Keywords

Communication, Patient-Centered Communication, Shared Decision-Making, Prognostication, Intensive Care, Acute Respiratory Failure, Acute Lung Injury, Acute Respiratory Distress Syndrome, Mechanical Ventilation

Disciplines

Bioethics and Medical Ethics | Medical Humanities

Abstract

A 56 year-old male presented with symptoms of pneumonia and findings consistent with acute lung injury (ALI). Deterioration of respiratory function occurred over the first 24 hours of hospitalization leading to placement in an intensive care unit (ICU) followed by tracheal intubation and mechanical ventilation (ETMV). At that time criteria defining acute respiratory distress syndrome (ARDS) were present. The palliative medicine service was asked to address concerns expressed by the patient’s spouse reflecting uncertainty regarding outcome expectations.

When interacting with families of incapacitated critically ill patients, clinicians are advised to employ a patient-centered communication process to alleviate family distress and facilitate making necessary decisions in a shared manner. Acknowledging and confronting the uncertainties of a critical illness is an essential component of patient-centered communication. Addressing and managing uncertainty for this case scenario requires consideration of both short- and long-term outcomes including mortality, ventilator independence, and adverse effects on quality of life for survivors. In this paper, ALI/ARDS requiring ETMV in the ICU was used as a focal point for preparing a prognostic assessment incorporating these issues. This assessment was based on a review of recently published literature regarding mortality and ventilator independence of survivors for adult patients receiving ETMV for ALI/ARDS in the ICU. In the studies reviewed, long-term survival reported at 60 days to 1 year was 50-73% with greater than 84% of the survivors in each study breathing independently. Selected articles discussing outcomes other than mortality or recovery of respiratory function, particularly quality of life implications for ALI/ARDS survivors, were also reviewed.

This case example of ALI/ARDS requiring ETMV in the ICU is used to illustrate the situation of an incapacitated critically ill patient where the outcome is uncertain. Patient-centered communication with the patient’s representative should acknowledge and address this uncertainty. Managing uncertainty consists of effectively expressing a carefully formulated prognostic assessment and using sound communication principles to alleviate the distress associated with the uncertain outcome probabilities.

Original Citation

Johnson, R. F., & Gustin, J. (2013). Acute lung injury and acute respiratory distress syndrome requiring tracheal intubation and mechanical ventilation in the intensive care unit. American Journal of Hospice and Palliative Medicine®, 30(6), 569-575. doi:10.1177/1049909112460566

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