Chronic critical illness: unintended consequence of intensive care medicine

Abstract

Advanced intensive care treatment prolongs the lives of those with conditions that would previously have been fatal, but can also produce a devastating condition known as chronic critical illness. A population-based prevalence of this complication in high-income countries is estimated to be around 35 cases per 100 000 people and growing. 1 Kahn JM Le T Angus DC for the ProVent Study Group InvestigatorsThe epidemiology of chronic critical illness in the United States. Crit Care Med. 2015; 43: 282-287 Crossref PubMed Scopus (244) Google Scholar More than 100 000 chronically critically ill patients are alive in the USA at any point in time. 2 Nelson JE Cox CE Hope AA Carson SS Chronic critical illness. Am J Respir Crit Care Med. 2010; 182: 446-454 Crossref PubMed Scopus (418) Google Scholar The burdens of persistent critical illness are enormous. They affect patients, their families, health-care providers, and society as a whole. Chronic critical illness causes higher mortality than do most malignancies (20–49%), 3 Nelson JE Tandon N Mercado AF Camhi SL Ely EW Morrison RS Brain dysfunction: another burden for the chronically critically ill. Arch Intern Med. 2006; 166: 1993-1999 Crossref PubMed Scopus (117) Google Scholar , 4 Kahn JM Carson SS Angus DC Linde-Zwirble WT Iwashyna TJ Development and validation of an algorithm for identifying prolonged mechanical ventilation in administrative data. Health Serv Outcomes Res Methodol. 2009; 9: 117-132 Crossref Scopus (21) Google Scholar and survivors tend to have functional and cognitive disabilities and are often readmitted to hospital. 2 Nelson JE Cox CE Hope AA Carson SS Chronic critical illness. Am J Respir Crit Care Med. 2010; 182: 446-454 Crossref PubMed Scopus (418) Google Scholar Most survivors end up in skilled nursing facilities or long-term acute care hospitals, and only one in five patients is eventually discharged home. 1 Kahn JM Le T Angus DC for the ProVent Study Group InvestigatorsThe epidemiology of chronic critical illness in the United States. Crit Care Med. 2015; 43: 282-287 Crossref PubMed Scopus (244) Google Scholar Furthermore, persistent critical illness is an expensive condition, with an annual cost estimated to be more than US$20 billion in the USA, straining the capacity of the health-care system as a whole. 5 Lamas D Chronic critical illness. N Engl J Med. 2014; 370: 175-177 Crossref PubMed Scopus (55) Google Scholar Finally, prolonging life at all costs is often not in accordance with most patients' wishes. When asked, nine of ten seriously ill patients indicated that they would rather die than survive with severe impairments and disabilities. 6 Hopkins RO Jackson JC Long-term neurocognitive function after critical illness. Chest. 2006; 130: 869-878 Summary Full Text Full Text PDF PubMed Scopus (276) Google Scholar Timing of onset and burden of persistent critical illness in Australia and New Zealand: a retrospective, population-based, observational studyOnset of persistent critical illness can be empirically measured at a population level. Patients with this condition consume vast resources, have high mortality, have much less chance of returning home than do typical ICU patients, and require dedicated future research. ICU clinicians should be aware that the risk of in-hospital mortality can change quickly over the first 2 weeks of an ICU course and be sure to incorporate such changes in their decision making and prognostication. Full-Text PDF