血液成份及输血疗法.ppt

Intensive communication: Four-year follow-up from a clinical practice study Ri 王信堯 Preface Fear, air hunger, pain, anxiety of dying Hospice care, intensive care ? End of life care, option ? Ineffective life support moving to a comfort-focused care plan Introduction Purpose: moving dying patients from ineffective lift support to comfort-focused care plan When to decide? Where the decision made? What memberships? Why do it? How to do? Intensive communication- the bridge between ICU support to comfort care Intensive communication The uniform application of a process of communication moving dying patients to comfort-focused care Noncoercive, patient and family-centered, multidisciplinary process Primary outcome variables --- length of ICU stay and mortality Secondary outcome varibles --- agreement among providers, team, patient, family Methods (1) 2891 adult patients admitted to ICU during 4-yr period from Oct. 31, 1998, to Sept. 30, 2002 10-bed medical ICU 1 attending physician, 2~3 residents, 3 interns, and 45 nurses (in shifts). Admission decision: physician not part of ICU team Discharge decision: critical care physician Methods (2) Initial meeting: within 72 hrs of ICU admission Criteria: 1. Predicted ICU stay = 5 days 2. Predicted mortality of 25 % 3. Function status potentially irreversible and sufficient to preclude eventual return to home Methods (3) Memberships: attending intensivists, nurse, house officer, family, patient ( if possible) Other members: outside expert, social workers, psychiatrist, even security expert Initial introductions, open-ended questions and patient current status and cure “ Red flags “ ---- Final interventions Methods (4) Discussion objects: 1. Review the medical facts and options for treatment 2. Patient’ s perspectives, acceptability of risks, and discomfort of critical care 3. Agree on a care plan 4. Agree on criteria by whic