EVIDENCE-BASED PRACTICE of CRITICAL CARE second edition Clifford S Deutschman, MS, MD, FCCM Vice Chair, Research, Department of Pediatrics Professor of Pediatrics and Molecular Medicine Hofstra North Shore-LIJ School of Medicine New Hyde Park, New York Investigator, Feinstein Institute for Medical Research Manhasset, New York Patrick J Neligan, MA, MB, FRCAFRCSI Department of Anaesthesia and Intensive Care University College Galway Galway, Ireland iii 1600 John F Kennedy Blvd Ste 1800 Philadelphia, PA 19103-2899 EVIDENCE-BASED PRACTICE OF CRITICAL CARE, SECOND EDITION ISBN: 978-0-323-29995-4 Copyright © 2016 by Elsevier, Inc All rights reserved No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein) Notices Knowledge and best practice in this field are constantly changing As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein Previous edition copyrighted 2010 Library of Congress Cataloging-in-Publication Data Deutschman, Clifford S., editor | Neligan, Patrick J., editor Evidence-based practice of critical care / [edited by] Clifford S Deutschman, Patrick J Neligan Second edition | Philadelphia, PA : Elsevier, [2016] | Includes bibliographical references and index LCCN 2015041109 | ISBN 9780323299954 (pbk : alk paper) | MESH: Critical Care | Evidence-Based Medicine | Intensive Care Units LCC RC86.7 | NLM WX 218 | DDC 616.02/8—dc23 LC record   available at http://lccn.loc.gov/2015041109 Senior Content Strategist: Suzanne Toppy Senior Content Development Specialist: Jennifer Ehlers Publishing Services Manager: Patricia Tannian Senior Project Manager: Claire Kramer Design Direction: Julia Dummitt Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1 To my family: Chris, who makes everything possible—and worthwhile Cate, Nicki, and Beth, who are now adults, and still make us proud every day, and Linus, who makes it entertaining To my former colleagues in the Surgical Intensive Care Unit at the Hospital of the University of Pennsylvania (including my coauthor): For tolerating 20 years of “Teaching by Confrontation” without ever taking it personally To my new colleagues at the Cohen Children’s Medical Center and the Feinstein Institute for Medical Research: We will figure it out Clifford S Deutschman, MS, MD New York To Diane, David, Conor, and Kate and to my parents Maurice and Dympna Neligan for their continued support and wisdom Patrick J Neligan, MA, MB, FRCAFRCSI Contributors Gareth L Ackland, PhD, FRCA, FFICM William Harvey Research Institute Queen Mary University of London London, United Kingdom Chapter 48 What Is the Role of Autonomic ­Dysfunction in Critical Illness? Dijillali Annane, MD General Intensive Care Unit Raymond Poincaré Hospital (AP-HP) University of Versailles SQY Laboratory of Inflammation and Infection U1173 INSERM Garches, France Chapter 71 Is There a Place for Anabolic ­Hormones in Critical Care? Pierre Asfar, MD, PhD Département de Réanimation Médicale et de Médecine Hyperbare Centre Hospitalier Universitaire Angers Angers, France Chapter 40 What MAP Objectives Should Be Targeted in Septic Shock? John G Augoustides, MD, FASE, FAHA Professor Anesthesiology and Critical Care Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania Chapter 52 When Is Hypertension a True Crisis, and How Should It Be Managed in the Intensive Care Unit? Chapter 82 Which Anticoagulants Should Be Used in the Critically Ill Patient? How Do I Choose? Hollman D Aya, MD Clinical and Research Fellow Intensive Care Department St George’s University Hospitals NHS Foundation Trust London, United Kingdom Chapter 84 Does ICU Admission Improve Outcome? Lorenzo Ball, MD IRCCS AOU San Martino-IST Department of Surgical Sciences and Integrated Diagnostics University of Genoa Genoa, Italy Chapter How Does One Evaluate and Monitor Respiratory Function in the Intensive Care Unit? Arna Banerjee, MD Associate Professor of Anesthesiology, Surgery, and Medical Education Department of Anesthesiology and Critical Care Vanderbilt University Medical Center Nashville, Tennessee Chapter 73 How Does One Diagnose, Treat, and Reduce Delirium in the Intensive Care Unit? John Bates, MD Anaesthesia and Intensive Care Medicine University Hospital Galway Galway, Ireland Chapter 24 How Do I Transport the Critically Ill Patient? S V Baudouin, MD, FRCP, FICM Department of Anaesthesia Royal Victoria Infirmary Newcastle upon Tyne, United Kingdom Chapter 36 Are Anti-inflammatory Therapies in ARDS Effective? Michael Bauer, MD Center for Sepsis Control and Care Department of Anesthesiology and Critical Care Medicine Jena University Hospital Jena, Germany Chapter 68 How Does Critical Illness Alter the Liver? Jeremy R Beitler, MD, MPH Division of Pulmonary and Critical Care Medicine University of California, San Diego San Diego, California Chapter 28 What Is the Clinical Definition of ARDS? Rinaldo Bellomo, MD, FCICM Australia and New Zealand Intensive Care Research Centre Department of Epidemiology and Preventive Medicine Monash University Melbourne, Australia Chapter Do Early Warning Scores and Rapid Response Teams Improve Outcomes? Franỗois Beloncle, MD Dộpartement de Rộanimation Mộdicale et de Médecine Hyperbare Centre Hospitalier Universitaire Angers Angers, France Chapter 40 What MAP Objectives Should Be Targeted in Septic Shock? vii viii    Contributors Kimberly S Bennett, MD, MPH Associate Professor Pediatric Critical Care University of Colorado School of Medicine Denver, Colorado Chapter 11 Is Extracorporeal Life Support an EvidenceBased Intervention for Critically Ill Adults with ARDS? Paulomi K Bhalla, MD Fellow, Division of Neurocritical Care Neurology Hospital of the University of Pennsylvania Philadelphia, Pennsylvania Chapter 63 How Should Aneurysmal Subarachnoid Hemorrhage Be Managed? Maneesh Bhargava, MD Assistant Professor of Pulmonary, Allergy, Critical Care, and Sleep Medicine University of Minnesota Medical School Minneapolis, Minnesota Chapter 32 Do Patient Positioning in General and Prone Positioning in Particular Make a Difference in ARDS? Alain F Broccard, MD St Vincent Seton Specialty Hospital Indianapolis, Indiana Chapter 32 Do Patient Positioning in General and Prone Positioning in Particular Make a Difference in ARDS? Josée Bouchard, MD Division of Nephrology Department of Medicine University of Montreal Montreal, Canada Chapter 56 How Does One Optimize Care in Patients at Risk for or Presenting with Acute Kidney Injury? Naomi E Cahill, RD, PhD Department of Public Health Sciences Queen’s University Kingston, Ontario, Canada Chapter 67 Is It Appropriate to “Underfeed” the Critically Ill Patient? Andrea Carsetti, MD Anaesthesia and Intensive Care Unit Department of Biomedical Sciences and Public Health Università Politecnica delle Marche Ancona, Italy Department of Intensive Care Medicine St George’s University Hospitals NHS Foundation Trust London, United Kingdom Chapter 84 Does ICU Admission Improve Outcome? Maurizio Cecconi, MD Department of Intensive Care St George’s Hospital London, United Kingdom Chapter 84 Does ICU Admission Improve Outcome? Celina D Cepeda, MD Division of Pediatric Nephrology Pediatric Department Rady Children’s Hospital Division of Nephrology and Hypertension Department of Medicine University of California, San Diego San Diego, California Chapter 56 How Does One Optimize Care in Patients at Risk for or Presenting with Acute Kidney Injury? Maurizio Cereda, MD Assistant Professor of Anesthesia and Critical Care Department of Anesthesia and Critical Care Perelman School of Medicine at the University of Pennsylvania Philadelphia, Pennsylvania Chapter 10 How Does Mechanical Ventilation Damage Lungs? What Can Be Done to Prevent It? John Chandler, MD, BDS, FDSRCS, FCARCSI Consultant in Anaesthesia and Intensive Care Cork University Hospital Cork, Ireland Chapter 24 How Do I Transport the Critically Ill Patient? Randall M Chesnut, MD, FCCM, FACS Integra Endowed Professor of Neurotrauma Department of Neurological Surgery Department of Orthopaedic Surgery Adjunct Professor School of Global Health Harborview Medical Center University of Washington Seattle, Washington Chapter 61 Is It Really Necessary to Measure Intracranial Pressure in Brain-Injured Patients? Meredith Collard, MD Department of Anesthesiology and Critical Care Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania Chapter What Are the Indications for Intubation in the Critically Ill Patient? Maya Contreras, MD, PhD, FCARCSI Department of Anesthesia St Michael’s Hospital Toronto, Ontario, Canada Chapter 31 Is Permissive Hypercapnia Useful in ARDS? David J Cooper, MD, BM, BS Australian and New Zealand Intensive Care–Research Centre School of Public Health and Preventive Medicine Monash University Alfred Hospital Campus The Alfred Hospital Melbourne, Australia Chapter What Is the Optimal Approach to Weaning and Liberation from Mechanical Ventilation? Contributors    ix Craig M Coopersmith, MD Professor of Surgery Department of Surgery Associate Director Emory Critical Care Center Vice Chair of Research Department of Surgery Director Surgical/Transplant Intensive Care Unit Emory University Hospital Atlanta, Georgia Chapter 46 Is Selective Decontamination of the Digestive Tract Useful? David Cosgrave, MB, BCh, BAO Anaesthesia SPR University Hospital Galway Galway, Ireland Chapter 24 How Do I Transport the Critically Ill Patient? Cheston B Cunha, MD Assistant Professor of Medicine Division of Infectious Disease Medical Director, Antimicrobial Stewardship Program Rhode Island Hospital and the Miriam Hospital Brown University Alpert School of Medicine Providence, Rhode Island Chapter 17 What Strategies Can Be Used to Optimize Antibiotic Use in the Critically Ill? Gerard F Curley, PhD, MB, MSc, FCAI, FJFICM Departments of Anesthesia and Critical Care Keenan Research Centre for Biomedical Science of St Michael’s Hospital St Michael’s Hospital Department of Anesthesia and Interdepartmental Division of Critical Care University of Toronto Toronto, Ontario, Canada Chapter 39 What Is the Role of Empirical Antibiotic Therapy in Sepsis? Randall J Curtis, MD Professor Division of Pulmonary and Critical Care Medicine A Bruce Montgomery–American Lung Association Endowed Chair in Pulmonary and Critical Care Medicine Section Head Harborview Medical Center Director Cambia Palliative Care Center of Excellence Harborview Medical Center Seattle, Washington Chapter 87 What Factors Influence a Family to Support a Decision Withdrawing Life Support? Allison Dalton, MD Assistant Professor of Anesthesia and Critical Care Department of Anesthesia and Critical Care University of Chicago Chicago, Illinois Chapter 15 How Do I Manage Hemodynamic Decompensation in a Critically Ill Patient? Kathryn A Davis, MD, MTR Medical Director Epilepsy Monitoring Unit Assistant Professor of Neurology Hospital of the University of Pennsylvania Philadelphia, Pennsylvania Chapter 65 How Should Status Epilepticus Be Managed? Daniel De Backer, MD, PhD Department of Intensive Care Erasme University Hospital Brussels, Belgium Chapter 13 What Is the Role of Invasive Hemodynamic Monitoring in Critical Care? Clifford S Deutschman, MS, MD, FCCM Vice Chair, Research, Department of Pediatrics Professor of Pediatrics and Molecular Medicine Hofstra North Shore–LIJ School of Medicine New Hyde Park, New York Investigator, Feinstein Institute for Medical Research Manhasset, New York Chapter Critical Care Versus Critical Illness Chapter 37 What Is Sepsis? What Is Septic Shock? What Are MODS and Persistent Critical Illness? Chapter 49 Is Sepsis-Induced Organ Dysfunction an Adaptive Response? Chapter 52 When Is Hypertension a True Crisis, and How Should It Be Managed in the Intensive Care Unit? Margaret Doherty, BMedSci, MB BCh BAO, FFARCSI, EDIC Interdepartmental Division of Critical Care Medicine University Health Network University of Toronto Toronto, Ontario, Canada Chapter 30 What Is the Best Mechanical Ventilation Strategy in ARDS? Tom Doris, MD FRCA Department of Anaesthesia Royal Victoria Infirmary Newcastle upon Tyne, United Kingdom Chapter 36 Are Anti-inflammatory Therapies in ARDS Effective? x    Contributors Todd Dorman, MD, FCCM Senior Associate Dean for Education Coordination Associate Dean Continuing Medical Education Professor and Vice Chair for Critical Care Department of Anesthesiology and Critical Care Medicine Joint Appointments in Medicine, Surgery, and the School of Nursing Johns Hopkins University School of Medicine Baltimore, Maryland Chapter 85 How Should Care Within an Intensive Care Unit or an Institution Be Organized? Tomas Drabek, MD, PhD Associate Professor of Anesthesiology Scientist Safar Center for Resuscitation Research University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania Chapter 22 Is Hypothermia Useful in Managing Critically Ill Patients? Which Ones? Under What Conditions? Stephen Duff, MB BCh St Vincent’s University Hospital Dublin, Ireland Chapter What Is the Optimal Approach to Weaning and Liberation from Mechanical Ventilation? Eimhin Dunne, MRCS, PG Dip (Clin pharm) Critical Care Clinical Fellow King’s College Hospital London, United Kingdom Chapter 18 Is Prophylaxis for Stress Ulceration Useful? Ali A El Solh, MD, MPH Division of Pulmonary, Critical Care, and Sleep Medicine Department of Medicine and Department of Social and Preventive Medicine State University of New York at Buffalo School of Medicine and Biomedical Sciences and School of Public Health and Health Professions VA Western New York Healthcare System Buffalo, New York Chapter 23 What Are the Special Considerations in the Management of Morbidly Obese Patients in the Intensive Care Unit? E Wesley Ely, MD, MPH Professor of Medicine Associate Director of Research GRECC Center for Health Services Research Department of Allergy, Pulmonary, and Critical Care Medicine Vanderbilt University Medical Center Nashville, Tennessee Chapter 73 How Does One Diagnose, Treat, and Reduce Delirium in the Intensive Care Unit? Andrés Esteban, MD, PhD Departamento de Cuidados Intensivos CIBER de Enfermedades Respiratorias Hospital Universitario de Getafe Madrid, Spain Chapter 28 What Is the Clinical Definition of ARDS? Laura Evans, MD Associate Professor Department of Medicine New York University School of Medicine New York, New York Chapter 43 Do the Surviving Sepsis Campaign Guidelines Work? Niall D Ferguson, MD, FRCPC, MSc Interdepartmental Division of Critical Care Medicine University Health Network University of Toronto Toronto, Ontario, Canada Chapter 30 What Is the Best Mechanical Ventilation Strategy in ARDS? Jonathan Frogel, MD Assistant Professor Anesthesiology and Critical Care Hospital of the University of Pennsylvania Philadelphia, Pennsylvania Chapter 53 How Does One Prevent or Treat Atrial Fibrillation in Postoperative Critically Ill Patients? Jakub Furmaga, MD Assistant Professor of Emergency Medicine Faculty in Medical Toxicology University of Texas Southwestern Medical Center Dallas, Texas Chapter 79 How Do I Diagnose and Manage Patients Admitted to the ICU After Common Poisonings? Ognjen Gajic, MD Professor of Medicine Pulmonary and Critical Care Medicine Mayo Clinic Rochester, Minnesota Chapter 12 What Factors Predispose Patients to Acute Respiratory Distress Syndrome? Alice Gallo De Moraes, MD Department of Medicine–Division of Pulmonary and Critical Care Mayo Clinic Rochester, Minnesota Chapter 12 What Factors Predispose Patients to Acute Respiratory Distress Syndrome? Erik Garpestad, MD Associate Chief, Pulmonary, Critical Care, and Sleep Division Director, Medical ICU Associate Professor Tufts University School of Medicine Boston, Massachusetts Chapter What Is the Role of Noninvasive Ventilation in the Intensive Care Unit? Hayley B Gershengorn, MD Departments of Medicine and Neurology Albert Einstein College of Medicine Montefiore Medical Center Bronx, New York Chapter Have Critical Care Outcomes Improved? Contributors    xi Emily K Gordon, MD Assistant Professor Anesthesiology and Critical Care Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania Chapter 52 When Is Hypertension a True Crisis, and How Should It Be Managed in the Intensive Care Unit? Chapter 82 Which Anticoagulants Should Be Used in the Critically Ill Patient? How Do I Choose? W Robert Grabenkort, PA MMSc, FCCM Director Nurse Practitioner/Physician Assistant Residency Program Emory Critical Care Center Emory Healthcare Atlanta, Georgia Chapter 86 What Is the Role of Advanced Practice Nurses and Physician Assistants in the ICU? Guillem Gruartmoner, MD Department of Critical Care Corporació Sanitària Universitària Parc Taulí Hospital de Sabadell Universitat Autònoma de Barcelona Barcelona, Spain Department of Intensive Care Erasmus Medical Center Rotterdam, The Netherlands Chapter 42 How Can We Monitor the Microcirculation in Sepsis? Does It Improve Outcome? Jacob T Gutsche, MD Assistant Professor Cardiothoracic and Vascular Section Anesthesiology and Critical Care Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania Chapter 26 How Do I Diagnose and Treat Pulmonary Embolism? Chapter 52 When Is Hypertension a True Crisis, and How Should It Be Managed in the Intensive Care Unit? Scott Halpern, MD, PhD Associate Professor of Medicine, Epidemiology, and Medical Ethics and Health Policy Director Fostering Improvement in End-of-Life Decision Science Program Deputy Director Center for Health Incentives & Behavioral Economics Department of Medical Ethics and Health Policy Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania Chapter 83 How Can Critical Care Resource Utilization in the United States Be Optimized? Ivan Hayes, MD Consultant Intensivist Cork University Hospital Cork, Ireland Chapter 18 Is Prophylaxis for Stress Ulceration Useful? Nicholas Heming, MD General Intensive Care Unit Raymond Poincaré Hospital (AP-HP) University of Versailles SQY Garches, France Chapter 71 Is There a Place for Anabolic Hormones in Critical Care? Daren K Heyland, MD Department of Critical Care Medicine Queen’s University Clinical Evaluation Research Unit Kingston General Hospital Kingston, Ontario, Canada Chapter 67 Is It Appropriate to “Underfeed” the Critically Ill Patient? Nicholas S Hill, MD Investigator Pulmonary Hypertension Clinic at Rhode Island Hospital Providence, Rhode Island Chief of the Pulmonary, Critical Care, and Sleep Division at Tufts-New England Medical Center Professor of Medicine Tufts University School of Medicine Boston, Massachusetts Chapter What Is the Role of Noninvasive Ventilation in the Intensive Care Unit? Eliotte Hirshberg, MD, MS Critical Care Attending Physician Intermountain Medical Center Associate Professor Internal Medicine Division of Pulmonary and Critical Care Medicine Assistant Professor (Adjunct) Pediatrics Division of Critical Care University of Utah Salt Lake City, Utah Chapter 11 Is Extracorporeal Life Support an EvidenceBased Intervention for Critically Ill Adults with ARDS? R Duncan Hite, MD Professor and Chairman Department of Critical Care Medicine Respiratory Institute Cleveland Clinic Cleveland, Ohio Chapter 11 Is Extracorporeal Life Support an EvidenceBased Intervention for Critically Ill Adults with ARDS? xii    Contributors Steven M Hollenberg, MD Gabriella Jäderling, MD, PhD Richard S Hotchkiss, MD Marc G Jeschke, MD, PhD, FACS, FCCM, FRCS(C) Professor of Medicine Cooper Medical School of Rowan University Director, Coronary Care Unit Cooper University Hospital Camden, New Jersey Chapter 54 Is Right Ventricular Failure Common in the Intensive Care Unit? How Should It Be Managed? Professor of Anesthesiology, Medicine, Surgery, Molecular Biology and Pharmacology Washington University School of Medicine St Louis, Missouri Chapter 38 Is There Immune Suppression in the Critically Ill Patient? Can Ince, PhD Department of Intensive Care Erasmus Medical Center Rotterdam, The Netherlands Chapter 42 How Can We Monitor the Microcirculation in Sepsis? Does It Improve Outcome? Margaret Isaac, MD Assistant Professor of Medicine Attending Physician General Internal Medicine and Palliative Care University of Washington/Harborview Medical Center Seattle, Washington Chapter 87 What Factors Influence a Family to Support a Decision Withdrawing Life Support? Shiro Ishihara, MD Biomarkers and Heart Diseases UMR-942 Institut National de la Santé et de la Recherche Médicale (INSERM) Paris, France Nippon Medical School Musashi-Kosugi Hospitals Kanagawa, Japan Chapter 50 How Do I Manage Acute Heart Failure? Theodore J Iwashyna, MD, PhD Associate Professor, Department of Internal Medicine Faculty Associate, Survey Research Center, Institute for Social Research Research Scientist, Center for Clinical Management Research Ann Arbor VA Health Services Research and Development Co-Director, Robert Wood Johnson Foundation Clinical Scholars Program Ann Arbor, Michigan Chapter What Problems Are Prevalent Among Survivors of Critical Illness and Which of Those Are Consequences of Critical Illness? Department of Anesthesiology Surgical Services and Intensive Care Karolinska University Hospital Stockholm, Sweden Chapter Do Early Warning Scores and Rapid Response Teams Improve Outcomes? Professor at the University of Toronto Department of Surgery Division of Plastic Surgery Department of Immunology Director, Ross Tilley Burn Centre Sunnybrook Health Sciences Centre Chair in Burn Research Senior Scientist Sunnybrook Research Institute Toronto, Ontario, Canada Chapter 76 How Should Patients with Burns Be Managed in the Intensive Care Unit? Lewis J Kaplan, MD Section Chief Surgical Critical Care Philadelphia VA Medical Center Associate Professor of Surgery Division of Trauma, Surgical Critical Care, and Emergency Surgery Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania Chapter 75 What Is Abdominal Compartment Syndrome and How Should It Be Managed? Scott E Kasner, MD Professor of Neurology University of Pennsylvania Director Comprehensive Stroke Center University of Pennsylvania Health System Philadelphia, Pennsylvania Chapter 64 How Should Acute Ischemic Stroke Be Managed in the Intensive Care Unit? Colm Keane, MD Department of Anaesthesia and Intensive Care National University of Ireland Galway, Ireland Chapter 41 What Vasopressor Agent Should Be Used in the Septic Patient? Mark T Keegan, MB, MRCPI, MSc Professor Division of Critical Care Department of Anesthesiology Mayo Clinic and Mayo Clinic College of Medicine Rochester, Minnesota Chapter 69 How Is Acute Liver Failure Managed? 85 How Should Care Within an Intensive Care Unit or an Institution Be Organized? Ho Geol Ryu, Todd Dorman In this chapter, we review the evidence for the association between intensive care unit (ICU) organization and optimal care delivery In addition, we review the evidence for ICU organization within a hospital and across a health system We recognize up front that only a few issues regarding organization of care have strong evidence based on highquality publications We remind the reader, though, that evidence-based medicine also allows for the consideration of lower levels of evidence, such as experience and observational data Various models of critical care delivery (ICU level and institution level) have been tested regarding the structure and process of ICU care, including the personnel responsible for providing care and their associated workload This chapter addresses all organization-related practices at the ICU through the health system level and will attempt to be clear where the evidence is the strongest and where the evidence is more observational HIGH-INTENSITY PHYSICIAN STAFFING In a 2002 systematic review, Pronovost and colleagues demonstrated that high-intensity physician staffing was associated with reduced ICU and hospital length of stay and lower ICU mortality (relative risk [RR], 0.61; 95% confidence interval [CI], 0.50 to 0.75) and hospital mortality (RR, 0.71; 95% CI, 0.62 to 0.82).1 Since then, many studies have confirmed these findings or uncovered additional benefits of high-intensity physician staffing in the ICUs of different types in various settings.2,3 As a result, the high-intensity approach is considered to be the staffing model of choice in most ICU settings It is now being applied worldwide and in atypical settings Institution of high-intensity physician staffing in an Army hospital ICU deployed in Afghanistan was associated with decreases in mortality, the duration of mechanical ventilation, and the incidence of ventilatorassociated pneumonia.4 Likewise, high-intensity physician staffing in a mixed ICU serving a regional nonteaching medical center was associated with a decrease in hospital length of stay, better compliance with evidence-based practices, and a significant increase in survival from sepsis.5 However, Levy et al performed a retrospective analysis of 101,832 ICU patients entered into the Surviving Sepsis 622 Campaign database and compared outcomes in ICUs where critical care physicians provided more than 95% of the care with those in ICUs where intensivists managed less than 5% of patients.6 Even when data were adjusted for severity of illness and patients were matched with propensity scores, intensivist-led care was associated with a higher standardized mortality ratio (RR, 1.09; 95% CI, 1.05 to 1.13 vs RR, 0.91; 5% CI, 0.88 to 0.94) and resulted in more interventions These results stand in stark contrast to numerous investigations and reports that showed an association between high-intensity physician staffing and outcome in ICUs of all types Although the authors acknowledge the study’s significant limitations (unclear definition of “critical care physician,” significant gaps in the dataset, unmeasured confounders), the large number of patients and the magnitude of the dataset cannot be ignored Since the publication of the report by Levy and colleagues, a retrospective cohort study of medical ICU patients (n = 107,324) that compared high-intensity physician staffing and multidisciplinary care teams with low-intensity physician staffing without multidisciplinary care teams reported that the former was associated with lower 30-day mortality (odds ratio [OR], 0.78; 95% CI, 0.68 to 0.89).7 In addition, a recent meta-analysis that included the study described previously6 indicated that high-­intensity physician staffing was associated with lower ICU (RR, 0.81; 95% CI, 0.68 to 0.96) and hospital mortality (RR, 0.83; 95% CI, 0.70 to 0.99).8 These results also suggested that ­surgical and combined medicosurgical ICUs received most of the benefits of high-intensity physician staffing Despite the overwhelming body of literature (>30 studies) touting the superiority of high-intensity physician staffing, the processes that link this approach to improved outcomes remain obscure It seems reasonable to ­postulate that consistent and reliable delivery of care using ­evidence-based standardized protocols by experienced and trained personnel contributed Indeed, daily rounds by a multidisciplinary team were associated with a reduction in adjusted mortality,7,9 and high-intensity physician staffing was associated with increased compliance with evidence-based practices.5 It has been suggested that other aspects of care delivery, such as interprofessional communication, are positively altered by high-intensity staffing, but supporting data are lacking Chapter 85  How Should Care Within an Intensive Care Unit or an Institution Be Organized?     623 NIGHTTIME INTENSIVIST STAFFING In an effort to further improve patient care in the ICU, some institutions have attempted to move beyond the Leapfrog standards10 and toward 24/7 intensivist coverage or nighttime intensivist coverage A survey of ICU program directors at academic medical centers in the United States indicated that one third (37%) of the respondents’ ICUs were covered 24/7 by board-certified or board-eligible in-house intensivists More than half of the respondents thought that 24/7 coverage is associated with better patient care and improved education for training fellows, although they did raise concerns about reductions in autonomy and the opportunity to make independent decisions.11 The assumption underlying the move to 24/7 staffing is that the intensity of physician staffing (“dose”) will improve patient outcomes (“response”) It is essential that this dose– response relationship remains sufficiently positive so that the benefit is worth the additional cost A randomized trial in an academic ICU running under a high-intensity physician staffing model compared the addition of nighttime inhospital intensivists with a model in which the nighttime intensivist (often the same one who covered in house during the day) provided coverage via telephone.12 The study did not demonstrate a difference in any of the selected outcome variables—ICU or hospital length of stay, mortality (OR, 1.08, P = .78), or readmission within 48 hours A retrospective cohort study showed that adding a nighttime intensivist to an ICU using a low-intensity physician staffing model during the day resulted in a reduction in mortality (OR, 0.62, P = .04).13 Thus the current evidence is not sufficient to justify 24/7 intensivist coverage in ICUs with daytime high-intensity physician staffing One could argue that the retrospective arm of the previous study indicates that nighttime coverage may be of benefit in ICUs operating under a low-intensity daytime model In addition, there are other reported benefits associated with 24/7 intensivist coverage (e.g., earlier decision making regarding end-of-life care,14 improvement in the quality of end-of-life care14,15) that have not been subjected to evidence-based investigation COPING WITH SHORTAGE OF INTENSIVISTS The demand for intensivists has been increasing and is projected to continue to so There is an ongoing shortage of intensivists, though, that has been foreseen for some time.16,17 The projected shortages have engendered strategies to provide enhanced coverage without a need for additional personnel Models under evaluation include telemedicine for remote or underserved ICUs and deployment of alternative providers—nonintensivist physicians (hospitalists) or nonphysicians (nurse practitioners, physician assistants) INTENSIVE CARE UNIT TELEMEDICINE The initial report by Rosenfeld and colleagues that showed a significant reduction in mortality, length of stay, and costs18 demonstrated that ICU telemedicine is a potential solution to ICU workforce shortages Several publications have addressed the issue A systematic review and meta-analysis using a preobservational and postobservational study design showed that telemedicine was associated with lower ICU (RR, 0.79; 95% CI, 0.65 to 0.96) and hospital mortality (RR, 0.83; 95% CI, 0.73 to 0.94) as well as a significant decrease in ICU and hospital length of stay when compared with standard care.19 However, a more recent study that evaluated ICU telemedicine using a pre- and postcomparison and a concurrent control ICU in a network of Veterans Affairs hospitals failed to show any improvement in ICU, hospital, or 30-day mortality or in ICU or hospital length of stay.20 A similar nonrandomized, unblended, preassessment and postassessment of ICUs involving 118,990 patients in 56 U.S ICUs showed that ICU telemedicine was associated with lower adjusted ICU and hospital mortality, as well as a reduction in ICU and hospital length of stay that was particularly pronounced in patients with very long ICU courses.21 ICU telemedicine was also associated with higher adherence to clinical practice guidelines.22 As is often the case in medicine, the clinical benefit to patients managed with ICU telemedicine is not a product of the technology alone In an observational, before-and-after comparison of ICU telemedicine use in six ICUs within a single health-care system, ICU telemedicine was not associated with any discernible benefit.23 Proposed explanations, including minimal delegation to the telemedicine team, a lack of access to clinical notes, and computerized physician order entry, suggest that the degree of integration of the telemedicine team into the ICU is an important determinant of efficacy The presence of an ICU culture dedicated to outcome improvement and the impact leadership models have also been touted, but they have not been sufficiently investigated Although ICU telemedicine may provide clinical benefits, it is an expensive undertaking that mandates careful financial consideration.24 Capital expenditures and maintenance costs for ICU telemedicine are not trivial, and to date the care in the United States is not subject to direct reimbursement Thus, use of ICU telemedicine will expand only if enhanced ICU use can offset the cost25 or if changes in health-care delivery and reimbursement (i.e., bundled payments) translate into an enhanced margin COPING WITH SHORTAGE OF INTENSIVISTS WITH NONINTENSIVISTS: HOSPITALISTS AS INTENSIVE CARE UNIT WORKFORCE Hospitalists have a primary focus on the general medical care of hospitalized patients They have increasingly been asked to care for patients with a lower severity of illness in the ICU and in step-down units A single small, prospective, observational study found no significant differences in ICU or hospital mortality or length of stay between medical ICU patients cared for by a hospitalist team and those cared for by an intensivist-led team.26 CAREGIVER WORKLOAD OF CAREGIVERS IN THE INTENSIVE CARE UNIT Although the concept seems intuitively obvious, only limited and controversial data support the suggestion that patient outcome is negatively affected by an increase in 624    Section XIX CRITICAL CARE RESOURCE USE AND MANAGEMENT the workload or census in the ICU In a retrospective study examining the records of more than 200,000 ICU patients, Dara and Afessa were unable to identify an association between the ICU census and patient mortality.32 Likewise, a retrospective cohort study in a medical ICU of a tertiary hospital compared patient outcomes when the intensivistto-patient ratio was 1:7.5 with those observed when the ratio was 1:15 Hospital and ICU mortality was similar, whereas a ratio of 1:15 was associated with a relatively increased ICU length of stay.33 Appropriately, the report prepared by the Society of Critical Care Medicine’s Task Force on ICU staffing declined to recommend a limit on the number of ICU patients that an individual intensivist should care for, suggesting instead that common sense be used.34 Studies on the contribution of critical care nurses to patient outcome provide a more consistent picture A study conducted in the United Kingdom reported that a heavy nursing workload was associated with a twofold increase in adjusted mortality.35 In addition, in a cross-sectional analysis of more than 55,000 patients in more than 300 hospitals in the United States, Kelly et al found an association between outcomes in elderly mechanically ventilated patients and both more nurturing critical care nurse environments and the presence of nurses with a higher level of education.36 Adverse drug events are common in the ICU, likely reflecting the severity of illness and the large number of drugs used per patient.37 Participation of pharmacists on ICU rounds was associated with a decreased rate of adverse drug events.38 It has been proposed that respiratory therapists contributed to improved outcomes by standardizing care and contributing to the consistent application of evidence-based principles and by reducing the workload of other team members.39 Physical therapists may contribute to improved clinical outcome through redistribution of workload, especially when rehabilitation is started early.40 Palliative care providers may also affect hospital and ICU length of stay while maintaining family satisfaction.41 ORGANIZATION OF INTENSIVE CARE UNIT CARE: INSTITUTIONAL AND HEALTH SYSTEM LEVELS The impact of ICU organizational structures on care at either the institutional or health system level has been subject to significant evidence-based investigation Consequently, this aspect of care remains fertile ground for study The most common institutional model is a distributed system of independent ICUs, in which each ICU is managed by a different group or department Indeed, different groups or departments manage different beds within a single ICU It is likely that standardization and protocols are very difficult if not impossible to achieve under these circumstances An arrangement of this sort, though, might enhance specialty practice and thus achieve high-level outcomes, especially at the interprofessional level Concerns about institutional objectives and improved service delivery have led to the creation of critical care committees with representation across the different ICUs This approach might also facilitate bed-sharing arrangements between ICUs to maximize specialty care while still addressing institutional objectives regarding efficient bed use There are several critical care centers in the United States These typically attempt to bind units across the institution in a formal construct and are clearly aimed at maximizing interprofessional care and outcomes while leveraging efficiency In some organizations, this approach has resulted in formation of a department of critical care medicine The impact of these approaches on providers, teams, and patients in such models remains unknown There are even fewer data addressing organizational characteristics across a health system At present, system-wide integration reflects the organization within the component hospitals There are several health systems that have successfully integrated ICUs within an institution and are attempting to extend this model across the health system via a center or a department Some systems are using telemedicine to more broadly leverage knowledge and experience AUTHORS’ RECOMMENDATIONS • High-intensity physician staffing has consistently been shown to significantly improve mortality and ICU and hospital length of stay over a wide range of conditions; however, these studies to date have failed to demonstrate the value of expanding the high-intensity staffing to 24/7 coverage • Hospitalists and nonphysician providers seem to be comparable to each other as alternatives to intensivists and house staff in ICUs caring for lower acuity patients • Telemedicine seems to be an attractive alternative model for care delivery However, cost considerations may limit its utility • Integration of ICU services across a health system has been insufficiently studied, but it may be the next step for further   improving delivery of critical care REFERENCES Pronovost PJ, Angus DC, Dorman T, et al Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review JAMA 2002;288(17):2151–2162 O’Malley RG, Olenchock B, Bohula-May E, et al Organization and staffing practices in US cardiac intensive care units: a survey on behalf of the American Heart Association Writing Group on the Evolution of Critical Care Cardiology Eur Heart J Acute Cardiovasc Care 2013;2(1):3–8 Suarez JI, Zaidat OO, Suri MF, et al Length of stay and mortality in neurocritically ill patients: impact of a specialized neurocritical care team Crit Care Med 2004;32(11):2311–2317 Lettieri CJ, Shah AA, Greenburg DL An intensivist-directed intensive care unit improves clinical outcomes in a combat zone Crit Care Med 2009;37(4):1256–1260 Iyegha UP, Asghar JI, Habermann EB, et al Intensivists improve outcomes and compliance with process measures in critically ill patients J Am Coll Surg 2013;216(3):363–372 Levy MM, Rapoport J, Lemeshow S, et al Association between critical care physician management and patient mortality in the intensive care unit Ann Intern Med 2008;148(11):801–809 Kim MM, Barnato AE, Angus DC, et al The effect of multidisciplinary care teams on intensive care unit mortality Arch Intern Med 2010;170(4):369–376 Wilcox ME, Chong CA, Niven DJ, et al Do intensivist staffing patterns influence hospital mortality following ICU admission? A systematic review and meta-analyses Crit Care Med 2013;41(10):2253–2274 Chapter 85  How Should Care Within an Intensive Care Unit or an Institution Be Organized?     625 Checkley W, Martin GS, Brown SM, et al Structure, process, and annual ICU mortality across 69 centers: United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study Crit Care Med 2014;42(2):344–356 10 Pronovost PJ, Needham DM, Waters H, et al Intensive care unit physician staffing: financial modeling of the Leapfrog standard Crit Care Med 2006;34(suppl 3):S18–S24 11 Diaz-Guzman E, Colbert CY, Mannino DM, et al 24/7 in-house intensivist coverage and fellowship education: a cross-sectional survey of academic medical centers in the United States Chest 2012;141(4):959–966 12 Kerlin MP, Small DS, Cooney E, et al A randomized trial of nighttime physician staffing in an intensive care unit N Engl J Med 2013;368(23):2201–2209 13 Wallace DJ, Angus DC, Barnato AE, et al Nighttime intensivist staffing and mortality among critically ill patients N Engl J Med 2012;366(22):2093–2101 14 Reineck LA, Wallace DJ, Barnato AE, et al Nighttime intensivist staffing and the timing of death among ICU decedents: a retrospective cohort study Crit Care 2013;17(5):R216 15 Wilson ME, Samirat R, Yilmaz M, et al Physician staffing models impact the timing of decisions to limit life support in the ICU Chest 2013;143(3):656–663 16 Halpern NA, Pastores SM, Oropello JM, et al Critical care medicine in the United States: addressing the intensivist shortage and image of the specialty Crit Care Med 2013;41(12):2754–2761 17 Angus DC, Kelley MA, Schmitz RJ, et al Caring for the critically ill patient Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population? JAMA 2000;284(21):2762–2770 18 Rosenfeld BA, Dorman T, Breslow MJ, et al Intensive care unit telemedicine: alternate paradigm for providing continuous intensivist care Crit Care Med 2000;28(12):3925–3931 19 Wilcox ME, Adhikari NK The effect of telemedicine in critically ill patients: systematic review and meta-analysis Crit Care 2012;16(4):R127 20 Nassar BS, Vaughan-Sarrazin MS, Jiang L, et al Impact of an intensive care unit telemedicine program on patient outcomes in an integrated health care system JAMA Intern Med 2014;174(7):1160–1167 21 Lilly CM, McLaughlin JM, Zhao H, et al A multicenter study of ICU telemedicine reengineering of adult critical care Chest 2014;145(3):500–507 22 Lilly CM, Cody S, Zhao H, et al Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes JAMA 2011;305(21):2175–2183 23 Thomas EJ, Lucke JF, Wueste L, et al Association of telemedicine for remote monitoring of intensive care patients with mortality, complications, and length of stay JAMA 2009;302(24):2671–2678 24 Kruklitis RJ, Tracy JA, McCambridge MM Clinical and financial considerations for implementing an ICU telemedicine program Chest 2014;145(6):1392–1396 25 Breslow MJ, Rosenfeld BA, Doerfler M, et al Effect of a multiplesite intensive care unit telemedicine program on clinical and economic outcomes: an alternative paradigm for intensivist staffing Crit Care Med 2004;32(1):31–38 26 Wise KR, Akopov VA, Williams Jr BR, et al Hospitalists and intensivists in the medical ICU: a prospective observational study comparing mortality and length of stay between two staffing models J Hosp Med 2012;7(3):183–189 27 Deleted in review 28 Deleted in review 29 Deleted in review 30 Deleted in review 31 Deleted in review 32 Iwashyna TJ, Kramer AA, Kahn JM Intensive care unit occupancy and patient outcomes Crit Care Med 2009;37(5):1545–1557 33 Dara SI, Afessa B Intensivist-to-bed ratio: association with outcomes in the medical ICU Chest 2005;128(2):567–572 34 Ward NS, Afessa B, Kleinpell R, et al Intensivist/patient ratios in closed ICUs: a statement from the Society of Critical Care Medicine Taskforce on ICU Staffing Crit Care Med 2013;41(2):638–645 35 Tarnow-Mordi WO, Hau C, Warden A, et al Hospital mortality in relation to staff workload: a 4-year study in an adult intensive-care unit Lancet 2000;356(9225):185–189 36 Kelly DM, Kutney-Lee A, McHugh MD, et al Impact of critical care nursing on 30-day mortality of mechanically ventilated older adults Crit Care Med 2014;42(5):1089–1095 37 Cullen DJ, Sweitzer BJ, Bates DW, et al Preventable adverse drug events in hospitalized patients: a comparative study of intensive care and general care units Crit Care Med 1997;25(8):1289–1297 38 Leape LL, Cullen DJ, Clapp MD, et al Pharmacist participation on physician rounds and adverse drug events in the intensive care unit JAMA 1999;282(3):267–270 39 Durbin Jr CG Therapist-driven protocols in adult intensive care unit patients Respir Care Clin N Am 1996;2(1):105–116 40 Schweickert WD, Pohlman MC, Pohlman AS, et al Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial Lancet 2009;373(9678):1874–1882 41 Aslakson R, Cheng J, Vollenweider D, et al Evidence-based palliative care in the intensive care unit: a systematic review of interventions J Palliat Med 2014;17(2):219–235 86 What Is the Role of Advanced Practice Nurses and Physician Assistants in the ICU? Ruth Kleinpell, W Robert Grabenkort At present, the U.S population uses 23.2 million intensive care unit (ICU) days at an estimated cost of $81.7 billion each year.1 This equates to 13.4% of hospital costs and 4.1% of the national health expenditure.1 It has been suggested that $3.3 million in annual cost savings could be realized for each 12- to 18-bed ICU if care were delivered by intensivist-led teams Currently, though, less than 40% of all ICU patients are treated with this model.1 The Association of American Medical Colleges expects a shortage of more than120,000 physicians by the end of this decade.2 A deficit of this magnitude is likely to threaten access to care, including ICU care One strategy for meeting ICU workforce needs is the addition of advanced practice professionals to ICU teams.3,4 Advanced practice providers, including nurse practitioners (NPs) and physician assistants (PAs), are an increasingly important component of the nation’s health-care workforce More than 250,000 (>180,000 NPs and >85,000 PAs) practice in the U.S health-care system.5,6 Consistent with the Institute of Medicine’s report,7 NPs and PAs play a vital role in delivering patient care, promoting multiprofessional collaboration, and advancing team approaches to care These clinicians provide primary, acute, and specialty care services to patients in countless acute and nonacute care settings NURSE PRACTITIONER AND PHYSICIAN ASSISTANT ROLES NPs are registered nurses who are prepared at either the master’s or doctoral level, have an independent license, and are required to pass a national certification examination in most states to practice NPs practice autonomously in most states with a scope of practice that is dependent on education, licensure, accreditation, and certification To be in compliance with the National Council of State Boards of Nursing’s recommendations for the Advanced Practice Registered Nurse Consensus Model for practice in the ICU setting, NPs should be certified in either acute care or adult gerontology acute care.8 Similarly, PAs are health-care professionals who are certified by a national examination 626 process Most PAs are prepared at the graduate level, but some have bachelor’s degrees.6 PAs are licensed healthcare professionals who practice under the supervision of a responsible physician who must be available for consultation by phone or in person.6 NPs and PAs often have similar roles in the ICU, but in some settings differences exist PAs focus on direct medical management or surgical assistance, whereas NP care encompasses direct patient care in addition to continuity of care components such as discharge planning; nursing, patient, and family education; and quality improvement/ research, among other subroles (Table 86-1).9-11 USE OF NURSE PRACTITIONERS AND PHYSICIAN ASSISTANTS IN THE ICU Data from national surveys on the use of NPs and PAs indicates that utilization in hospital settings has increased because of the higher acuity of hospitalized patients, restrictions placed on medical resident work hours, the need for continuity of care, and workforce shortages.12 In university-based hospital settings where the new Accreditation Council for Graduate Medical Education duty-hour regulations for physicians in training have been implemented, the integration of NPs and PAs into multidisciplinary provider models represents a solution to the gap in coverage.12 A study of 25 academic medical centers indicated that an additional role for NP and PA care has resulted from the need for improved access, improved continuity of care, patient throughput, and medical resident training restrictions, among others (Fig 86-1).12 Role components of NPs and PAs in the ICU are detailed in Table 86-2.14 Several studies have linked improved quality and reduced costs to the participation of NPs and PAs in care (Table 86-3) Because ICU care is often team based, assessing the impact of NPs and PAs in the ICU can be difficult Several studies, though, have demonstrated that NP- and PA-provided care resulted in improved outcomes (Table 86-4).15-27 On the basis of reports of established and developing models of care with NPs and PAs and research demonstrating Chapter 86  What Is the Role of Advanced Practice Nurses and Physician Assistants in the ICU?     627 Table 86-1  NP and PA Role Comparisons Category PA NP Definition Health-care professionals licensed to practice medical care with physician supervision Registered nurses with advanced education and training who have independent license Philosophy/ model Medical/physician model, disease centered, with emphasis on the biological/pathologic aspects of health, assessment, diagnosis, treatment Practice model is a team approach relationship with physicians Medical/nursing model, biopsychosocial centered, with emphasis on disease adaptation, health promotion, wellness, and prevention Practice model is a collaborative relationship with physicians Education Affiliated with medical schools Previous health-care experience required; Affiliated with nursing schools BSN is premost require entry-level bachelor’s degree The program curriculum requisite and education is at master’s or is advanced science based Approximately 2000 clinical hours All PAs doctoral level; curriculum is biopsychosocial are trained as generalists (a primary care model), and some receive based, based on behavioral, natural, and postgraduate specialty training Education is procedure and skill humanistic sciences Approximately 750 to oriented with emphasis on diagnosis, treatment, surgical skills, and pa1000 clinical hours NPs choose a specialty tient education Currently, more than 50% of programs award master’s training track in adult, acute care, pediatric, degrees and all are currently transitioning to the master’s level women’s health, or gerontology Certification/ licensure Separate accreditation and certification bodies require successful comple- National certification is required in majority tion of an accredited program and NCCPA national certification exam of states Recertification Recertification requires 100 hr of CME every years and exam every 10 years All PAs are licensed by their State Medical Board and the Medical Practice Act provisions Recertification requires, on average, 75 CEUs every 5-6 years NPs are licensed by their State Board of Nursing Scope of practice The supervising physician has relatively broad discretion in delegating medical tasks within his/her scope of practice to the PA in accordance with state regulations PAs in Maryland may prescribe Schedule II-V controlled substances if the physician delegates this On-site supervision is not required NP scope of practice is based on licensure, accreditation, certification, and education NPs have independent practice in majority of states; some states have physician collaboration requirements NPs may prescribe controlled substances On-site supervision is not required Third-party coverage and reimbursement PAs are eligible for certification as Medicaid and Medicare providers Commercial payer reimbursement is currently variable NPs are eligible for certification as Medicaid and Medicare providers and generally receive favorable reimbursement from commercial payers Adapted from: Maryland Academy of Physician Assistants http://www.mdapa.org/maryland/differences.asp BSN, bachelor of science in nursing; CEU, continuing education unit; CME, continuing medical education; NCCPA, National Commission on Certification of Physician Assistants; NP, nurse practitioner; PA, physician assistant their effectiveness, the use of NPs and PAs in the ICU is now a recognized solution to workforce challenges in managing critically ill patients.28 Integrating NPs and PAs in the ICU can help to facilitate the delivery of high-quality medical care and can provide continuity of care NPs and PAs can become important elements of multiprovider ICU teams.29 CONCLUSIONS NPs and PAs are increasingly being integrated into ICUs Care provided by teams that include NPs and PAs has been demonstrated to be comparable to that provided in other staffing models.30,31 Increasing patient acuity levels, burgeoning requirements for ICU care, and a need to have ICU-trained clinicians provide for critically ill patients presents an important opportunity to integrate NPs and PAs as ICU care providers Continued dissemination of successful ICU staffing models integrating NPs and PAs as well as additional research on ICU staffing models that include NPs and PAs is needed to identify best strategies for promoting optimal care for critically ill patients 628    Section XIX CRITICAL CARE RESOURCE USE AND MANAGEMENT MD time for nonclinical duties Table 86-2  Roles of NPs and PAs in the ICU Patient care management Reduce LOS Rounding Obtaining history and performing physical examinations Improve continuity Diagnosing and treating illnesses Ordering and interpreting tests Initiating orders, often under protocols Physician productivity Prescribing and performing diagnostic, pharmacologic, and therapeutic interventions consistent with education, practice, and state regulations Patient throughput Performing procedures (as credentialed and privileged, such as arterial line insertion, suturing, and chest tube insertion) Improve access Assessing and implementing nutrition Collaborating and consulting with the interdisciplinary team, patient, and family ACGME limits Assisting in the operating room 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Other Primary Figure 86-1.  Reasons for hiring nurse practitioners and physician assistants as reported by 25 academic medical centers ACGME, Accreditation Council for Graduate Medical Education; LOS, length of stay; MD, medical doctor (Adapted from Moote M, Krsek C, Kleinpell R et al Physician assistant and nurse practitioner utilization in academic medical centers Am J Med Qual 2011;5:1–9.11) Education of staff, patients, and families Practice guideline implementation Lead, monitor, and reinforce practice guidelines for ICU patients (e.g., central line insertion procedures, infection prevention measures, stress ulcer prophylaxis) Research Data collection Enrollment of subjects Research study management Quality assurance Lead quality-assurance initiatives such as ventilator-associated pneumonia bundle, sepsis bundle, rapid response team Communication Promote and enhance communication with ICU staff, family members, and the multidisciplinary team Discharge planning Transfer and referral consultations Patient and family education regarding anticipated plan of care Adapted from Kleinpell RM, Ely EW, Grabenkort R Nurse practitioners and physician assistants in the ICU: an evidence-based review Crit Care Med 2008;26:2888–2897 ICU, intensive care unit, NP, nurse practitioner, PA, physician assistant Chapter 86  What Is the Role of Advanced Practice Nurses and Physician Assistants in the ICU?     629 Table 86-3  Selected Studies on NP and PA Care in the ICU Study Method/Focus Main Results Burns et al, 2002; Before and after comparison of ventilator days, LOS, Decreased ventilator days by day, ICU LOS by days, hospiBurns et al, 2003 and per-patient cost after adding an NP as compared tal LOS by days, and mortality rate from 38% to 31% Over to before NP role comparing 125 patients in ICUs $3,000,000 in cost savings after to 575 before Cowan et al, 2006 Quasiexperimental design comparing NP-led group to Average LOS of NP group = 5 days, usual care = 6 days control group of usual care LOS and hospital profit ­Hospital profit NP group = $1591 per patient, usual determined from cost savings care = $639 per patient Ettner et al, 2006 Comparison of 1207 patients randomized to either an NP/MD group or an MD-only group NP/MD group had net cost savings of $978 per patient over MD-only group Gershengorn HB et al, 2011 Retrospective review of 590 daytime admissions to MICUs with use of NPs and PA coverage No significant difference in hospital mortality, ICU LOS, or hospital LOS Discharge to a skilled care facility was similar for NP/PA care compared with medical resident care Gershengorn HB et al, 2012 Literature review of the use of NP and PA providers in NPs and PAs have been used in ICUs as a replacement for phythe ICU sicians in training or to provide onsite semiclosed staffing to care for critically ill patients Data suggest that use of NPs and PAs is safe and equally efficacious for patient care Kapu et al, 2014 Evaluation of impact of adding NP to the rapid response team In 2011, the new teams responded to 898 calls, averaging 31.8 per call The most frequent diagnoses were respiratory distress (18%), postoperative pain (13%), hypotension (12%), and tachyarrhythmia (10%) The teams facilitated 360 transfers to intensive care and provided 3056 diagnostic and therapeutic interventions Communication with the primary team was documented on 97% of the calls After implementation, charge nurses were surveyed, with 96% expressing high satisfaction associated with enhanced service and quality Kapu et al, 2014 Retrospective, secondary analysis of return on investment after adding NPs to teams Gross collections compared with expenses for NP-led teams for 2-year time periods were 62%, 36%, 47%, and 32% Average risk-adjusted LOS for the time periods after adding NPs decreased and charges decreased Kawar and DiGiovine, 2011 Comparison of clinical outcomes between patients There was no difference in hospital mortality or in ICU admitted to a resident-run MICU and a PA-run MICU mortality between the two groups either in uncontrolled or with retrospective analysis of prospectively collected controlled analyses Survival analyses showed no difference data for 5346 patients admitted to an MICU from in 28-day survival between the groups January 2004 through January 2007; 3971 patients were admitted to a resident-run MICU (resident group) and 1375 to a PA-run MICU (PA group) McMillen et al, 2012 Surgical ICU care for 13,020 patients by PA team in 12-bed stepdown unit Annual surgical mortality decreased and surgical volume increased Meyer et al, 2005 Retrospective comparison of 1-year outcomes of NP care for postoperative CV surgery patients After NPs added, LOS decreased by 1.91 days and total cost decreased by $5039 per patient Russell et al, 2002 Prospective analysis of LOS, rates of UTIs, and skin LOS after NP = 8 days vs baseline = 11 days UTI NP = 2% vs breakdown before and after addition of NPs to the baseline 6%; skin breakdown NP = 0% vs baseline = 2% practice The baseline included randomized sample Patient days showed 2306 fewer days than baseline group of 122 patients admitted to a neurologic ICU over 12 with total cost savings of $2,467,328 months as compared with 402 patients admitted in first months of the following year after NPs added Sirleaf et al, 2014 Comparison of procedures by NPs, PAs, and MDs for 1404 patients MDs performed 1020 procedures, with 21 complications (complication rate, 2%) NP/PAs completed 555 procedures; with 11 complications (complication rate, 2%) There was no difference in the mean ICU and hospital LOS Mortality rates were also comparable between the groups (MD 11% vs NP/PA 9.7%) Sise et al, 2011 Prospective analysis of adding NPs to level trauma center Analysis of demographics, injury severity scores, LOS, complications, total direct costs of care, and outcomes After addition of NPs, a decrease in complications by 28.4%, LOS by 36.2, and costs of care by 30.4% CV, cerebrovascular; ICU, intensive care unit; LOS, length of stay; MD, medical doctor; MICU, medical intensive care unit; NP, nurse practitioner; PA, physician assistant; UTI, urinary tract infection 630    Section XIX CRITICAL CARE RESOURCE USE AND MANAGEMENT Table 86-4  NP- and PA-Performed Tasks That Enhance the Quality of Care15-27 Reduced length of stay Reduced rates of urinary tract infections Reduced rates of skin breakdown Reduced time to bladder catheter removal Reduced time to mobilization Reduced duration of mechanical ventilation Increased compliance with clinical practice guidelines Reduced rates of reintubation Increased time in coordination of care activities and cost-effective care NP, nurse practitioner; PA, physician assistant AUTHORS’ RECOMMENDATIONS • ICU models of care that incorporate NPs and PAs should be disseminated through publications and presentations to promote replication and extension • Additional research that demonstrates the effect of NP and PA care for ICU patients is needed • Funding should be allocated for research that explores optimal ICU workforce and staffing models that include NPs   and PAs REFERENCES Gupta R, Zad O, Jimenez E Analysis of the variations between Accreditation Council for Graduate Medical Education requirements for critical care training programs and their effects on the current critical care workforce J Crit Care 2013;28:1042–1047 Association of American Medical Colleges AAMC Physician Workforce Policy Recommendations AAMC; 2012 Pastores SM, O’Connor MF, Kleinpell RM, et al The ACGME resident duty-hour new standards: history, changes, and impact on staffing of intensive care units Crit Care Med 2012;39:2540–2549 Ward N, Afessa B, Kleinpell R, et al Intensivist/patient ratios in closed ICUs: A statement from the society of critical care medicine taskforce on ICU staffing Crit Care Med 2013;41:638–645 American Association of Nurse Practitioners (AANP) Nurse Practitioner Fact Sheet http://www.aanp.org/all-about-nps/np-factsheet Accessed 20.09.14 American Academy of Physician Assistants (AAPA) What is a Physician Assistant? http://www.aanp.org/all-about-nps/npfact-sheet Institute of Medicine The Future of Nursing: Leading Change, Advancing Health Washington, DC: National Academies Press; 2011:638–645 National Council of State Boards of Nursing Advanced Practice Registered Nurse (APRN) Consensus Model Chicago: NCSBN; 2008 Kleinpell R Acute care nurse practitioner practice: results of a year longitudinal study Am J Crit Care 2005;14:211–219 10 Kleinpell R, Buchman T, Boyle WA, eds Integrating Nurse Practitioners and Physician Assistants in the ICU: Strategies for Optimizing Contributions to Care Society of Critical Care Medicine; 2012 11 Moote M, Krsek C, Kleinpell R, et al Physician assistant and nurse practitioner utilization in academic medical centers Am J Med Qual 2011;5:1–9 12 Nurse practitioners and physician assistants: Do you know the difference? Medsurg Nurs 2007;16:404–407 13 Deleted in review 14 Kleinpell RM, Ely EW, Grabenkort R Nurse practitioners and physician assistants in the ICU: an evidence based review Crit Care Med 2008;26:2888–2897 15 Gershengorn HB, Johnson MP, Factor P The use of nonphysician providers in adult intensive care unit Am J Respir Crit Care Med 2012;185:600–605 16 Russell D, VorderBruegge M, Burns SM Effect of an outcomesmanaged approach to care of neuroscience patients by acute care nurse practitioners Am J Crit Care 2002;11:353–362 17 Gracias VH, Sicoutris CP, Satwicki SP, et al Critical care nurse practitioners improve compliance with clinical practice guidelines in semi-closed surgical intensive care unit J Nurs Care Qual 2008;23:338–344 18 Hoffman LA, Miller TH, Zullo TG, Donahoe MP Comparison of models for managing tracheotomized patients in a subacute medical intensive care unit Respir Care 2006;51:1230–1236 19 Dubayo BA, Samson MK, Carlson RW The role of physician assistants in critical care units Chest 1991;99:89–91 20 Kapu AN, Kleinpell R, Pilon B Quality and financial impact of adding nurse practitioners to inpatient care teams J Nurs Adm 2014;44:87–96 21 Paton A, Stein D, D’Agostino R, Pastores S, Halpern NA Critical care medicine advanced practice provider model at a comprehensive cancer center: successes and challenges Am J Crit Care 2013;22:439–443 22 Kawar E, DiGiovine B MICU care delivered by PAs versus residents: PAs measure up J Am Acad Physician Assistants 2011;24:36–41 23 Gershengorn HN, Wunsch H, Wahab R, et al Impact of nonphysician staffing on outcomes in a medical ICU Chest 2011;139:1347– 1353 24 Sirleaf M, Jefferson B, Christmas AB, et al Comparisons of procedural complications between resident physicians and advanced clinical providers J Trauma Acute Care Surg 2014;77:143–147 25 Barocas DA, Kulahalli CS, Ehrenfeld JM, et al Benchmarking the use of a rapid response team by surgical services at a tertiary care hospital J Am Coll Surg 2014;218:66–72 26 Kapu AN, Wheeler AP, Lee B Addition of acute care nurse practitioners to medical and surgical rapid response: a pilot program Crit Care Nurse 2014;34:51–59 27 Kapu AN, Kleinpell R, Pilon B Quality and financial impact of adding nurse practitioners to inpatient care teams J Nurs Adm 2014;44:87–96 28 Perlmutter L, Nataraja S Developing the Sustainable Critical Care Team Washington, DC: The Advisory Board Company Physician Executive Council; 2012 29 McCarthy C, O’Rourke NC, Madison JM Integrating advanced practice providers into medical care teams Chest 2013;143: 847–850 30 Garland A, Gershengorn HB Staffing in ICUs Chest 2013;143 31 Hing E, Uddin S Physician Assistant and Advance Practice Nurse Care in Hospital Outpatient Departments: United States, 20082009 U.S Department of Health and Human Services Centers for Disease Control and Prevention National Center for Health Statistics (NCHS) Data Brief No 77 87 What Factors Influence a Family to Support a Decision Withdrawing Life Support? Randall J Curtis, Margaret Isaac Most patients who die in the intensive care unit (ICU) so after having life-sustaining interventions withheld or withdrawn.1 Evidence suggests that more than 70% of elderly patients in the United States require a surrogate decision maker at the end of life,2 and involving surrogates in medical decision making at the end of life can be exceedingly challenging For families of patients with life-threatening illnesses in the ICU, many factors can affect decisions to either continue or withdraw lifesustaining interventions Clinical status and prognosis can affect how both surrogate decision makers and physicians approach such end-of-life decisions Patient and family factors, including race, ethnicity, culture, l­ anguage, religion, and spirituality, and socioeconomic status can also shape how these decisions are approached Fortunately, advance care planning can help both surrogate decision makers and clinicians better understand the wishes of patients who lack decisional capacity Physician factors, including their own race, religion, and geographic location, can shape attitudes toward end-of-life care decisions and specifically toward opinions about withholding or withdrawing life-sustaining interventions Communication strategies used by clinicians and institutional and system factors can also have an effect on surrogates’ experiences with decision making PATIENT FACTORS Medical/Health Status and Prognosis Only a small minority of patient surrogates cite physicians’ explicit statements of prognosis as their sole source of information on possible outcomes—reporting reliance on their own perceptions of patient factors (e.g., the patient’s character and will to live, the patient’s history of illness and resilience, and the patient’s physical appearance)3 and surrogate factors such as their own personal outlook, faith, and intuition.4 In addition, most surrogate decision makers express doubt in physicians’ ability to prognosticate accurately,5,6 which may be understandable given that doctors are often poor at prognostication for individual patients and have been shown to overestimate prognosis in terminally ill patients by a factor of 5.3.7 Advanced patient age, functional limitations, and comorbidities appear to have an important effect on the intensity of care at the end of life—influencing both patients and clinicians’ approaches8 to these types of care decisions Patient Characteristics, Values, and Preferences Race, Ethnicity, and Culture Broad differences in preferences for end-of-life care have been noted across racial and ethnic groups, although there is great heterogeneity within groups As such, clinicians are advised to address treatment preferences specifically with patients and surrogates rather than relying on broad generalizations about group preferences and values In general, African Americans tend to prefer more aggressive use of life support at the end of life9 when compared with other racial and ethnic groups.8 Nonwhite patients use more life-sustaining interventions at the end of life than white patients.8,10 Asians and Latinos9,11 are more likely to favor a family-centered decision-making process, and nonwhite racial and ethnic groups are less likely to have knowledge of and support with advance care planning.9 One study comparing white and African American caregivers of patients with advanced lung cancer suggested that African American caregivers had more optimistic expectations for treatment outcomes, which may be part of what shapes these observed differences in expressed preferences by patients and their surrogates.12 Another study of families of critically ill patients compared family perceptions among patients of similar severity of illness and found that African Americans tended to perceive the illness as less enduring and serious, reported more confidence in treatment efficacy, and reported lower illness comprehension compared with whites.13 A review found that some of the differences between African American patients and non-Hispanic white patients were related to historic mistrust of the health-care system, differences in knowledge and access to services, and differences in spiritual beliefs between these two groups.14 In addition, clinicians appear to be influenced by patient race, with physicians being more likely to recommend withdrawal of life support with nonwhite patients, although nonwhite patients are more likely to die with full life support in place.15 633 634    Section XX CRITICAL CARE ETHICS In a study of U.S caregivers, those who were less “Americanized” or acculturated to the United States (as determined by language preference and questions related to cultural identity) expressed different preferences for endof-life care, including a more positive preference for feeding tubes/artificial nutrition, a feeling that they received too much information from physicians, and a desire to receive additional services, including complementary therapies and mental health and nutritional counseling.16 catheters, and had increased mortality despite being younger in age, having fewer comorbidities, and having a lower probability of death at the time of admission to the ICU.32 Low literacy has been identified as a risk factor for not having an advance directive in place,33 which can limit surrogates’ abilities to understand patients’ values and wishes In addition, low or marginal health literacy has been shown to be associated with a preference for more aggressive care at the end of life.34 Language Fluency Role of Advance Directives and Advance Care Planning Families with limited English proficiency receive less information and fewer explicit statements of support in family conferences,17 although it is not clear how this affects their decisions about issues such as withdrawal of life support Use of professional interpreters rather than ad hoc interpreters (e.g., family members) can foster accurate communication and minimize errors in translation, particularly when discussing emotionally charged topics such as endof-life care.18 Interpreted family conferences also contain fewer elements of shared decision making and a greater ratio of physician/family speech,19 which has been associated with decreased family satisfaction.20 Religious and Spiritual Beliefs Patients who identify as religious or spiritual or who identify as using spiritual coping strategies are more likely to choose life-prolonging treatments at the end of life21-23 and are more likely to oppose do-not-attempt-resuscitation (DNAR) orders.24 Specifically, individuals who believe strongly that the length of one’s life is controlled by a higher power are less likely to engage in advance care planning,25 and those who express deference to God’s will tend to choose more life-prolonging treatments (e.g., continuation of life support).26 There is great variability in the approaches to medical decision making dictated by theology and by religious authorities, and increasingly, religious authorities have been called on to weigh in on matters related to use of medical technology, medical ethics, and end-of-life care Furthermore, there is considerable heterogeneity in the application and interpretation of religious tenets within individual religious traditions, and many of the approaches common to specific religious groups are more appropriately attributed to cultural beliefs, not being grounded in specific religious doctrine or teachings.27 In addition, when patients’ or families’ spiritual care needs go unmet, patients rate their care more poorly.28,29 Indeed, evidence suggests that unmet spiritual care needs are associated with increased medical costs at the end of life.30 Socioeconomic Status and Education Socioeconomic status and education may also impact endof-life care, although very few studies have examined these specific factors in this context A systematic review found that uninsured patients were more likely to have life support withdrawn in the ICU.31 In one study, uninsured ICU patients, when compared with those with insurance being cared for at the same hospital, received fewer procedures, including hemodialysis and placement of central venous Advance care planning generally and advance directives specifically can be helpful for surrogates in clarifying the wishes of their loved one Indeed, the absence of an advance directive has been identified by ICU directors as a barrier to optimal end-of-life care.35 Historically, the prevalence of advance directives has been low, ranging from 5% to approximately one third of patients.36-39 Several more recent studies demonstrate much higher rates of advance directive use,2,40,41 a change that has been attributed in part to the aging of the U.S population, as well as increased familiarity with and growing public discourse around the importance of advance care planning.40 Some evidence suggests that patients who have engaged in advance care planning or who have advance directives are more likely to receive care that mirrors their stated preferences2,42 and less likely to receive technologically aggressive interventions.2 In addition, the presence of a living will has been shown to improve families’ assessments of the quality of death and dying for their loved one in the ICU.43 Importantly, there is a growing understanding that advance directives are most helpful in the context of a broader process of advance care planning that helps patients and their families prepare to be able to make the best “in the moment” decisions about life-sustaining treatments.44 SURROGATE DECISION MAKER/FAMILY FACTORS Surrogate Preferences for Control, Role, and Decision Making Historically, physicians have used a parentalist approach to medical decision making Calls for increased patient and family autonomy have led to implementation of alternate models of decision control Decision control can be viewed as a spectrum, with patient and family autonomy/ informed consent at one end and clinician parentalism at the other In between these extremes is shared decision making, a model in which clinicians share medical information; patients and/or surrogate decision makers share information about values, goals, and preferences; and both parties discuss and come to an agreement about an optimal plan of care Although shared decision making has been endorsed by critical care societies as the preferred default approach,45-47 clinicians should recognize that patient/surrogate preferences related to decision control can vary widely and are influenced by factors that include gender, personality, education, socioeconomic status, and culture.9,48,49 To optimize communication, Chapter 87  What Factors Influence a Family to Support a Decision Withdrawing Life Support?     635 clinicians must assess preferences related to decision control for each patient and family and modify their approach to reflect these preferences Although it is not clear how these different approaches might affect choices specifically around the withdrawal of life-sustaining interventions, it is important to consider what approach might be preferred and be most effective with surrogate decision makers before beginning family conferences focused on these decisions In addition, surrogates use varying approaches to their role as a proxy decision maker Many medical ethicists and clinicians suggest that surrogates apply the principle of substituted judgment,50,51 in other words, asking surrogates to use their knowledge of the patient’s values, goals, and preferences to articulate what the patient would choose were the patient able to participate in medical decision making Evidence, though, suggests that many surrogate decision makers have difficulty in determining what the wishes of their loved one might be, with about a third of surrogates incorrectly predicting the treatment preferences of patients.52,53 This may be in part because some patients’ wishes change and evolve,54-56 although most patients show stability in medical preferences over time.57,58 In addition, in cases in which surrogates inaccurately predict the wishes of their loved one, their preferences on behalf of their loved one more closely approximate their own personal wishes about end-of-life care,59,60 highlighting the challenges of applying a substituted judgment standard Surrogates use different factors in medical decision making, including factors other than the patient’s perceived wishes; these factors include their own personal values, religious beliefs and preferences, family consensus, and shared experiences with the patient.4,61,62 Family relationships seem to have an impact on the accuracy of proxies to predict the wishes of their loved one Spouse proxies have been found to be more accurate than adult children of patients.63 Patients with highly supportive and well-functioning families are more likely to engage in advance care planning,64,65 and lower levels of family conflict have also been associated with higher proxy–patient accuracy in medical decision making.63 CLINICIAN FACTORS Physician Bias and Influence Many clinician factors can influence decisions around the withholding and withdrawing of life support For example, clinicians’ overall religiosity and specific religious affiliation can influence the likelihood that life-sustaining interventions are either withheld or withdrawn, with religious physicians more likely to favor more aggressive interventions and less likely to favor withdrawal of life-sustaining interventions.68 In one European study, withdrawal of life support was more common among physicians who identified as Catholic, Protestant, or nonreligious, whereas a decision to withhold rather than withdraw life support was more common among Jewish, Greek Orthodox, and Muslim physicians.69 Most physicians select DNAR status for themselves when presented with a hypothetical end-of-life scenario70,71 and express a personal preference to receive less aggressive care in general.8 It remains unclear why physician and layperson preferences are so different and whether these personal preferences have an impact on treatment approaches toward patients It seems reasonable, though, that clinical experiences and witnessed suffering might affect physicians’ personal preferences This hypothesis suggests a possible opportunity for physicians to better communicate with patients and their families about their own clinical experiences and to offer to make recommendations to families who likely have considerably less experience with both critical care and end-of-life care Physician factors such as white race, residence in North American or northern Europe, more clinical experience, and experience in ICU care predict provision of less technologically aggressive end-of-life care,8 although there are conflicting data about the effect that physician age might have on comfort with DNAR orders and, in general, on treatment decisions in patients with advanced illness.72-74 Medical residents have been found to be marginally more likely than attending physicians to promote aggressive end-of-life care,75 with the least experienced residents the most likely to prescribe technologically aggressive care at the end of life.72 Patient Preferences for Surrogate Latitude in Decision Making Communication Strategies and Skill In addition to the difficulty in implementing substituted judgment as a surrogate decision maker, patients vary in the latitude they choose to give to their surrogate decision makers Most patients, in the event of decisional incapacity, would want decisions made on their behalf using both substituted judgment and best interest standards and involving both surrogates and physicians.66 Many patients show a great deal of trust in the decisions of surrogates as well—with more than three quarters of patients in one study preferring that physicians follow the preferences of their surrogate even when those preferences were at odds with previously stated wishes.67 The fact, though, that some patients prefer that advance directives be followed even if surrogates disagree highlights the importance of discussing surrogate latitude as part of advance care planning Communication strategies and skill can have a major influence on surrogates’ medical decision making There is significant variability in physicians’ roles in navigating complex medical decision making, and few physicians explicitly negotiate their roles with individual families.76 Patient families are also highly variable in their preferences regarding physicians’ recommendations about care decisions at the end of life.77 One study found that most physicians think that making recommendations about end-of-life care is appropriate, although there is significant heterogeneity in whether physicians actually make these recommendations to families.78 Prognostic information can also be easily misunderstood, and some data suggest that surrogates’ interpretation of a report of a poor prognosis may be overly optimistic.3 Furthermore, in one study nearly a third of 636    Section XX CRITICAL CARE ETHICS surrogates stated that they would choose to continue lifesustaining interventions even in the face of poor prognosis (