Journal Article Annotations
2021, 4th Quarter
Annotations by R Garrett Key, MD and Barbara Lubrano, MD
The authors describe a new intervention for caring for patients with Advanced Illness (AI). Specifically, the authors describe issues with the typical triage paths that often leads to intensive and aggressive hospital care and care discordant with patient wishes, increased costs, and suboptimal outcomes. In the“AI Beds” intervention, “patients whose wishes aligned with minimizing aggressive, curative medical care were provided an enhanced level of nursing and medical care, providing improved symptom management.” This strategy was based on the observation that many ICU beds are occupied by AI patients who do not need highly invasive interventions but do need the increased level of attention provided in ICU. The benefits of the restructured care were decreased ICU length of stay for AI patients, improved bed availability and throughput for ICU beds, care better aligned with patient wishes, and improved resource utilization in both supply expenditure and staffing costs. Hospice referrals were also increased, correlating with decreased in-hospital deaths.
Strength and weaknesses:
Strengths of the pilot were that it was performed across multiple sites and ran for 3 years, allowing for substantial data collection and a robust feasibility assessment across multiple settings. Weaknesses include the reliance of the model on effective clinician communication and the possibility that results were skewed by patient selection. Each eligible patient received a goals of care discussion and were offered the ability to opt into the AI-Beds care model. No control group was created with patients who had in depth goals of care discussions for which the AI Beds model was not offered, therefore, it is unclear how much of the benefit is from the bed model and how much might have been from having a dedicated goals of care discussion.
C-L Psychiatrists often provide care for chronically complex patients and in palliative contexts. We may be able to improve patient care and resource utilization through improvement in care design and an implementation of an AI Beds or similar model to help patients receive care that is more aligned with their wishes while also improving financial outcomes for the healthcare system.
In this article, the authors review the clinical features, assessment tools, epidemiology, etiologies and diagnosis precipitants, and pharmacological and non-pharmacological interventions of delirium in patients with terminal disease. Delirium at the end of life often becomes “the final struggle of palliative management.” Evidence suggests that delirium in patients with advanced illness frequently represents a sign of impending death. Determining if delirium is reversible or not remains a challenge. The use of pharmacological and non-pharmacological treatments continues to have limited evidence, posing another difficulty in its management. Additionally, ethical problems may arise when the administration of palliative sedation is left as the only way to control symptoms in patients with refractory agitated delirium. When considering the use of palliative sedation, it is critical to be informed about the norms and laws of the country or states within a single country concerning end-of-life issues.
Strengths and weaknesses
The strength of this article is its in-depth review of the literature on the topic of delirium, its etiologies, and management. Although delirium management remains similar independent of its etiology, the article could have provided more information on palliative sedation for refractory delirium, the ethical dilemma associated with it, and the impact that this may have on patients and caregivers.
The C-L psychiatrist’s role is constantly expanding and includes the care of patients facing end-of-life issues. Delirium and refractory delirium may require different management and different education to colleagues, patients, and caregivers. As such, it is important that C-L Psychiatrists continue to become familiar and comfortable with its management, particularly when palliative sedation may be the only way to control symptoms in patients with refractory agitated delirium.