BACKGROUND:Goals of care (GOC) conversations in the emergency department (ED) are often a brief discussion of code status rather than a patient-oriented dialogue. We aimed to develop a guide to facilitate conversations between ED clinicians and patients to elicit patient values and establish goals for end-of-life care, while maintaining ED efficiency. Paths of ED Care, a conversation guide, is the product of this work.DESIGN:A multidisciplinary/multispecialty group used recommended practices to adapt a GOC conversation guide for ED patients. ED clinicians used the guide and provided feedback on content, design, and usability. Patient-clinician interactions were recorded for discussion analysis, and both were surveyed to inform iterative refinement. A series of discussions with patient representatives, multidisciplinary clinicians, bioethicists, and health care designers yielded feedback. We used a process similar to the International Patient Decision Aid Standards and provide comparison to these.RESULTS:A conversation guide, eight pages with each page 6 by 6 inches in dimension, uses patient-oriented prompts and includes seven sections: 1) evaluation of patient/family understanding of disease, 2) explanation of possible trajectories, 3) introduction to different pathways of care, 4) explanation of pathways, 5) assessment of understanding and concerns, 6) code status, and 7) personalized summary.LIMITATIONS:Recruitment of sufficient number of patients/providers to the project was the primary limitation. Methods are limited to qualitative analysis of guide creation and feasibility without quantitative analysis.CONCLUSIONS:Paths of ED Care is a guide to facilitate patient-centered shared decision making for ED patients, families, and clinicians regarding GOC. This may ensure care concordant with patients' values and preferences. Use of the guide was well-received and facilitated meaningful conversations between patients and providers.

Objectives: To understand how patients and family members experience dehumanizing or humanizing treatment when in the ICU. Design: Qualitative study included web-based focus groups and open-ended surveys posted to ICU patient/family social media boards. Focus groups were audio recorded and transcribed. Social media responses were collected and organized by stakeholder group. Data underwent qualitative analysis. Setting: Remote focus groups and online surveys. Patients: ICU patient survivors, family members, and ICU teams. Interventions: Not available. Measurements and Main Results: Semi-structured questions and open-ended survey responses. We enrolled 40 patients/family members and 31 ICU team members. Focus groups and surveys revealed three primary themes orienting humanizing/dehumanizing ICU experiences: 1) communication, 2) outcomes, and 3) causes of dehumanization. Dehumanization occurred during “communication” exchanges when ICU team members talked “over” patients, made distressing remarks when patients were present, or failed to inform patients about ICU-related care. “Outcomes” of dehumanization were associated with patient loss of trust in the medical team, loss of motivation to participate in ICU recovery, feeling of distress, guilt, depression, and anxiety. Humanizing behaviors were associated with improved recovery, well-being, and trust. “Perceived causes” of dehumanizing behaviors were linked to patient, ICU team, and healthcare system factors. CONCLUSIONS: Behaviors of ICU clinicians may cause patients and families to feel dehumanized when in the ICU. Negative behaviors are noticed by patients and families, possibly contributing to poor outcomes including mental health, recovery, and lack of trust in ICU teams. Supporting ICU clinicians may enable a more empathic environment and in turn more humanizing clinician-patient encounters.

Background: Little is known about the impact of socioeconomic status (SES) as a key element of social determinants of health on intensive care unit (ICU) outcomes for adults. Objective: We assessed whether a validated individual SES index termed HOUSES (HOUsing-based SocioEconomic status index) derived from housing features was associated with short-term outcomes of critical illness including ICU mortality, ICU-free days, hospital-free days, and ICU readmission. Methods: We performed a population-based cohort study of adult patients living in Olmsted County, Minnesota, admitted to 7 intensive care units at Mayo Clinic from 2011 to 2014. We compared outcomes between the lowest SES group (HOUSES quartile 1 [Q1]) and the higher SES group (HOUSES Q2-4). We stratified the cohort based on age (<50 years old and ≥50 years old). Results: Among 4134 eligible patients, 3378 (82%) patients had SES successfully measured by the HOUSES index. Baseline characteristics, severity of illness, and reason for ICU admission were similar among the different SES groups as measured by HOUSES except for larger number of intoxications and overdoses in younger patients from the lowest SES. In all adult patients, there were no overall differences in mortality, ICU-free days, hospital-free days, or ICU readmissions in patients with higher SES compared to lower SES. Among older patients (>50 years), those with higher SES (HOUSES Q2-4) compared to those with lower SES (HOUSES Q1) had lower mortality rates (hazard ratio = 0.72; 95% CI: 0.56-0.93; adjusted P = .01), increased ICU-free days (mean 1.08 days; 95% CI: 0.34-1.84; adjusted P = .004), and increased hospital-free days (mean 1.20 days; 95% CI: 0.45-1.96; adjusted P = .002). There were no differences in ICU readmission rates (OR = 0.74; 95% CI: 0.55-1.00; P = .051). Conclusion: Individual-level SES may be an important determinant or predictor of critical care outcomes in older adults. Housing-based socioeconomic status may be a useful tool for enhancing critical care research and practice.

Purpose: To understand the healthcare team's perceptions of the negative consequences of suboptimal communication and their recommendations to improve communication with patients and families who have Limited English Proficiency (LEP) in the Intensive Care Unit (ICU). Materials and methods: We performed a qualitative study using semi-structured interviews of physicians, nurses, and interpreters from 3 ICUs at Mayo Clinic Rochester, between November 2017 and April 2018. Results: We identified 5 consequences of suboptimal communication: 1) Suboptimal assessment and treatment of patient symptoms, 2) Unmet patient and family expectations, 3) Decreased patient autonomy, 4) Unmet end of life wishes and 5) Clinician Distress. Recommendations to improve communication include: 1) Education and training for patients,families, clinicians and interpreters, 4) Greater integration of interpreters into the ICU team 5) Standardized timeline for goals of care conversations with patients and families with LEP. Conclusions: Patients with LEP are at risk of experiencing suboptimal communication with the healthcare team in the ICU. There are several educational and quality improvement strategies that ICUs and institutions can take to mitigate these issues. (C) 2020 Published by Elsevier Inc.

The Centers for Medicare and Medicaid Services (CMS) introduced 2 Current Procedural Terminology (CPT) codes that allow clinicians to bill for time spent discussing advance care planning (ACP) effective January 1, 2016. As defined by Sudore et al,1Sudore R.L. Lum H.D. You J.J. et al.Defining advance care planning for adults: a consensus definition from a multidisciplinary Delphi panel.J Pain Symptom Manage. 2017; 53: 821-832.e1Abstract Full Text Full Text PDF PubMed Scopus (446) Google Scholar ACP is "a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care….[with] the goal…that people receive medical care that is consistent with their values, goals and preferences during serious and chronic illness." Proponents applauded this new policy as a method to incentivize ACP, potentially increasing the uptake of ACP and thereby improving the delivery of medical care that aligns with the patients' goals, values, and preferences.2Carr D. Luth E.A. Advance care planning: contemporary issues and future directions.Innov Aging. 2017; 1: 1-10Crossref PubMed Scopus (45) Google Scholar The purpose of this article is to examine the 2016 reimbursement policy through the lens of the ethical principles at stake: beneficence, autonomy, and justice, by considering conflict of interest, quality not quantity of CPT coding, and potential disparities that may occur. Following several years of deliberation, the CMS approved 2 CPT codes for ACP in January 2016. The CPT code 99497 allows clinicians to be reimbursed $80 to $86 for the first 30 minutes of a face-to-face conversation with patients and/or surrogates related to ACP. The CPT code 99498 allows clinicians to be reimbursed $75 for each subsequent 30-minute increment in time. Physicians, nurse practitioners, or physician assistants of any specialty may use these codes to bill for ACP. Additionally, clinicians can bill for conversations in outpatient, inpatient, or nursing home settings, provided these discussions take place in person. The CMS also expects that certain activities be documented in the patient's medical record, including (1) total time of discussion in minutes, (2) that the patient or surrogate was given an opportunity to decline the discussion, (3) who was involved in the discussion, (4) some detail about what was discussed, (5) spiritual factors, (6) understanding of illness and why specific decisions were reached, and (7) whether an advance directive was completed.3Institute for Healthcare ImprovementEnd-of-life care conversations: Medicare reimbursement FAQs.http://theconversationproject.org/wp-content/uploads/2016/06/CMS-Payment-One-Pager.pdfDate: Published 2016Date accessed: November 15, 2016Google Scholar For billing purposes, it is not a requirement that the patient or surrogate complete an advance directive. Many medical and surgical professional organizations supported the introduction of these new CPT codes.4Gurman A.W. AMA on Medicare's proposed plan to cover advance care planning [press release].https://www.ama-assn.org/content/ama-response-medicares-proposed-plan-cover-advance-care-planningDate: Published July 9, 2015Date accessed: December 13, 2016Google Scholar, 5Agrawal N. Sage J. Ollapally V. Provisions in the 2016 Medicare physician fee schedule that will affect surgical practice: an overview.Bull Am Coll Surg. 2016; 101: 11-17PubMed Google Scholar, 6American Academy of Family Physicians2016 Proposed Medicare physician fee schedule: AAFP lauds payment stability, action on advance care planning codes.https://www.aafp.org/news/government-medicine/20150713feeschedule.htmlDate: Published July 13, 2015Google Scholar The American College of Physicians has described ACP conversations as "the standard of care."7American College of Physicians Internists support advance care planning codes included in 2016 physician fee schedule proposed rule [press release].https://www.acponline.org/acp-newsroom/internists-support-advance-care-planning-codes-included-in-2016-physician-fee-schedule-proposed-ruleDate: Published July 8, 2015Date accessed: December 13, 2016Google Scholar A letter of support for the CPT codes from the American Academy of Hospice and Palliative Medicine to the Secretary of Health and Human Services signed by 66 medical and health associations stated that published, peer-reviewed research shows that ACP leads to "better care, higher patient and family satisfaction, fewer unwanted hospitalizations, and lower rates of caregiver distress, depression, and lost productivity."8Rudolf P. Multistakeholder sign on letter in support of voluntary advance care.in: Burwell S.S.M. American Academy of Hospice and Palliative Medicine website. American Academy of Hospice and Palliative Medicine, 2015Google Scholar Advance care planning is particularly important for Medicare beneficiaries because many have multiple chronic illnesses and receive care at home from family and other caregivers, and their children and other family members are often involved in making medical decisions.4Gurman A.W. AMA on Medicare's proposed plan to cover advance care planning [press release].https://www.ama-assn.org/content/ama-response-medicares-proposed-plan-cover-advance-care-planningDate: Published July 9, 2015Date accessed: December 13, 2016Google Scholar,8Rudolf P. Multistakeholder sign on letter in support of voluntary advance care.in: Burwell S.S.M. American Academy of Hospice and Palliative Medicine website. American Academy of Hospice and Palliative Medicine, 2015Google Scholar These codes were intended to benefit patients and families by improving access to ACP conversations and increasing the occurrence of conversations because clinicians will be allowed to charge for the time spent discussing ACP. In this way, the codes were intended to reduce uncertainty and reliev[e] families with the emotional and financial burden of costly end-of-life care. Despite widespread support for these new CPT codes, there are several potential ethical tensions surrounding the use of the CPT codes, their positive and negative impact on patients and the public, and whether they can meaningfully improve goal-concordant care during serious or chronic illness. For example, although many physician organizations maintain that billing for ACP promotes patient autonomy, others worry that these changes could compromise patient interests or beneficence by incentivizing the completion of documents that limit patient care, potentially without the benefit of in-depth discussions of goals of care at the end of life. This situation would violate the principal of non-maleficence. Conflict of interest is defined as occurring when a person's private interests conflict with his/her official responsibilities in a position of trust (Merriam Webster definition). Opponents of the CPT codes argue that physicians and health care systems may inappropriately overengage in ACP for the purposes of financial reimbursement. Financial incentives may lead clinicians to conduct nonbeneficial or even potentially harmful ACP conversations. Such nonbeneficial conversations may take place under several circumstances: (1) by clinicians who are unqualified to conduct such conversations, (2) by clinicians at inappropriate times, or (3) by clinicians at an unnecessarily high frequency. Advance care planning and advance directive completion can be nuanced. Many contextual factors and conversation components can substantially influence patient treatment preferences. Evidence suggests that patients welcome ACP discussions with their clinicians and want to know that their clinician is comfortable talking about death and dying.9Steinhauser K.E. Christakis N.A. Clipp E.C. et al.Preparing for the end of life: preferences of patients, families, physicians, and other care providers.J Pain Symptom Manage. 2001; 22: 727-737Abstract Full Text Full Text PDF PubMed Scopus (350) Google Scholar Patients are not compelled to complete advance directive documentation during these billed visits. In certain cases, these conversations may lead to advance directive completion or more specific decisions regarding treatments that a patient wishes to pursue or decline. In this way, ACP discussions foster autonomy provided they are used properly. Specialists may be highly qualified to conduct necessary and beneficial ACP conversations about specific, anticipated decisions for a chronic, progressive condition. In fact, disease-specific advance directives, such as those for amyotrophic lateral sclerosis, are lauded for precisely this reason.12Auriemma C.L. Chen L. Olorunnisola M. et al.Public opinion regarding financial incentives to engage in advance care planning and complete advance directives.Am J Hosp Palliat Care. 2017; 34: 721-728Crossref PubMed Scopus (4) Google Scholar In addition, many specialists may also act as primary care physicians for a group of patients—and such specialists may be optimally poised to engage in ACP with such patients. Although clinicians from a variety of specialties, including primary care, have utilized the CPT codes for ACP, it should be specifically noted that palliative care specialists have seen the highest uptake in 2016 and 2017.11Barnato A.E. Moore R. Moore C.G. Kohatsu N.D. Sudore R.L. Financial incentives to increase advance care planning among Medicaid beneficiaries: lessons learned from two pragmatic randomized trials.J Pain Symptom Manage. 2017; 54: 85-95.e1Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar In a recently published study by Auriemma et al,14Volpp K.G. John L.K. Troxel A.B. Norton L. Fassbender J. Loewenstein G. Financial incentive–based approaches for weight loss: a randomized trial.JAMA. 2008; 300: 2631-2637Crossref PubMed Scopus (546) Google Scholar 90% of surveyed adults supported programs promoting ACP. Lay population participants were presented with hypothetical mechanisms to incentivize ACP, including payments dispersed directly to patients, insurance coverage contingent on completion of an advance directive, and different physician reimbursement structures. The physician reimbursement structures garnered the lowest support from participants, with only 23% of those surveyed supporting physician reimbursement vs 58% supporting patient reimbursement for completing an advance directive. Financial incentives can help patients overcome an up-front unpleasant activity (of contemplating death) in exchange for a future health benefit, much as they have been shown to increase weight loss and encourage smoking cessation.11Barnato A.E. Moore R. Moore C.G. Kohatsu N.D. Sudore R.L. Financial incentives to increase advance care planning among Medicaid beneficiaries: lessons learned from two pragmatic randomized trials.J Pain Symptom Manage. 2017; 54: 85-95.e1Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar, 12Auriemma C.L. Chen L. Olorunnisola M. et al.Public opinion regarding financial incentives to engage in advance care planning and complete advance directives.Am J Hosp Palliat Care. 2017; 34: 721-728Crossref PubMed Scopus (4) Google Scholar, 13Volpp K.G. Troxel A.B. Pauly M.V. et al.A randomized, controlled trial of financial incentives for smoking cessation.N Engl J Med. 2009; 360: 699-709Crossref PubMed Scopus (538) Google Scholar, 14Volpp K.G. John L.K. Troxel A.B. Norton L. Fassbender J. Loewenstein G. Financial incentive–based approaches for weight loss: a randomized trial.JAMA. 2008; 300: 2631-2637Crossref PubMed Scopus (546) Google Scholar If we consider the financial incentives from a justice perspective, one could argue that prioritizing patients for reimbursement would have been a more effective and fairer strategy to encourage uptake of ACP. Furthermore it would negate concerns about conflict of interest for clinicians jeopardizing beneficence and give precedence to patient autonomy. It is unclear if patients would be eager to participate in ACP conversations (and how the ACP conversations might change) if patients knew a priori that their clinician would be billing for and receiving reimbursement for such conversations. There is general agreement that promoting ACP conversations can benefit patients.18Institute of MedicineDying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. National Academies Press, Washington, DC2015Google Scholar However, measures of quality and clinical impact of encounters reimbursed for ACP remain elusive.2Carr D. Luth E.A. Advance care planning: contemporary issues and future directions.Innov Aging. 2017; 1: 1-10Crossref PubMed Scopus (45) Google Scholar,16Gallegos A. Final fee schedule includes payment for advance care planning.Caring for the Ages. 2015; 16: 1, 4, 5Abstract Full Text Full Text PDF Google Scholar To protect patient autonomy, patients must have a clear understanding of likely treatment decisions and options they might face as well as the potential clinical contexts in which they could receive them.17Dansicker A. Paying docs for end-of-life discussions: can monetary incentives change the failures inherent with physician-patient communication?.Saint Louis U J Health Law Policy. 2015; 9: 149-178Google Scholar It may be hard for patients to imagine diverse situations and account for all possibilities in an advance directive, and therefore, ACP discussions that do not focus on specifics are helpful.10Benditt J.O. Smith T.S. Tonelli M.R. Empowering the individual with ALS at the end-of-life: disease-specific advance care planning.Muscle Nerve. 2001; 24: 1706-1709Crossref PubMed Scopus (33) Google Scholar Patients must have the opportunity to ask questions and express concerns during discussions. There is always a potential risk that poor-quality ACP discussions could mislead patients into accepting care that is not concordant with their personal values and goals, or, conversely, declining interventions that they may desire under certain circumstances. For example, patients might inadvertently articulate that they would never want to be on a ventilator when a time-limited trial of life-sustaining treatment would be a medically acceptable option that aligns with the patient's values. Although these limitations have been inherent in ACP since its inception, the new CPT codes, with resultant increase in the number of potentially poor-quality ACP conversations, have the potential of causing underinformed decison making to become more prevalent. Whereas metrics exist for assessing procedural performance (for example, postoperative infection data, length of stay, readmission rates, redo rates), no analogous metrics exist for evaluation of ACP on the individual level, let alone the population level. The introduction of billing codes alone is insufficient to ensure that high-quality care preference conversations are occurring and are available for future reference in decisions about end-of-life care, whether in an advance directive or in a clinical note. Therefore, it is critical that suitable metrics be developed and deployed. To improve the quality of ACP conversations, we must continue to emphasize clinician training and develop best-practice standards.18Institute of MedicineDying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. National Academies Press, Washington, DC2015Google Scholar Navigating ACP discussions requires not only knowledge of the potential interventions and morbidity that patients may experience but also sensitivity and an ability to invite open discussion about personal goals and values. Many clinicians report little or no training in these skills and may feel underprepared to engage in ACP with their patients.3Institute for Healthcare ImprovementEnd-of-life care conversations: Medicare reimbursement FAQs.http://theconversationproject.org/wp-content/uploads/2016/06/CMS-Payment-One-Pager.pdfDate: Published 2016Date accessed: November 15, 2016Google Scholar,19von Gunten C.F. Ferris F.D. Emanuel L.L. Ensuring competency in end-of-life care: communication and relational skills.JAMA. 2000; 284: 3051-3057Crossref PubMed Scopus (202) Google Scholar Minority communities and vulnerable populations generally have lower rates of ACP completion for a variety of reasons, including cultural and faith-based beliefs about end-of-life care as well as mistrust of the health care system and clinicians.20Caralis P.V. Davis B. Wright K. Marcial E. The influence of ethnicity and race on attitudes toward advance directives, life-prolonging treatments, and euthanasia.J Clin Ethics. 1993; 4: 155-165PubMed Google Scholar,21Cohen M.J. McCannon J.B. Edgman-Levitan S. Kormos W.A. Exploring attitudes toward advance care directives in two diverse settings.J Palliat Med. 2010; 13: 1427-1432Crossref PubMed Scopus (25) Google Scholar There is a substantial body of literature documenting that minority groups utilize health care less than the general population during most of their lifespan but more at the end of life. Clinician reimbursement for ACP could be viewed by these populations as incentivizing conversations to limit the care that members of these communities receive. Conversations with minority patients, especially those with limited English proficiency or low health literacy, may also require more time and sensitivity to cultural beliefs and practices—two things that clinicians may lack. Some may argue that incremental recognition and compensation for these conversations is better than none. However, one could contend that investing in this mechanism to improve goal concordance at the end of life ignores the inherent and glaring differences in ACP acceptability and uptake. Indeed, when Pelland et al22Pelland K. Morphis B. Harris D. Gardner R. Assessment of first-year use of Medicare's advance care planning billing codes.JAMA Intern Med. 2019; 179: 827-829Crossref PubMed Scopus (22) Google Scholar analyzed uptake of ACP CPT coding among Medicare beneficiaries in New England, they found that Hispanic and Asian patients had a lower odds ratio of having had an eligible visit. Although ACP does tend to influence end-of-life care, it has many limitations.15Brinkman-Stoppelenburg A. Rietjens J.A. van der Heide A. The effects of advance care planning on end-of-life care: a systematic review.Palliat Med. 2014; 28: 1000-1025Crossref PubMed Scopus (630) Google Scholar Furthermore, there are multiple other systemic and organizational factors that may influence the effectiveness of the CPT codes on ACP discussions. Although the introduction of CPT codes to encourage ACP discussions between clinicians and patients represents an important step in recognition and remuneration for ACP, this policy change, and its implications for clinical practice, warrant ongoing scrutiny and systematic study. Public opinion supports direction of financial incentives for ACP to patients over clinicians.12Auriemma C.L. Chen L. Olorunnisola M. et al.Public opinion regarding financial incentives to engage in advance care planning and complete advance directives.Am J Hosp Palliat Care. 2017; 34: 721-728Crossref PubMed Scopus (4) Google Scholar As a profession, we must sensitively acknowledge and mitigate the potential conflict inherent in receiving reimbursement for ACP; the public, and particularly members of underserved populations, may justifiably view this fee structure with skepticism. Because of the sensitivities surrounding ACP, use of these billing codes to augment a clinic's revenue stream would be particularly egregious and erosive of public trust.

Background: Chronic obstructive pulmonary disease (COPD) is characterized by frequent exacerbations. Purpose: To evaluate the comparative effectiveness and adverse events (AEs) of pharmacologic interventions for adults with exacerbation of COPD. Data Sources: English-language searches of several bibliographic sources from database inception to 2 January 2019. Study Selection: 68 randomized controlled trials that enrolled adults with exacerbation of COPD treated in out- or inpatient settings other than intensive care and compared pharmacologic therapies with placebo, "usual care," or other pharmacologic interventions. Data Extraction: Two reviewers independently extracted data and rated study quality and strength of evidence (SOE). Data Synthesis: Compared with placebo or management without antibiotics, antibiotics given for 3 to 14 days were associated with increased exacerbation resolution at the end of the intervention (odds ratio [OR], 2.03 [95% CI, 1.47 to 2.80]; moderate SOE) and less treatment failure at the end of the intervention (OR, 0.54 [CI, 0.34 to 0.86]; moderate SOE), independent of severity of exacerbations in out- and inpatients. Compared with placebo in out- and inpatients, systemic corticosteroids given for 9 to 56 days were associated with less treatment failure at the end of the intervention (OR, 0.01 [CI, 0.00 to 0.13]; low SOE) but also with a higher number of total and endocrine-related AEs. Compared with placebo or usual care in inpatients, other pharmacologic interventions (aminophyllines, magnesium sulfate, anti-inflammatory agents, inhaled corticosteroids, and shortacting bronchodilators) had insufficient evidence, showing either no or inconclusive effects (with the exception of the mucolytic erdosteine) or improvement only in lung function. Limitation: Scant evidence for many interventions; several studies had unclear or high risk of bias and inadequate reporting of AEs. Conclusion: Antibiotics and systemic corticosteroids reduce treatment failure in adults with mild to severe exacerbation of COPD.

To assess the rates and variability of do-not-intubate orders in patients with acute respiratory failure. We conducted a systematic review of observational studies that enrolled adult patients with acute respiratory failure requiring noninvasive ventilation or high-flow nasal cannula oxygen from inception to 2019. Twenty-six studies evaluating 10,755 patients were included. The overall pooled rate of do-not-intubate orders was 27%. The pooled rate of do-not-intubate orders in studies from North America was 14% (range 9–22%), from Europe was 28% (range 13–58%), and from Asia was 38% (range 9–83%), p = 0.001. Do-not-intubate rates were higher in studies with higher patient age and in studies where do-not-intubate decisions were made without reported patient/family input. There were no significant differences in do-not-intubate orders according to illness severity, observed mortality, malignancy comorbidity, or methodological quality. Rates of do-not-intubate orders increased over time from 9% in 2000–2004 to 32% in 2015–2019. Only 12 studies (46%) reported information about do-not-intubate decision-making processes. Only 4 studies (15%) also reported rates of do-not-resuscitate. One in four patients with acute respiratory failure (who receive noninvasive ventilation or high-flow nasal cannula oxygen) has a do-not-intubate order. The rate of do-not-intubate orders has increased over time. There is high inter-study variability in do-not-intubate rates—even when accounting for age and illness severity. There is high variability in patient/family involvement in do-not-intubate decision making processes. Few studies reported differences in rates of do-not-resuscitate and do-not-intubate—even though recovery is very different for acute respiratory failure and cardiac arrest.

Much of the debate surrounding the coronavirus disease 2019 (COVID-19) pandemic in the popular press has focused on invasive (via endotracheal tube or tracheostomy) ventilation of severely sick patients and potential ventilator shortages. Amid increasing concerns from medical professionals about the harms associated with invasive ventilation, there is interest to explore the role of noninvasive positive pressure ventilation (NIPPV) in the treatment of acute hypoxemic respiratory failure (AHRF) and acute respiratory distress syndrome (ARDS) due to COVID-19.

BACKGROUND: As more individuals survive sepsis, there is an urgent need to understand its effects on patient-reported outcomes. RESEARCH QUESTION: What is the effect of sepsis on self-rated health, and what role, if any, does functional disability play in mediating this effect? STUDY DESIGN AND METHODS: We conducted a surveyand administrative claims-based retrospective cohort study using the US Health and Retirement Study, a nationally representative cohort-based survey of older adults in the United States, from 2000 through 2016. We matched Medicare beneficiaries hospitalized with sepsis in 2000 to 2008 to nonhospitalized individuals. Self-rated health and functional disability were tracked biannually for 8 years. Differences in self-rated health between the cohorts were measured using mixed models with and without controlling for changes in functional disability. RESULTS: Seven hundred fifty-eight individuals with sepsis were matched 1:1 to 758 nonhospitalized individuals, all aged 65 years and older. Among survivors, sepsis was associated with worse self-rated health in years 2 and 4 (adjusted absolute difference in self-rated health on a 5-point scale in year 2: -0.24 [95% CI, -0.38 to -0.10] and year 4: -0.17 [95% CI, -0.33 to -0.02]) but not in years 6 or 8. After accounting for changes in functional status, the association between sepsis and self-rated health was still present but reduced in year 2 (adjusted absolute difference in self-rated health, -0.18 [95% CI, -0.31 to -0.05]) and was not present in years 4, 6, or 8. INTERPRETATION: Self-rated health worsened initially after sepsis but returned to the level of that of nonhospitalized control subjects by year 6. Mitigating sepsis-related functional disability may play a key role in improving self-rated health after sepsis.

Background: Chronic obstructive pulmonary disease (COPD) is characterized by frequent exacerbations. Purpose: To evaluate the comparative effectiveness and adverse events (AEs) of pharmacologic interventions for adults with exacerbation of COPD. Data Sources: English-language searches of several bibliographic sources from database inception to 2 January 2019. Study Selection: 68 randomized controlled trials that enrolled adults with exacerbation of COPD treated in out- or inpatient settings other than intensive care and compared pharmacologic therapies with placebo, "usual care," or other pharmacologic interventions. Data Extraction: Two reviewers independently extracted data and rated study quality and strength of evidence (SOE). Data Synthesis: Compared with placebo or management without antibiotics, antibiotics given for 3 to 14 days were associated with increased exacerbation resolution at the end of the intervention (odds ratio [OR], 2.03 [95% CI, 1.47 to 2.80]; moderate SOE) and less treatment failure at the end of the intervention (OR, 0.54 [CI, 0.34 to 0.86]; moderate SOE), independent of severity of exacerbations in out- and inpatients. Compared with placebo in out- and inpatients, systemic corticosteroids given for 9 to 56 days were associated with less treatment failure at the end of the intervention (OR, 0.01 [CI, 0.00 to 0.13]; low SOE) but also with a higher number of total and endocrine-related AEs. Compared with placebo or usual care in inpatients, other pharmacologic interventions (aminophyllines, magnesium sulfate, anti-inflammatory agents, inhaled corticosteroids, and short-acting bronchodilators) had insufficient evidence, showing either no or inconclusive effects (with the exception of the mucolytic erdosteine) or improvement only in lung function. Limitation: Scant evidence for many interventions; several studies had unclear or high risk of bias and inadequate reporting of AEs. Conclusion: Antibiotics and systemic corticosteroids reduce treatment failure in adults with mild to severe exacerbation of COPD. Primary Funding Source: Agency for Healthcare Research and Quality. (PROSPERO: CRD42018111609)

A consensus conference on frailty in solid organ transplantation took place on February 11, 2018, to discuss the latest developments in frailty, adopt a standardized approach to assessment, and generate ideas for future research. The findings and consensus of the Frailty Heart Workgroup (American Society of Transplantation's Thoracic and Critical Care Community of Practice) are presented here. Frailty is defined as a clinically recognizable state of increased vulnerability resulting from aging-associated decline in reserve and function across multiple physiologic systems such that the ability to cope with every day or acute stressors is compromised. Frailty is increasingly recognized as a distinct biologic entity that can adversely affect outcomes before and after heart transplantation. A greater proportion of patients referred for heart transplantation are older and have more complex comorbidities. However, outcomes data in the pretransplant setting, particularly for younger patients, are limited. Therefore, there is a need to develop objective frailty assessment tools for risk stratification in patients with advanced heart disease. These tools will help to determine appropriate recipient selection for advanced heart disease therapies including heart transplantation and mechanical circulatory support, improve overall outcomes, and help distinguish frailty phenotypes amenable to intervention.

OBJECTIVES:To understand healthcare team perceptions of the role of professional interpreters and interpretation modalities during end of life and critical illness discussions with patients and families who have limited English proficiency in the intensive care unit (ICU). METHODS:We did a secondary analysis of data from a qualitative study with semi-structured interviews of 16 physicians, 12 nurses, and 12 professional interpreters from 3 ICUs at Mayo Clinic, Rochester. RESULTS:We identified 3 main role descriptions for professional interpreters: 1) Verbatim interpretation; interpreters use literal interpretation; 2) Health Literacy Guardian; interpreters integrate advocacy into their role; 3) Cultural Brokers; interpreters transmit information incorporating cultural nuances. Clinicians expressed advantages and disadvantages of different interpretation modalities on the professional interpreter's role in the ICU. CONCLUSION:Our study illuminates different professional interpreters' roles. Furthermore, we describe the perceived relationship between interpretation modalities and the interpreter's roles and influence on communication dynamics in the ICU for patients with LEP. PRACTICE IMPLICATIONS:Patients benefit from having an interpreter, who can function as a cultural broker or literacy guardian during communication in the ICU setting where care is especially complex, good communication is vital, and decision making is challenging.

As more individuals survive sepsis, there is an urgent need to understand its effects on patient-reported outcomes.What is the effect of sepsis on self-rated health, and what role, if any, does functional disability play in mediating this effect?We conducted a survey- and administrative claims-based retrospective cohort study using the US Health and Retirement Study, a nationally representative cohort-based survey of older adults in the United States, from 2000 through 2016. We matched Medicare beneficiaries hospitalized with sepsis in 2000 to 2008 to nonhospitalized individuals. Self-rated health and functional disability were tracked biannually for 8 years. Differences in self-rated health between the cohorts were measured using mixed models with and without controlling for changes in functional disability.Seven hundred fifty-eight individuals with sepsis were matched 1:1 to 758 nonhospitalized individuals, all aged 65 years and older. Among survivors, sepsis was associated with worse self-rated health in years 2 and 4 (adjusted absolute difference in self-rated health on a 5-point scale in year 2: -0.24 [95% CI, -0.38 to -0.10] and year 4: -0.17 [95% CI, -0.33 to -0.02]) but not in years 6 or 8. After accounting for changes in functional status, the association between sepsis and self-rated health was still present but reduced in year 2 (adjusted absolute difference in self-rated health, -0.18 [95% CI, -0.31 to -0.05]) and was not present in years 4, 6, or 8.Self-rated health worsened initially after sepsis but returned to the level of that of nonhospitalized control subjects by year 6. Mitigating sepsis-related functional disability may play a key role in improving self-rated health after sepsis.