – 80%) of all days alive in a hospital or postacute care facility or receiving home healthcare.
At 1 year, only 11 patients (9%) had a good outcome, with no functional dependency. Thirty-three patients (26%) had a fair outcome (alive with moderate dependency), and the majority of patients (n = 82 [65%]) had a poor outcome. Of these, 4 patients (21%) were alive with complete functional dependency, and 56 (44%) had died. The patients who died during follow-up lived a median of 79 days (interquartile range, 46 – 125 days).
Patients with poor outcomes were older, had more comorbid conditions, and were discharged to postacute care facilities more often compared with patients with either fair or good outcomes (P < .05 for all comparisons).
The study also found that the mean cost per patient was $306,135 (SD, $285,467), and the cost for the entire cohort was $38.1 million. The estimated cost for each independently functioning survivor at 1 year was $3.5 million.
The findings of this study are important for patients, families, clinicians, and policy makers, the authors write, noting that the effect on the US healthcare system of prolonged mechanical ventilation has probably been substantially underestimated.
They also suggest that managing patients with intermediate or fair outcomes — those who survive but have moderate functional dependencies — may be the most challenging, because of the uncertainty of their prognosis. Nevertheless, these patients rarely improved over time, in spite of their decision makers’ initial optimism, “instead cycling frequently between postacute care facilities and hospitals.”
The circumstances under which decisions about prolonged mechanical ventilation occur favor the pursuit of aggressive care for a variety of reasons, they write. For one, communication between physicians and surrogates is inadequate for fully shared decision making, as most surrogates receive no information about functional dependency or expected 1-year survival. In addition, both clinicians and surrogates overestimate prospects for recovery and fail to anticipate the amount and intensity of care that will be required. Finally, internists are often uncomfortable discussing uncertain prognoses under such conditions, and the complex nature of critical illness can be hard for them to explain.
To this end, the authors suggest that the health outcomes used in their study (good, fair, poor) might help in the decision-making process.
Limitations of the study include the use of participant self-reports to quantify the duration of postdischarge care, which may have resulted in inaccurate assessment of costs, an inability to quantify the “notable” financial strain on patients and their caregivers of such critical illness, and the fact that the study was done in a single institution, and so the findings may not be not be generalizable to other patients receiving prolonged mechanical ventilation at other institutions or to those patients with different sociocultural or linguistic backgrounds.
The authors conclude: “Currently, the decision-making process for prolonged mechanical ventilation is marked by unrealistic expectations and poor communication. It seems prudent that, in the context of prolonged mechanical ventilation, physicians not only discuss long-term outcomes with surrogates in terms that they can easily understand but also explicitly convey the probable demands of treatment and the future functional dependence patients will probably have.”
This study was supported by the National Institutes of Health. Dr. Unroe has disclosed no relevant financial relationships.
Ann Intern Med. 2010;153:167-175.