A recent study in the New England Journal of Medicine http://www.ncbi.nlm.nih.gov/pubmed/24088092 found that 40% of 821 ICU patients with respiratory failure or shock had cognitive impairment 3 months after discharge and 24% had scores at 12 months that were similar to those with mild Alzheimer’s disease. A longer duration of delirium in the ICU was associated with worse cognition after discharge but the use of sedation/analgesia was not. Deficits were found in both younger and older patients.
This adds to a growing, although heterogeneous, body of evidence http://www.medscape.com/viewarticle/772342_2 about the long-term consequences of serious or extended critical illness:
- Prolonged ventilation after acute illness- At 1 year, only 9% had a good outcome (alive with no functional dependency), 26% had a fair outcome (alive with moderate dependency), and 65% had a poor outcome (either alive with complete functional dependency [21%] or dead [44%]). Patients with poor outcomes were older, had more co-morbid conditions, and were more frequently discharged to a post-acute care facility than patients with either fair or good outcomes http://www.ncbi.nlm.nih.gov/pubmed/?term=20679561
- Pneumonia/sepsis- Significant and lasting adverse consequences in terms of frailty with 40% 1 year mortality and 70% 5-year mortality http://www.biomedcentral.com/1472-6963/12/432
- Elderly (65+)- 33% die within 6 months. Among survivors at 6 months, health-related quality of life significantly worsened in oldest patients http://www.ncbi.nlm.nih.gov/pubmed/21263318
- PTSD and depressive symptoms, 16% and 31%, at 3 months post- ICU and 15% and 17%, respectively, at 12 months http://www.ncbi.nlm.nih.gov/pubmed/?term=23369507
- Family effects-Up to 40% of ICU patient families 1 year after death meet criteria for psychiatric illnesses such as generalized anxiety, major depressive disorders, or complicated grief. http://www.ncbi.nlm.nih.gov/pubmed/22914431
These are often the patients palliative care teams are called to see. However, my sense is that their loved ones lack this outcome data when making difficult treatment decisions. Instead, families seem to consent to very aggressive ICU interventions in the hope that their loved ones will survive to resume their pre-hospital baseline. We now know that this is unlikely for many of these patients. Would families make different decisions if they knew the likelihood of post-hospital mortality, disability, nursing home placement, etc.? How many, a few months or a year afterwards, regret the aggressive care they agreed to?
Critical and palliative care providers need to recognize that a prolonged ICU stay is only the first step in what may be a difficult, disappointing, and probably shorter than expected, journey. Families need all the long-term facts before they consent to things like trachs, feeding tubes, dialysis, etc. Otherwise, their consent is not truly informed.