Ventilator Use and Advanced Dementia

iStock_000053775120_MediumAs a hospital increases its number of ICU beds, more and more people are put on mechanical ventilation, even those with advanced dementia. That's the sobering conclusion of a study published in JAMA Internal Medicine that Rick and I discuss on PodMed this week, and one that also demonstrates no improvement in outcomes for these folks.

The study examined data from just over 380,000 Medicare beneficiaries with advanced dementia from 2000 to 2013. This group experienced over 630,000 hospitalizations.  During this time period use of mechanical ventilation among those patients with advanced dementia, about 75% of whom were bedridden prior to admission to the hospital, increased from 39 per 1000 hospitalizations to 78 per 1000 hospitalizations.  The likelihood that such a patient would be placed on mechanical ventilation increased as a hospital acquired more ICU beds, yet no improvement in outcomes was seen.

Yikes. Rick and I both agree that use of mechanical ventilation in many of these folks is questionable at best.  There are several likely scenarios where such a choice might be made but they point to a common problem: lack of accurate, timely communication between the patient, their family and loved ones, and the medical team.  This problem can be successfully overcome with use of a POLST, or in the state of Maryland a MOSLT: physician order for life sustaining treatment, or Maryland order for life sustaining treatment, respectively. This is an actual medical document that is created between the physician and the patient, or if the patient is unable to communicate on their own their healthcare proxy. It specifically delineates care preferences and along with advance directives, improves the odds that such ultimately futile care will not be rendered.

Other topics this week include Trends in Dietary Supplement Use Among US Adults From 1999-2012, an app for detecting atrial fibrillation: http://heart.bmj.com/content/early/2016/08/26/heartjnl-2016-309993.short?g=w_heart_ahead_tab, and calcium intake and coronary artery calcification: http://jaha.ahajournals.org/content/5/10/e003815.full.  Until next week, y'all live well.

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