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Risk Factors for Delirium in Patients Undergoing Hematopoietic Stem Cell Transplantation (767)
Vol. 41 No. 1 January 2011
Schedule with Abstracts
the issues that complicate care of patients with LVADs including infections, hemodynamic instability, ethical issues surrounding discontinuation, and difficulties of transitions of care. Palliative consultation for this complex case helped to establish his goals, including surgical removal, and despite his death, allowed for those goals to be carried to fruition.
What Are We Asking? The Impact of Surrogate Decision Making (766) Judith Webb, DNP, MGH Institute of Health Professions, Boston, MA. (Webb has disclosed no relevant financial relationships.) Objectives 1. Discuss the clinical practice of end-of-life decision making. 2. Describe the population of surrogate decision makers. 3. Compare the level of distress following death of a loved one between decision-makers and non-decision makers. Background. Approximately 70% of adults more than 60 years old will lose decision-making capacity at the end of their lives, requiring a surrogate to make decisions. Surrogate decision makers play an important role, yet little is known the long-term impact on them. Following the death of a loved one, people may experience varying degrees of psychological morbidity including PTSD. Research objectives. The purpose of the study was to investigate the long-term impact of the death of a loved one and compare distress between decision-makers and non-decision makers, and to determine prevalence of SDMs and further describe the population. Methods. This descriptive study used social networks to conduct an electronic survey of adults who have experienced the death of a loved one in hospital and nonhospital settings. Distress was measured using the Impact of Event Scale-Revised. Results. Among 339 subjects, 37% had served as surrogate decision makers. Comparison of mean scores on the three subscales: intrusion, avoidance, and arousal, indicated both decision makers and non-decision makers reported mild to moderate distress within the previous week. Younger surrogates reported significantly greater symptoms of intrusive thoughts and arousal, even though for a majority the death
313
had been longer than 3 years prior to the survey. Surrogates had less distress over time than did nonsurrogates. Conclusion. Healthcare providers regularly involve loved ones in making end-of-life decisions. Providers should consider not only the risks and benefits to the patient, but the long-term effects these experiences may have on the survivors. Implications for research, policy, or practice. An understanding of differences in long-term distress among various groups of bereaved individuals will inform the clinical practice of health care providers when counseling loved ones during end-of-life decision making. When providers must designate decision makers, the impact on younger surrogates should be considered. Providers may play a role in seeking group consensus as a buffer for this distress.
Risk Factors for Delirium in Patients Undergoing Hematopoietic Stem Cell Transplantation (767) Michelle Weckmann University of Iowa, Iowa City, IA. (Weckmann has disclosed no relevant financial relationships.) Objectives 1. Identify the risk factors for delirium in hospitalized patients following hematopoietic stem cell transplantation (HSCT). 2. Recognize the morbidity and mortality related to delirium in HSCT patients. 3. Discuss the benefits of screening high risk patients for delirium. Background. Increasingly, nonhospice palliative care teams are asked to provide care for cancer patients undergoing hematopoietic stem cell transplant (HSCT). Evidence suggests that early recognition and treatment of delirium can improve long term outcomes yet little is known about the risk factors for delirium in this population. Research objectives. Determine the risk factors for delirium in hospitalized patients following stem-cell transplantation. Methods. Fifty-four patients admitted to an academic hospital for HSCT were assessed prospectively throughout their stay for delirium using The Memorial Delirium Assessment Scale (MDAS) and the Delirium Rating Scale (DRS). Patient’s self-reported medical history and computerized medical records were used to identify transplantation risk factors.
314
Schedule with Abstracts
Results. The incidence of delirium (MDAS > 8 or DRS >12) was 34% and occurred with highest frequency during the initial 2 weeks following transplantation. Post-transplantation risk factors for developing delirium were higher serum creatinine, higher blood urea nitrogen, lower creatinine clearance, and hypoxia; additionally, lower albumin and lower hemoglobin showed a correlation but were not statistically significant. There was no observed association with functional status, transplant type, disease severity, medical comorbidity, sex, age, or conditioning regimen. Conclusion. At least a third of patients who undergo HSCT experience an episode of delirium after transplantation. Fewer risk factors than expected where associated with delirium in this patient population, but the associated risk factors (BUN, Cr, hypoxia) were routinely followed. Consideration should be given to closely monitoring the mental status of HSCT patients for the 48 hours following abnormal laboratory values indicating renal or pulmonary insufficiency. Implications for research, policy, or practice. Delirium is a costly medical condition with burdens on the patient, family, medical system and society. Risk factors can assist in the identification of high risk patients to improve early detection and treatment of delirium post-transplant to decrease the overall morbidity caused by delirium.
Is a Good Death Possible After Withdrawal of Life-Sustaining Therapy? (768) Debra Wiegand, PhD RN, University of Maryland, Baltimore, MD. (Wiegand has disclosed no relevant financial relationships.) Objectives 1. Describe what families perceive as good and bad deaths after withdrawal of life-sustaining therapy from patients with unexpected, lifethreatening illnesses or injuries. 2. Discuss strategies to prepare families for the dying process after life-sustaining therapy is withdrawn. Background. More than 500,000 deaths occur each year in the critical care setting and the majority involve withdrawal of life-sustaining therapy (WLST). Little is known about family perceptions of these deaths. Research objectives. The purpose of this study was to determine if families perceived that their
Vol. 41 No. 1 January 2011
family members had a good or a bad death when a family member in a critical care setting had LST withdrawn after an unexpected, life-threatening illness or injury. Methods. A qualitative hermeneutic phenomenological study was conducted. A convenience, purposive sample of 22 family members participated in interviews 1e2 years after the patient’s death. Units of meaning, clusters, and categories were inductively determined. Methodological rigor was established. Results. Twelve family members perceived that their family member had a good death and five family members perceived that their family member had a bad death. Four family members felt that the patient’s death was both good and bad, and one family member was unsure. Deaths were perceived as good if they were pain-free, the death was fast, the patient was not aware, and the patient was peaceful. Deaths were perceived as bad if the ill or injured family member had a prolonged hospital course with up and down periods, if death was perceived as being premature, and if signs of discomfort were present. Conclusion. The majority of family members perceived that their loved ones died good deaths. This is especially significant given the context of the deaths; deaths that occurred when LST was withdrawn from critically ill adults after unexpected illnesses or injuries. Implications for research, policy, or practice. Deaths after withdrawal of LST can be recognized even by bereaved family members as good deaths. Healthcare providers need to strive to achieve good patient deaths. While the timing and circumstances around a person’s death may be bad in many ways, the actual dying and death can be good.
‘‘Keeping It Congruent with Reality’’: Palliative Care and Surgical Physicians’ Perspectives on Family Members in the SICU (769) Beverly Williams, PhD, Birmingham VAMC, Birmingham, AL. Rodney Tucker, MD, University of Alabama Center for Palliative Care, Birmingham, AL. Michael Barnett, MD, University of Alabama at Birmingham, Birmingham, AL. Christine Ritchie, MD MSPH FACP, University of Alabama at Birmingham, Birmingham, AL. (All speakers have disclosed no relevant financial relationships.)
Schedule with Abstracts
the issues that complicate care of patients with LVADs including infections, hemodynamic instability, ethical issues surrounding discontinuation, and difficulties of transitions of care. Palliative consultation for this complex case helped to establish his goals, including surgical removal, and despite his death, allowed for those goals to be carried to fruition.
What Are We Asking? The Impact of Surrogate Decision Making (766) Judith Webb, DNP, MGH Institute of Health Professions, Boston, MA. (Webb has disclosed no relevant financial relationships.) Objectives 1. Discuss the clinical practice of end-of-life decision making. 2. Describe the population of surrogate decision makers. 3. Compare the level of distress following death of a loved one between decision-makers and non-decision makers. Background. Approximately 70% of adults more than 60 years old will lose decision-making capacity at the end of their lives, requiring a surrogate to make decisions. Surrogate decision makers play an important role, yet little is known the long-term impact on them. Following the death of a loved one, people may experience varying degrees of psychological morbidity including PTSD. Research objectives. The purpose of the study was to investigate the long-term impact of the death of a loved one and compare distress between decision-makers and non-decision makers, and to determine prevalence of SDMs and further describe the population. Methods. This descriptive study used social networks to conduct an electronic survey of adults who have experienced the death of a loved one in hospital and nonhospital settings. Distress was measured using the Impact of Event Scale-Revised. Results. Among 339 subjects, 37% had served as surrogate decision makers. Comparison of mean scores on the three subscales: intrusion, avoidance, and arousal, indicated both decision makers and non-decision makers reported mild to moderate distress within the previous week. Younger surrogates reported significantly greater symptoms of intrusive thoughts and arousal, even though for a majority the death
313
had been longer than 3 years prior to the survey. Surrogates had less distress over time than did nonsurrogates. Conclusion. Healthcare providers regularly involve loved ones in making end-of-life decisions. Providers should consider not only the risks and benefits to the patient, but the long-term effects these experiences may have on the survivors. Implications for research, policy, or practice. An understanding of differences in long-term distress among various groups of bereaved individuals will inform the clinical practice of health care providers when counseling loved ones during end-of-life decision making. When providers must designate decision makers, the impact on younger surrogates should be considered. Providers may play a role in seeking group consensus as a buffer for this distress.
Risk Factors for Delirium in Patients Undergoing Hematopoietic Stem Cell Transplantation (767) Michelle Weckmann University of Iowa, Iowa City, IA. (Weckmann has disclosed no relevant financial relationships.) Objectives 1. Identify the risk factors for delirium in hospitalized patients following hematopoietic stem cell transplantation (HSCT). 2. Recognize the morbidity and mortality related to delirium in HSCT patients. 3. Discuss the benefits of screening high risk patients for delirium. Background. Increasingly, nonhospice palliative care teams are asked to provide care for cancer patients undergoing hematopoietic stem cell transplant (HSCT). Evidence suggests that early recognition and treatment of delirium can improve long term outcomes yet little is known about the risk factors for delirium in this population. Research objectives. Determine the risk factors for delirium in hospitalized patients following stem-cell transplantation. Methods. Fifty-four patients admitted to an academic hospital for HSCT were assessed prospectively throughout their stay for delirium using The Memorial Delirium Assessment Scale (MDAS) and the Delirium Rating Scale (DRS). Patient’s self-reported medical history and computerized medical records were used to identify transplantation risk factors.
314
Schedule with Abstracts
Results. The incidence of delirium (MDAS > 8 or DRS >12) was 34% and occurred with highest frequency during the initial 2 weeks following transplantation. Post-transplantation risk factors for developing delirium were higher serum creatinine, higher blood urea nitrogen, lower creatinine clearance, and hypoxia; additionally, lower albumin and lower hemoglobin showed a correlation but were not statistically significant. There was no observed association with functional status, transplant type, disease severity, medical comorbidity, sex, age, or conditioning regimen. Conclusion. At least a third of patients who undergo HSCT experience an episode of delirium after transplantation. Fewer risk factors than expected where associated with delirium in this patient population, but the associated risk factors (BUN, Cr, hypoxia) were routinely followed. Consideration should be given to closely monitoring the mental status of HSCT patients for the 48 hours following abnormal laboratory values indicating renal or pulmonary insufficiency. Implications for research, policy, or practice. Delirium is a costly medical condition with burdens on the patient, family, medical system and society. Risk factors can assist in the identification of high risk patients to improve early detection and treatment of delirium post-transplant to decrease the overall morbidity caused by delirium.
Is a Good Death Possible After Withdrawal of Life-Sustaining Therapy? (768) Debra Wiegand, PhD RN, University of Maryland, Baltimore, MD. (Wiegand has disclosed no relevant financial relationships.) Objectives 1. Describe what families perceive as good and bad deaths after withdrawal of life-sustaining therapy from patients with unexpected, lifethreatening illnesses or injuries. 2. Discuss strategies to prepare families for the dying process after life-sustaining therapy is withdrawn. Background. More than 500,000 deaths occur each year in the critical care setting and the majority involve withdrawal of life-sustaining therapy (WLST). Little is known about family perceptions of these deaths. Research objectives. The purpose of this study was to determine if families perceived that their
Vol. 41 No. 1 January 2011
family members had a good or a bad death when a family member in a critical care setting had LST withdrawn after an unexpected, life-threatening illness or injury. Methods. A qualitative hermeneutic phenomenological study was conducted. A convenience, purposive sample of 22 family members participated in interviews 1e2 years after the patient’s death. Units of meaning, clusters, and categories were inductively determined. Methodological rigor was established. Results. Twelve family members perceived that their family member had a good death and five family members perceived that their family member had a bad death. Four family members felt that the patient’s death was both good and bad, and one family member was unsure. Deaths were perceived as good if they were pain-free, the death was fast, the patient was not aware, and the patient was peaceful. Deaths were perceived as bad if the ill or injured family member had a prolonged hospital course with up and down periods, if death was perceived as being premature, and if signs of discomfort were present. Conclusion. The majority of family members perceived that their loved ones died good deaths. This is especially significant given the context of the deaths; deaths that occurred when LST was withdrawn from critically ill adults after unexpected illnesses or injuries. Implications for research, policy, or practice. Deaths after withdrawal of LST can be recognized even by bereaved family members as good deaths. Healthcare providers need to strive to achieve good patient deaths. While the timing and circumstances around a person’s death may be bad in many ways, the actual dying and death can be good.
‘‘Keeping It Congruent with Reality’’: Palliative Care and Surgical Physicians’ Perspectives on Family Members in the SICU (769) Beverly Williams, PhD, Birmingham VAMC, Birmingham, AL. Rodney Tucker, MD, University of Alabama Center for Palliative Care, Birmingham, AL. Michael Barnett, MD, University of Alabama at Birmingham, Birmingham, AL. Christine Ritchie, MD MSPH FACP, University of Alabama at Birmingham, Birmingham, AL. (All speakers have disclosed no relevant financial relationships.)