Case report: isolation of Hydrogenophaga from septic blood culture following near-death drowning in lakewater.

A patient suffered a non-fatal wet drowning in a freshwater lake and developed bacteraemia several days later. Blood culture grew a Gram-negative rod that could not be identified by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS). 16S ribosomal RNA sequencing of the isolate identified the microbe as Hydrogenophaga laconesensis - an environmental microbe commonly found in freshwater. The recovery of multiple pathogenic micro-organisms (although not H. laconesensis ) from culture of respiratory specimens prompted the initiation of antibiotic therapy with cefepime and, later, vancomycin. The patient's clinical course gradually improved over the course of 2 weeks and she was ultimately discharged home with minimal sequelae. To our knowledge, this is the first evidence of human infection with bacteria in the genus Hydrogenophaga . Hydrogenophaga may be considered in cases of freshwater near-drowning, and MALDI-TOF MS databases should be updated to include H. laconesensis .

The Critical Care Nurse Communicator Program: An Integrated Primary Palliative Care Intervention.

Twenty percent of Americans die in an intensive care unit (ICU), often incapacitated or requiring assisted decision making. Surrogates are often required to make urgent, complex, high-stakes decisions. Communication among patients, families, and clinicians is often delayed and inefficient with frequent missed opportunities to support the emotional and psychological needs of surrogates, particularly at the end of life. The Critical Care Nurse Communicator program is a nurse-led, primary palliative care intervention designed to improve the quality and consistency of communication in the ICU and address the informational, psychological, and emotional needs of surrogate decision-makers through the shared decision-making process.

Association Between Sepsis and Microvascular Brain Injury.

OBJECTIVES: Many survivors of sepsis suffer long-term cognitive impairment, but the mechanisms of this association remain unknown. The objective of this study was to determine whether sepsis is associated with cerebral microinfarcts on brain autopsy. DESIGN: Retrospective cohort study. SETTING AND SUBJECTS: Five-hundred twenty-nine participants of the Adult Changes in Thought, a population-based prospective cohort study of older adults carried out in Kaiser Permanente Washington greater than or equal to 65 years old without dementia at study entry and who underwent brain autopsy. MEASUREMENTS AND MAIN RESULTS: Late-life sepsis hospitalization was identified using administrative data. We identified 89 individuals with greater than or equal to 1 sepsis hospitalization during study participation, 80 of whom survived hospitalization and died a median of 169 days after discharge. Thirty percent of participants with one or more sepsis hospitalization had greater than two microinfarcts, compared with 19% participants without (χ p = 0.02); 20% of those with sepsis hospitalization had greater than two microinfarcts in the cerebral cortex, compared with 10% of those without (χ p = 0.01). The adjusted relative risk of greater than two microinfarcts was 1.61 (95% CI, 1.01-2.57; p = 0.04); the relative risk for having greater than two microinfarcts in the cerebral cortex was 2.12 (95% CI, 1.12-4.02; p = 0.02). There was no difference in Braak stage for neurofibrillary tangles or consortium to establish a registry for Alzheimer's disease score for neuritic plaques between, but Lewy bodies were less significantly common in those with sepsis. CONCLUSIONS: Sepsis was specifically associated with moderate to severe vascular brain injury as assessed by microvascular infarcts. This association was stronger for microinfarcts within the cerebral cortex, with those who experienced severe sepsis hospitalization being more than twice as likely to have evidence of moderate to severe cerebral cortical injury in adjusted analyses. Further study to identify mechanisms for the association of sepsis and microinfarcts is needed.

Factors Nurses in the Intensive Care Unit Consider When Making Decisions About Patient Mobility.

BACKGROUND: Early mobility interventions in the intensive care unit can improve patients' outcomes, yet they are not routinely implemented in many intensive care units. In an effort to identify opportunities to implement and sustain evidence-based practice, prior work has demonstrated that understanding the decision-making process of health professionals is critical for identifying opportunities to improve program implementation. Nurses are often responsible for mobilizing patients, but how they overcome barriers and make decisions to mobilize patients in the intensive care unit is not understood. OBJECTIVE: To describe processes that nurses in intensive care units use to make decisions and barriers that influence their decision-making about patient mobility. METHODS: An exploratory descriptive approach using semi-structured interviews of a purposive sample of registered nurses in 2 intensive care units at 2 hospitals was used. Interviews were transcribed and analyzed by using directed content analysis to identify categories that describe nurses' decision-making about patient mobility. RESULTS: Semistructured interviews were conducted with 20 nurses in a 1-on-1 setting. Four main categories that influenced nurses' decision-making about mobility were identified in the directed content analysis: purpose of mobility, gathering information, establishing and activating the plan, and barriers to progressing the plan. CONCLUSIONS: Deciding to mobilize patients in the intensive care unit is a multifaceted, individualized decision made by nurses, and numerous patient-, nurse-, and unit-related factors influence that decision. Future studies that target unit culture and interprofessional perspectives are needed.

Association Between Postextubation Dysphagia and Long-Term Mortality Among Critically Ill Older Adults.

BACKGROUND: Dysphagia following extubation is common in intensive care unit (ICU) patients. Diagnosing postextubation dysphagia allows identification of patients who are at highest risk for aspiration and its associated adverse outcomes. Older adults are at an increased risk of postextubation dysphagia and its complications due to multiple comorbidities, a higher baseline risk of dysphagia, and increased risk of pneumonia. OBJECTIVES: We aimed to investigate the association between postextubation dysphagia and 1-year mortality in older patients. Secondary outcomes included ICU and hospital lengths of stay, ICU readmission, and place of discharge. METHODS: We performed a retrospective cohort study from January 1 to December 31, 2013. ICU patients, aged 65 years and older, who were successfully extubated and underwent a formal swallow evaluation by a speech and language pathologist (SLP) were included. Dysphagia was graded using a seven-point scale, and those with at least mild-moderate dysphagia were labeled as having clinically significant dysphagia. RESULTS: Of 1075 patients who were screened, 359 were survivors, aged 65 years and older; and of these survivors, 111 had a swallow evaluation performed by an SLP after liberation from mechanical ventilation. Mean age was 73.8 years (SD = 7.0 years), and 41.4% had clinically significant dysphagia. In a multivariable regression model, there was no significant association between dysphagia and 1-year mortality. Furthermore, there was no statistically significant difference in ICU or hospital length of stay, ICU readmission, or place of discharge of those with clinically significant dysphagia compared to those without. CONCLUSIONS: Among mechanically ventilated ICU patients, aged 65 years and older, who underwent a swallow evaluation following extubation, dysphagia was not associated with mortality, ICU and hospital lengths of stay, ICU readmission, and place of discharge. Given conflicting evidence in the literature, larger prospective studies are needed to clarify whether postextubation dysphagia is associated with worse outcomes in older patients admitted to the ICU. J Am Geriatr Soc 67:1895-1901, 2019.

Post-extubation Dysphagia: Does Timing of Evaluation Matter?

Swallowing evaluations are often delayed at least 24 h following extubation with the assumption that swallow function improves over time. The purpose of this prospective cohort study was to determine if dysphagia, as measured by aspiration and need for diet modification, declines over the first 24-h post-extubation, whereby providing evidence-based evaluation guidelines for this population. Forty-nine patients completed FEES at 2-4 h post-extubation and 24-26 h post-extubation. We compared Penetration-Aspiration Scale scores and diet recommendation between time points. Multivariable logistic regression models were created to investigate associations between age, reason for admission, reason for intubation, and a history of COPD and outcomes of aspiration or silent aspiration at either FEES exam. Sixty-nine percent of participants safely swallowed at least one texture without aspiration at 2-4 h post-extubation. Within participants, there was a significant decrease in penetration/aspiration at 24 h and 79% showed improvement in airway protection on at least one bolus type, suggesting an improvement in swallow function over the first day following extubation. These findings suggest that although patients may be safe to begin a modified diet soon after extubation, delaying evaluation until 24-h post-extubation may allow for a less restricted diet.

Sepsis Survivors Admitted to Skilled Nursing Facilities: Cognitive Impairment, Activities of Daily Living Dependence, and Survival.

OBJECTIVE: Severe sepsis survivors frequently experience cognitive and physical functional impairment. The degree of impairment and its association with mortality is understudied, particularly among those discharged to a skilled nursing facility. Our objective was to quantify the cognitive and physical impairment among severe sepsis survivors discharged to a skilled nursing facility and to investigate the relationship between impairment and long-term mortality. DESIGN: Retrospective cohort study. SETTING: United States. SUBJECTS: Random 5% sample of Medicare patients discharged following severe sepsis hospitalization, 2005-2009 (n = 135,370). MEASUREMENT AND MAIN RESULTS: Medicare data were linked with the Minimum Data Set; Minimum Data Set-Cognition Scale was used to assess cognitive function, and the Minimum Data Set activities of daily living hierarchical scale was used to assess functional dependence. Associations were evaluated using multivariable logistic regression, Kaplan-Meier curves, and Cox proportional hazards regression. Of 66,540 beneficiaries admitted to a skilled nursing facility following severe sepsis, 34% had severe or very severe cognitive impairment, and 72.5% had maximal, dependence, or total dependence in activities of daily living. Median survival was 19.4 months for those discharged to a skilled nursing facility without having been in a skilled nursing facility in the preceding 1 year and 10.4 months for those discharged to a skilled nursing facility who had spent time in a skilled nursing facility in the prior year. The adjusted hazard ratio for death was 3.1 for those with very severe cognitive impairment relative to those who were cognitively intact (95% CI, 2.9-3.2; p < 0.001) and 4.3 for those with "total dependence" in activities of daily livings relative to those who were independent (95% CI, 3.8-5.0; p < 0.001). CONCLUSIONS: Discharge to a skilled nursing facility following severe sepsis hospitalization among Medicare beneficiaries was associated with shorter survival, and cognitive impairment and activities of daily living dependence were each strongly associated with shortened survival. These findings can inform decision-making by patients and physicians and underscores high palliative care needs among sepsis survivors discharged to skilled nursing facility.

Manifestations of HIV stigma and their impact on retention in care for people transitioning from prisons to communities.

BACKGROUND: While most people living with HIV who are incarcerated in United States receive appropriate HIV care while they are in prison, interruptions in antiretroviral therapy and virologic failure are extremely common after they are released. The purpose of this study was to describe whether and how HIV stigma influences continuity of care for people living with HIV while they transition from prison to community settings. METHODS: We conducted semi-structured, telephone-based interviews with 32 adults who received HIV care while residing in a Wisconsin state prison, followed by a second interview 6 months after they returned to their home community. Interview transcripts were analyzed by an interdisciplinary research team using conventional content analysis. We identified themes based on commonly-reported experiences that were characterized as internalized stigma, perceived stigma, vicarious stigma, or enacted stigma. RESULTS: All four forms of HIV stigma appeared to negatively influence participants' engagement in community-based HIV care. Mechanisms described by participants included care avoidance due to concerns about HIV status disclosure and symptoms of depression and anxiety caused by internalized stigma. Supportive social relationships with clinic staff, professional case managers and supportive peers appeared to mitigate the impact of HIV stigma by increasing motivation for treatment adherence. CONCLUSIONS: HIV stigma is manifest in several different forms by people living with HIV who were recently incarcerated, and are perceived by patients to negatively influence their desire and ability to engage in HIV care. By being cognizant of the pervasive influence of HIV stigma on the lives of criminal justice involved adults, HIV care providers and clinical support staff can ameliorate important barriers to optimal HIV care for a vulnerable group of patients.

Emergency Department Patients' Perceptions of Radiation From Medical Imaging.

OBJECTIVE: To evaluate emergency department patients' knowledge of radiation exposure and subsequent risks from computed tomography (CT) and magnetic resonance imaging (MRI) scans. METHODS: This is a cross-sectional survey study of adult, English-speaking patients from June to August 2011 at 2 emergency departments--1 academic and 1 community-based--in the upper Midwest. The survey consisted of 2 sets of 3 questions evaluating patients' knowledge of radiation exposure from medical imaging and subsequent radiation-induced malignancies and was based on a previously published survey. The question sets paralleled each other, but one pertained to CT and the other to MRI. Questions in the survey ascertained patients' understanding of (1) the relative amount of radiation exposed from CT/MRI compared with a single chest x-ray; (2) the relative amount of radiation exposed from CT/MRI compared with a nuclear power plant accident; and (3) the possibility of radiation-induced malignancies from CT/MRl. Sociodemographic data also were gathered. The primary outcome measure was the proportion of correct answers to each survey question. Multiple logistic regression then was used to examine the relationship between the percentage correct for each question and sociodemographic variables, using odds ratios with 95% confidence intervals. P-values less than 0.05 were considered statistically significant. RESULTS: There were 500 participants in this study, 315 from the academic center and 185 from the community hospital. Overall, 14.1% (95% CI, 11.0%-17.2%) of participants understood the relative radiation exposure of a CT scan compared with a chest x-ray, while 22.8% (95% CI, 18.9%-26.7%) of respondents understood the lack of ionizing radiation use with MRI. At the same time, 25.6% (95% CI, 21.8%- 29.4%) believed that there was an increased risk of developing cancer from repeated abdominal CTs, while 55.6% (95% CI, 51.1%-60.1%) believed this to be true of abdominal MRI. Higher educational level and identification as a health care professional were associated with correct responses. However, even within these groups, a significant majority gave incorrect responses to all questions. CONCLUSION: Patients did not demonstrate understanding of the degree of radiation exposure from CT scans and the subsequent risks associated with this exposure, namely radiation-induced malignancies. Moreover, they did not understand that MRI scans do not expose them to ionizing radiation and therefore lack this downstream effect. While patient preference is integral to patient-centered care, physicians should be aware of the significant lack of knowledge as it pertains to the selection of medical imaging tests.

Trends in the Use of Medical Imaging to Diagnose Appendicitis at an Academic Medical Center.

OBJECTIVE: To quantify the trends in imaging use for the diagnosis of appendicitis. METHODS: A retrospective study covering a 22-year period was conducted at an academic medical center. Patients were identified by International Classification of Diseases-9 diagnosis code for appendicitis. Medical record data extraction of these patients included imaging test used (ultrasound, CT, or MRI), gender, age, and body mass index (BMI). The proportion of patients undergoing each scan was calculated by year. Regression analysis was performed to determine whether age, gender, or BMI affected imaging choice. RESULTS: The study included a total of 2,108 patients, including 967 (43.5%) females and 599 (27%) children (<18 years old). CT use increased over time for the entire cohort (2.9% to 82.4%, P < .0001), and each subgroup (males, females, adults, children; P < .0001 for each). CT use increased more in females and adults than in males and children, but differences in trends were not statistically significant (male versus female, P = .8; adult versus child, P = .1). The percentage of patients who had no imaging used for the diagnosis of appendicitis decreased over time (P < .0001 overall and for each subgroup), and no difference was found in trends between complementary subgroups (male versus female, P = .53; adult versus child, P = .66). No statistically significant changes were found in use of ultrasound or MRI over the study period. With increasing BMI, CT was more frequently used. CONCLUSIONS: Of those diagnosed with appendicitis at an academic medical center, CT use increased more than 20-fold. However, no statistically significant trend was found for increased use of ultrasound or MRI.

Prospective evaluation of the ability of clinical scoring systems and physician-determined likelihood of appendicitis to obviate the need for CT.

OBJECTIVE: To determine whether clinical scoring systems or physician gestalt can obviate the need for computed tomography (CT) in patients with possible appendicitis. METHODS: Prospective, observational study of patients with abdominal pain at an academic emergency department (ED) from February 2012 to February 2014. Patients over 11 years old who had a CT ordered for possible appendicitis were eligible. All parameters needed to calculate the scores were recorded on standardised forms prior to CT. Physicians also estimated the likelihood of appendicitis. Test characteristics were calculated using clinical follow-up as the reference standard. Receiver operating characteristic curves were drawn. RESULTS: Of the 287 patients (mean age (range), 31 (12-88) years; 60% women), the prevalence of appendicitis was 33%. The Alvarado score had a positive likelihood ratio (LR(+)) (95% CI) of 2.2 (1.7 to 3) and a negative likelihood ratio (LR(-)) of 0.6 (0.4 to 0.7). The modified Alvarado score (MAS) had LR(+) 2.4 (1.6 to 3.4) and LR(-) 0.7 (0.6 to 0.8). The Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) score had LR(+) 1.3 (1.1 to 1.5) and LR(-) 0.5 (0.4 to 0.8). Physician-determined likelihood of appendicitis had LR(+) 1.3 (1.2 to 1.5) and LR(-) 0.3 (0.2 to 0.6). When combined with physician likelihoods, LR(+) and LR(-) was 3.67 and 0.48 (Alvarado), 2.33 and 0.45 (RIPASA), and 3.87 and 0.47 (MAS). The area under the curve was highest for physician-determined likelihood (0.72), but was not statistically significantly different from the clinical scores (RIPASA 0.67, Alvarado 0.72, MAS 0.7). CONCLUSIONS: Clinical scoring systems performed equally well as physician gestalt in predicting appendicitis. These scores do not obviate the need for imaging for possible appendicitis when a physician deems it necessary.

Trajectories and Prognosis of Older Patients Who Have Prolonged Mechanical Ventilation After High-Risk Surgery.

OBJECTIVES: Surgical patients often receive routine postoperative mechanical ventilation with excellent outcomes. However, older patients who receive prolonged mechanical ventilation may have a significantly different long-term trajectory not fully captured in 30-day postoperative metrics. The objective of this study is to describe patterns of mortality and hospitalization for Medicare beneficiaries 66 years old and older who have major surgery with and without prolonged mechanical ventilation. DESIGN: Retrospective cohort study. SETTING: Hospitals throughout the United States. PATIENTS: Five percent random national sample of elderly Medicare beneficiaries (age ≥ 66 yr) who underwent 1 of 227 operations previously defined as high risk during an inpatient stay at an acute care hospital between January 1, 2005, and November 30, 2009. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We identified 117,917 episodes for older patients who had high-risk surgery; 4% received prolonged mechanical ventilation during the hospitalization. Patients who received prolonged mechanical ventilation had higher 1-year mortality rate than patients who did not have prolonged ventilation (64% [95% CI, 62-65%] vs 17% [95% CI, 16.4-16.9%]). Thirty-day survivors who received prolonged mechanical ventilation had a 1-year mortality rate of 47% (95% CI, 45-48%). Thirty-day survivors who did not receive prolonged ventilation were more likely to be discharged home than patients who received prolonged ventilation 71% versus 10%. Patients who received prolonged ventilation and were not discharged by postoperative day 30 had a substantially increased 1-year mortality (adjusted hazard ratio, 4.39 [95% CI, 3.29-5.85]) compared with patients discharged home by day 30. Hospitalized 30-day survivors who received prolonged mechanical ventilation and died within 6 months of their index procedure spent the majority of their remaining days hospitalized. CONCLUSIONS: Older patients who require prolonged mechanical ventilation after high-risk surgery and survive 30 days have a significant 1-year risk of mortality and high burdens of treatment. This difficult trajectory should be considered in surgical decision making and has important implications for surgeons, intensivists, and patients.

Prospective study of a proactive palliative care rounding intervention in a medical ICU.

PURPOSE: To evaluate the effects of a palliative care intervention on clinical and family outcomes, and palliative care processes. METHODS: Prospective, before-and-after interventional study enrolling patients with high risk of mortality, morbidity, or unmet palliative care needs in a 24-bed academic intensive care unit (ICU). The intervention involved a palliative care clinician interacting with the ICU physicians on daily rounds for high-risk patients. RESULTS: One hundred patients were enrolled in the usual care phase, and 103 patients were enrolled during the intervention phase. The adjusted likelihood of a family meeting in ICU was 63% higher (RR 1.63, 95% CI 1.14-2.07, p = 0.01), and time to family meeting was 41% shorter (95% CI 52-28% shorter, p < 0.001). Adjusted ICU length of stay (LOS) was not significantly different between the two groups (6% shorter, 95% CI 16% shorter to 4% longer, p = 0.22). Among those who died in the hospital, ICU LOS was 19% shorter in the intervention (95% CI 33-1% shorter, p = 0.043). Adjusted hospital LOS was 26% shorter (95% CI 31-20% shorter, p < 0.001) with the intervention. Post-traumatic stress disorder (PTSD) symptoms were present in 9.1% of family respondents during the intervention versus 20.7% prior to the intervention (p = 0.09). Mortality, family depressive symptoms, family satisfaction and quality of death and dying did not significantly differ between groups. CONCLUSIONS: Proactive palliative care involvement on ICU rounds for high-risk patients was associated with more and earlier ICU family meetings and shorter hospital LOS. We did not identify differences in family satisfaction, family psychological symptoms, or family-rated quality of dying, but had limited power to detect such differences.

Systematic review and meta-analysis of the accuracy of MRI to diagnose appendicitis in the general population.

PURPOSE: To perform a systematic review and meta-analysis of all published studies since 2005 that evaluate the accuracy of magnetic resonance imaging (MRI) for the diagnosis of acute appendicitis in the general population presenting to emergency departments. MATERIALS AND METHODS: All retrospective and prospective studies evaluating the accuracy of MRI to diagnose appendicitis published in English and listed in PubMed, Web of Science, Cinahl Plus, and the Cochrane Library since 2005 were included. Excluded studies were those without an explicitly stated reference standard, with insufficient data to calculate the study outcomes, or if the population enrolled was limited to pregnant women or children. Data were abstracted by one investigator and confirmed by another. Data included the number of true positives, true negatives, false positives, false negatives, number of equivocal cases, type of MRI scanner, type of MRI sequence, and demographic data including study setting and gender distribution. Summary test characteristics were calculated. Forest plots and a summary receiver operator characteristic plot were generated. RESULTS: Ten studies met eligibility criteria, representing patients from seven countries. Nine were prospective and two were multicenter studies. A total of 838 subjects were enrolled; 406 (48%) were women. All studies routinely used unenhanced MR images, although two used intravenous contrast-enhancement and three used diffusion-weighted imaging. Using a bivariate random-effects model the summary sensitivity was 96.6% (95% confidence interval [CI]: 92.3%-98.5%) and summary specificity was 95.9% (95% CI: 89.4%-98.4%). CONCLUSION: MRI has a high sensitivity and specificity for the diagnosis of appendicitis, similar to that reported previously for computed tomography. J. Magn. Reson. Imaging 2016;43:1346-1354.

Physical Function and Disability After Acute Care and Critical Illness Hospitalizations in a Prospective Cohort of Older Adults.

OBJECTIVES: To investigate associations between acute care and critical illness hospitalizations and performance on physical functional measures and activities of daily living (ADLs). DESIGN: Prospective cohort study. SETTING: Large health maintenance organization. PARTICIPANTS: Two thousand nine hundred twenty-six participants in Adult Changes in Thought, a study of aging enrolling dementia-free individuals aged 65 and older not living in a nursing home from 1994 to September 30, 2008 (N = 2,926). MEASUREMENTS: The exposure of interest was hospitalization during study participation, subdivided by presence of critical illness. Outcomes included gait speed, grip strength, chair stand speed, and difficulty and dependence in performing ADLs measured at biennial visits. RESULTS: Median time between hospital discharge and the next study visit was 311 days (interquartile range (IQR) 151-501 days) after acute care hospitalization and 359 days (IQR 181-420 days) after critical illness hospitalization. Gait speed was slower after acute care (-0.05 m/s, 95% confidence interval (CI) = 0.01-0.04 m/s slower, P < .001) and critical illness (-0.16 m/s, 95% CI = -0.22 to -0.10, P < .001). Grip was weaker after acute care hospitalization (-0.8 kg, 95% CI = -1.0 to -0.6, P < .001) but not significantly different after critical illness hospitalization. Chair-stand speed was slower after acute care hospitalization (-0.04 stands/s, 95% CVI = -0.05 to -0.04, P < .001) and critical illness hospitalization (-0.09, 95% CI = -0.15 to -0.03, P = .003). The odds of difficulty with (odds ratio (OR) = 1.4, 95% CI = 1.2-1.6, P < .001) or dependence in (OR = 2.0, 95% CI = 1.2-3.2, P = .006) one or more ADLs was higher after acute care hospitalization, as were the odds of difficulty with (OR = 1.9, 95% CI = 1.1-3.6, P = .03) or dependence in (OR = 7.9, 95% CI = 2.5-25.7, P = .001) one or more ADLs after critical illness. CONCLUSION: In older adults, hospitalization, especially for critical illness, was associated with clinically relevant decline in gait and chair stand speed and strongly associated with difficulty with and dependence in ADLs.

An official American Thoracic Society policy statement: managing conscientious objections in intensive care medicine.

RATIONALE: Intensive care unit (ICU) clinicians sometimes have a conscientious objection (CO) to providing or disclosing information about a legal, professionally accepted, and otherwise available medical service. There is little guidance about how to manage COs in ICUs. OBJECTIVES: To provide clinicians, hospital administrators, and policymakers with recommendations for managing COs in the critical care setting. METHODS: This policy statement was developed by a multidisciplinary expert committee using an iterative process with a diverse working group representing adult medicine, pediatrics, nursing, patient advocacy, bioethics, philosophy, and law. MAIN RESULTS: The policy recommendations are based on the dual goals of protecting patients' access to medical services and protecting the moral integrity of clinicians. Conceptually, accommodating COs should be considered a "shield" to protect individual clinicians' moral integrity rather than as a "sword" to impose clinicians' judgments on patients. The committee recommends that: (1) COs in ICUs be managed through institutional mechanisms, (2) institutions accommodate COs, provided doing so will not impede a patient's or surrogate's timely access to medical services or information or create excessive hardships for other clinicians or the institution, (3) a clinician's CO to providing potentially inappropriate or futile medical services should not be considered sufficient justification to forgo the treatment against the objections of the patient or surrogate, and (4) institutions promote open moral dialogue and foster a culture that respects diverse values in the critical care setting. CONCLUSIONS: This American Thoracic Society statement provides guidance for clinicians, hospital administrators, and policymakers to address clinicians' COs in the critical care setting.

The influence of hospitalization or intensive care unit admission on declines in health-related quality of life.

RATIONALE: Survivors of critical illness report impaired health-related quality of life (HRQoL) after hospital discharge, but the degree to which these impairments are attributable to critical illness is unknown. OBJECTIVES: We sought to examine changes in HRQoL associated with an intensive care unit (ICU) stay and the differential association of type of hospitalization (critical illness versus noncritical illness) on changes in HRQoL. METHODS: We identified 11,243 participants in the Ambulatory Care Quality Improvement Project (a multicenter randomized trial of Veterans conducted March 1997 to August 2000) completing at least two Medical Outcomes Study Short-Form 36 questionnaires over 2 years, and categorized patients by hospitalization status during the interval between measures. We used multiple linear regression with generalized estimating equations for analysis. MEASUREMENTS AND MAIN RESULTS: Our primary outcome was change in the Physical Component Summary score. Participants requiring hospitalization or ICU admission had significantly worse baseline HRQoL than those not hospitalized (P < 0.001). Compared with patients who were not hospitalized, follow-up Physical Component Summary scores were lower among non-ICU hospitalized patients and ICU patients (adjusted ß-coefficient = -1.40 [95% confidence interval, -1.81, -0.99] and adjusted ß-coefficient = -1.53 [95% confidence interval, -2.11, -0.95], respectively), with no difference between the two groups (P value = 0.80). Similar results were seen for the Mental Component Summary score and each of the Medical Outcomes Study Short-Form 36 subdomains. CONCLUSIONS: Prehospital HRQoL is a significant determinant of HRQoL after hospitalization or ICU admission. Hospitalization is associated with increased risk of impairment in HRQoL after discharge, yet the overall magnitude of this reduction is small and similar between non-ICU hospitalized and critically ill patients.