Adapting to a New Normal After Severe Acute Brain Injury: An Observational Cohort Using a Sequential Explanatory Design.
Adapting to a New Normal After Severe Acute Brain Injury: An Observational Cohort Using a Sequential Explanatory Design.
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DOI：
10.1097/ccm.0000000000004947
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发表时间：
2021-08-01
影响因子：
8.8
通讯作者：
Creutzfeldt CJ
中科院分区：
文献类型：
--
作者：
Rutz Voumard R;Kiker WA;Dugger KM;Engelberg RA;Borasio GD;Curtis JR;Jox RJ;Creutzfeldt CJ
严重急性脑损伤（SABI）后的治疗决策需要考虑患者的护理目标和长期结果。以家庭成员为调查对象，我们的目的是评估ICU患者的护理目标，并探讨适应对未达到最初认为可接受的恢复水平的幸存者的影响。前瞻性、观察性、混合方法队列研究。美国太平洋西北部综合中风和一级创伤中心。SABI患者的家属在ICU中超过2天，并且格拉斯哥昏迷量表评分<12。在入组时，我们询问患者可以接受的身体和认知恢复水平。在6个月时，我们通过家庭调查和图表审查评估恢复水平。结果低于被认为是可以接受的患者家属被邀请进行半结构化访谈，内容分析检查。对于184名患者，大多数家庭成员将患者最低可接受的认知恢复设定为“能够思考和沟通”或更好（82%），身体恢复为独立或更好（66%）。在170例已知6个月结局的患者中，40%在医院死亡。在102名幸存者中，33%能够思考和交流，13%能够独立，10%在出院后死亡。在幸存者中，其家庭成员将最低可接受的认知功能设定为“能够思考和交流”，64%的幸存者低于该水平;对于那些在独立时具有最低可接受的身体功能的人，80%的幸存者低于该水平。定性分析揭示了2个关键主题：家庭努力适应新的，但不确定的，正常的，并要求支持和指导与正在进行的治疗决定。SABI后六个月，大多数患者存活到他们的家人最初认为无法接受的状态。幸存者及其家人需要更多的支持和指导，以适应新的常态，并与持续的不确定性作斗争。
Treatment decisions following severe acute brain injury (SABI) need to consider patients’ goals-of-care and long-term outcomes. Using family members as respondents, we aimed to assess patients’ goals-of-care in the ICU and explore the impact of adaptation on survivors who did not reach the level of recovery initially considered acceptable. Prospective, observational, mixed-methods cohort study. Comprehensive stroke and level-one trauma-center in Pacific Northwest US. Family members of patients with SABI in an ICU for > 2 days and Glasgow Coma Scale score <12. At enrollment, we asked what level of physical and cognitive recovery the patient would find acceptable. At 6 months, we assessed level of recovery through family surveys and chart review. Families of patients whose outcome was below that considered acceptable were invited for semi-structured interviews, examined with content analysis. For 184 patients, most family members set patients’ minimally acceptable cognitive recovery at “able to think and communicate” or better (82%) and physical recovery at independence or better (66%). Among 170 patients with known 6-month outcome, 40% had died in-hospital. Of 102 survivors, 33% were able to think and communicate, 13% were independent, 10% died after discharge. Among survivors whose family member had set minimally acceptable cognitive function at “able to think and communicate”, 64% survived below that level; for those with minimally acceptable physical function at independence, 80% survived below that. Qualitative analysis revealed 2 key themes: Families struggled to adapt to a new, yet uncertain, normal and asked for support and guidance with ongoing treatment decisions. Six months after SABI, most patients survived to a state their families initially thought would not be acceptable. Survivors and their families need more support and guidance as they adapt to a new normal and struggle with persistent uncertainty.