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1.  A Randomized Clinical Trial of an Intervention to Relieve Thirst and Dry Mouth in Intensive Care Unit Patients 
Intensive care medicine  2014;40(9):1295-1302.
Purpose
To test an intervention bundle for thirst intensity, thirst distress, and dry mouth, which are among the most pervasive, intense, distressful, unrecognized, and under-treated symptoms in ICU patients, but for which data-based interventions are lacking.
Methods
Single-blinded, randomized clinical trial in three ICUs in a tertiary medical center in urban California. 252 cognitively intact patients reporting thirst intensity (TI) and/or thirst distress (TD) scores ≥ 3 on 0–10 numeric rating scales (NRS) were randomized to Intervention or Usual Care groups. A Research Team Nurse (RTN#1) obtained patients’ pre-procedure TI and TD scores and reports of dry mouth. She then administered a thirst bundle to the Intervention group: oral swab wipes, sterile ice cold water sprays, and a lip moisturizer, or observed patients in the Usual Care group. RTN#2, blinded to group assignment, obtained post-procedure TI and TD scores. Up to 6 sessions per patient were conducted across two days.
Results
Multilevel linear regression determined that the average decreases in TI and TD scores from pre-procedure to post-procedure were significantly greater in the Intervention group (2.3 and 1.8 NRS points, respectively) versus the Usual Care group (0.6 and 0.4 points, respectively) (p < 0.05). The Usual Care group was 1.9 times more likely than the Intervention group to report dry mouth for each additional session on Day 1.
Conclusion
This simple, inexpensive thirst bundle significantly decreased ICU patients’ thirst and dry mouth and can be considered a practice intervention for patients experiencing thirst.
Clinical trial registered with www.clinicalTrials.gov (NCT01015755).
doi:10.1007/s00134-014-3339-z
PMCID: PMC4149585  PMID: 24894026
thirst relief; dry mouth; ICU; symptom; non-pharmacological; palliation
2.  Risk Factors for Long-Term Brain Dysfunction after Chronic Critical Illness 
Rationale: Factors associated with long-term brain dysfunction (LTBD) in survivors of chronic critical illness (CCI) have not been explored but may be important for clinical practice and planning by patients, families, and providers.
Objectives: To identify risk factors for LTBD after treatment for CCI and to explore the association between acute delirium and coma during hospital treatment and LTBD.
Methods: A prospective cohort study of adults admitted to a respiratory care unit for treatment of CCI.
Measurements and Main Results: Using the Confusion Assessment Method for ICU and the Richmond Agitation and Sedation Scale, we evaluated patients for delirium and coma during their hospital treatment for CCI. We collected data on other potential risk factors for LTBD by prospectively reviewing the patients’ medical records and interviewing surrogates. We contacted survivors by telephone at 6 months after discharge to assess brain function using the telephone Confusion Assessment Method. Among 385 patients treated for CCI, 213 (56.1%) were dead at 6 months, and 108 of 167 (64.7%) of survivors were impaired. We used multinomial logistic regression in which the outcomes were (1) death, (2) brain dysfunction, and (3) survival without LTBD. Older patients, patients with higher Acute Physiology Score, and those with multiple complications during treatment for CCI were more likely to have LTBD. Acute brain dysfunction during hospital treatment was also associated with an increased risk of LTBD (odds ratio, 2.14; 95% confidence interval, 1.02–4.52).
Conclusions: LTBD after treatment for CCI is associated with brain dysfunction during such treatment as well as with older age and higher severity of illness of the patients.
doi:10.1513/AnnalsATS.201211-099OC
PMCID: PMC3960906  PMID: 23952849
critical illness; prolonged mechanical ventilation; cognition disorders; delirium
3.  Training Nurses for Interdisciplinary Communication with Families in the Intensive Care Unit: An Intervention 
Journal of Palliative Medicine  2011;14(12):1325-1332.
Abstract
Background
Critical care nurse communication training has largely been limited to didactic materials, interactive training for nurse supervisors, or brief participatory learning programs within the context of comprehensive end-of-life care educational seminars. Preliminary evidence suggests that an interactive approach can also be effective in communication skills training for intensive care unit (ICU) nurses.
Methods
We implemented a 1-day educational intervention in five acute care hospitals within Veterans Integrated Service Network (VISN) 3 (New York-New Jersey region) of the Department of Veterans Affairs and focused solely on communication skills and targeted specifically to nurses providing bedside care for critically ill patients. A “learner centered” approach to skills training that has several integral components was employed. Among these are: a cognitive, evidence-based foundation upon which to build new skills; a method such as role-play that allows participants to practice newly learned skills; and an affective component, during which trainees can freely discuss their impressions of the exercise or explore difficulties that may have been encountered. Before and after the program we conducted a detailed assessment of participants' self-rated communication skills and of the techniques and materials we used.
Results and conclusions
Post-program responses documented significant improvement in self-evaluated skills for each of the core tasks we assessed. Evidence suggests that communication with patients and families in the ICU can be most effectively approached in an interdisciplinary way. For nurses to fully realize their potential for optimal communication as members of the multidisciplinary team, they must be equipped with the necessary skills. We believe this new program helps to expand the range of approaches for training nurses in essential communication skills.
doi:10.1089/jpm.2011.0225
PMCID: PMC3263486  PMID: 22132740
4.  Integrating Palliative Care in the ICU 
Palliative care is increasingly recognized as an integral component of comprehensive intensive care for all critically ill patients, regardless of prognosis, and for their families. Here we discuss the key role that nurses can and must continue to play in making this evidence-based paradigm a clinical reality across a broad range of ICUs. We review the contributions of nurses to implementation of ICU safety initiatives as a model that can be applied to ICU palliative care integration. We focus on the importance of nursing involvement in design and application of work processes that facilitate this integration in a systematic way, including processes that ensure the participation of nurses in discussions and decision making with families about care goals. We suggest ways that nurses can help to operationalize an integrated approach to palliative care in the ICU and to define their own essential role in a successful, sustainable ICU palliative care improvement effort. Finally, we identify resources including The IPAL-ICU Project™, a new initiative by the Center to Advance Palliative Care that can assist nurses and other healthcare professionals to move such efforts forward in diverse critical care settings.
doi:10.1097/NJH.0b013e318203d9ff
PMCID: PMC3162372  PMID: 21874122
intensive care; nurse's role; palliative care
5.  Communication About Chronic Critical Illness 
Archives of internal medicine  2007;167(22):2509-2515.
Background
Despite poor outcomes, life-sustaining treatments including mechanical ventilation are continued for a large and growing population of patients with chronic critical illness. This may be owing in part to a lack of understanding resulting from inadequate communication between clinicians and patients and families. Our objective was to investigate the informational needs of patients with chronic critical illness and their families and the extent to which these needs are met.
Methods
In this prospective observational study conducted at 5 adult intensive care units in a large, university-affiliated hospital in New York, New York, 100 patients with chronic critical illness (within 3–7 days of elective tracheotomy for prolonged mechanical ventilation) or surrogates for incapacitated patients were surveyed using an 18-item questionnaire addressing communication about chronic critical illness. Main outcome measures included ratings of importance and reports of whether information was received about questionnaire items.
Results
Among 125 consecutive, eligible patients, 100 (80%) were enrolled; questionnaire respondents included 2 patients and 98 surrogates. For all items, more than 78% of respondents rated the information as important for decision making (>98% for 16 of 18 items). Respondents reported receiving no information for a mean (SD) of 9.0 (3.3) of 18 items, with 95% of respondents reporting not receiving information for approximately one-quarter of the items. Of the subjects rating the item as important, 77 of 96 (80%) and 69 of 74 (93%) reported receiving no information about expected functional status at hospital discharge and prognosis for 1-year survival, respectively.
Conclusions
Many patients and their families may lack important information for decision making about continuation of treatment in the chronic phase of critical illness. Strategies for effective communication in this clinical context should be investigated and implemented.
doi:10.1001/archinte.167.22.2509
PMCID: PMC3157319  PMID: 18071175
6.  Chronic Critical Illness 
Although advances in intensive care have enabled more patients to survive an acute critical illness, they also have created a large and growing population of chronically critically ill patients with prolonged dependence on mechanical ventilation and other intensive care therapies. Chronic critical illness is a devastating condition: mortality exceeds that for most malignancies, and functional dependence persists for most survivors. Costs of treating the chronically critically ill in the United States already exceed $20 billion and are increasing. In this article, we describe the constellation of clinical features that characterize chronic critical illness. We discuss the outcomes of this condition including ventilator liberation, mortality, and physical and cognitive function, noting that comparisons among cohorts are complicated by variation in defining criteria and care settings. We also address burdens for families of the chronically critically ill and the difficulties they face in decision-making about continuation of intensive therapies. Epidemiology and resource utilization issues are reviewed to highlight the impact of chronic critical illness on our health care system. Finally, we summarize the best available evidence for managing chronic critical illness, including ventilator weaning, nutritional support, rehabilitation, and palliative care, and emphasize the importance of efforts to prevent the transition from acute to chronic critical illness. As steps forward for the field, we suggest a specific definition of chronic critical illness, advocate for the creation of a research network encompassing a broad range of venues for care, and highlight areas for future study of the comparative effectiveness of different treatment venues and approaches.
doi:10.1164/rccm.201002-0210CI
PMCID: PMC2937238  PMID: 20448093
respirator, artificial; critical illness; chronic disease; respiratory care units
7.  Development and Validation of a Printed Information Brochure for Families of Chronically Critically Ill Patients 
Critical Care Medicine  2012;40(1):73-78.
Objective
Families and other surrogate decision-makers for chronically critically ill patients often lack information about patient prognosis or options for care. This study describes an approach to develop and validate a printed information brochure about chronic critical illness aimed at improving comprehension of the disease process and outcomes for patients’ families and other surrogate decision-makers.
Design
Investigators reviewed existing literature to identify key domains of informational needs. Content of these domains was incorporated in a draft brochure that included graphics and a glossary of terms. Clinical sensibility, balance, and emotional sensitivity of the draft brochure were tested in a series of evaluations by cohorts of experienced clinicians (n=49) and clinical content experts (n=8), with revisions after each review. Cognitive testing of the brochure was performed through interviews of 10 representative family members of chronically critically ill patients with quantitative and qualitative analysis of responses.
Measurements and Main Results
Clinical sensibility and balance were rated in the two most favorable categories on a 5-point scale by more than two thirds of clinicians and content experts. After review, family members described the brochure as clear and readable and recommended that the brochure be delivered to family members by clinicians, followed by a discussion of its contents. They indicated that the glossary was useful and recommended supplementation by additional lists of local resources. After reading the brochure, their prognostic estimates became more consistent with actual outcomes.
Conclusions
We have developed and validated a printed information brochure that may improve family comprehension of chronic critical illness and its outcomes. The structured process that is described can serve as a template for the development of other information aids for use with seriously ill populations.
doi:10.1097/CCM.0b013e31822d7901
PMCID: PMC3339568  PMID: 21926610
critically ill; mechanical ventilation; communication; information sharing; tracheostomies; validation studies
8.  The intensive care unit family meeting: Making it happen☆ 
Journal of Critical Care  2009;24(4):629.e1-629.12.
The intensive care unit (ICU) family meeting is an important forum for discussion about the patient’s condition, prognosis, and care preferences; for listening to the family’s concerns; and for decision making about appropriate goals of treatment. For patients, families, clinicians, and health care systems, the benefits of early and effective communication through these meetings have been clearly established. Yet, evidence suggests that family meetings still fail to occur in a timely way for most patients in ICUs. In this article, we address the “quality gap” between knowledge and practice with respect to regular implementation of family meetings. We first examine factors that may serve as barriers to family meetings. We then share practical strategies that may be helpful in overcoming some of these barriers. Finally, we describe performance improvement initiatives by ICUs in different parts of the country that have achieved striking successes in making family meetings happen.
doi:10.1016/j.jcrc.2008.10.003
PMCID: PMC3365583  PMID: 19327312
Family meetings; Intensive care; Communication; Quality improvement
9.  Meeting standards of high-quality intensive care unit palliative care: Clinical performance and predictors 
Critical Care Medicine  2012;40(4):1105-1112.
Objectives
High-quality care for intensive care unit patients and families includes palliative care. To promote performance improvement, the Agency for Healthcare Research and Quality’s National Quality Measures Clearinghouse identified nine evidence-based processes of intensive care unit palliative care (Care and Communication Bundle) that are measured through review of medical record documentation. We conducted this study to examine how frequently the Care and Communication Bundle processes were performed in diverse intensive care units and to understand patient factors that are associated with such performance.
Design
Prospective, multisite, observational study of performance of key intensive care unit palliative care processes.
Settings
A surgical intensive care unit and a medical intensive care unit in two different large academic health centers and a medical-surgical intensive care unit in a medium-sized community hospital.
Patients
Consecutive adult patients with length of intensive care unit stay ≥5 days.
Interventions
None.
Measurements and Main Results
Between November 2007 and December 2009, we measured performance by specified day after intensive care unit admission on nine care process measures: identify medical decision-maker, advance directive and resuscitation preference, distribute family information leaflet, assess and manage pain, offer social work and spiritual support, and conduct interdisciplinary family meeting. Multivariable regression analysis was used to determine predictors of performance of five care processes. We enrolled 518 (94.9%) patients and 336 (83.6%) family members. Performances on pain assessment and management measures were high. In contrast, interdisciplinary family meetings were documented for <20% of patients by intensive care unit day 5. Performance on other measures ranged from 8% to 43%, with substantial variation across and within sites. Chronic comorbidity burden and site were the most consistent predictors of care process performance.
Conclusions
Across three intensive care units in this study, performance of key palliative care processes (other than pain assessment and management) was inconsistent and infrequent. Available resources and strategies should be utilized for performance improvement in this area of high importance to patients, families, and providers.
doi:10.1097/CCM.0b013e3182374a50
PMCID: PMC3307856  PMID: 22202706
10.  Integrating palliative care in the surgical and trauma intensive care unit: A report from the Improving Palliative Care in the Intensive Care Unit (IPAL-ICU) Project Advisory Board and the Center to Advance Palliative Care 
Critical Care Medicine  2012;40(4):1199-1206.
Objective
Although successful models for palliative care delivery and quality improvement in the intensive care unit have been described, their applicability in surgical intensive care unit settings has not been fully addressed. We undertook to define specific challenges, strategies, and solutions for integration of palliative care in the surgical intensive care unit.
Data Sources
We searched the MEDLINE database from inception to May 2011 for all English language articles using the term “surgical palliative care” or the terms “surgical critical care,” “surgical ICU,” “surgeon,” “trauma” or “transplant,” and “palliative care” or “end-of- life care” and hand-searched our personal files for additional articles. Based on review of these articles and the experiences of our interdisciplinary expert Advisory Board, we prepared this report.
Data Extraction and Synthesis
We critically reviewed the existing literature on delivery of palliative care in the surgical intensive care unit setting focusing on challenges, strategies, models, and interventions to promote effective integration of palliative care for patients receiving surgical critical care and their families.
Conclusions
Characteristics of patients with surgical disease and practices, attitudes, and interactions of different disciplines on the surgical critical care team present distinctive issues for intensive care unit palliative care integration and improvement. Physicians, nurses, and other team members in surgery, critical care and palliative care (if available) should be engaged collaboratively to identify challenges and develop strategies. “Consultative,” “integrative,” and combined models can be used to improve intensive care unit palliative care, although optimal use of trigger criteria for palliative care consultation has not yet been demonstrated. Important components of an improvement effort include attention to efficient work systems and practical tools and to attitudinal factors and “culture” in the unit and institution. Approaches that emphasize delivery of palliative care together with surgical critical care hold promise to better integrate palliative care into the surgical intensive care unit.
doi:10.1097/CCM.0b013e31823bc8e7
PMCID: PMC3307874  PMID: 22080644
end-of-life care; ICU palliative care; surgeon attitude; surgical intensive care; surgical outcome; surgical palliative care
11.  Integrating palliative care with intensive care for critically ill patients with lung cancer 
With newer information indicating more favorable outcomes of intensive care therapy for lung cancer patients, intensivists increasingly are willing to initiate an aggressive trial of this therapy. Concerns remain, however, that the experience of the intensive care unit for patients with lung cancer and their families often may be distressing. Regardless of prognosis, all patients with critical illness should receive high-quality palliative care, including symptom control, communication about appropriate care goals, and support for both patient and family throughout the illness trajectory. In this article, we suggest strategies for integrating palliative care with intensive care for critically ill lung cancer patients. We address assessment and management of symptoms, knowledge and skill needed for effective communication, and interdisciplinary collaboration for patient and family support. We review the role of expert consultants in providing palliative care in the intensive care unit, while highlighting the responsibility of all critical care clinicians to address basic palliative care needs of patients and their families.
doi:10.1186/2110-5820-2-3
PMCID: PMC3306209  PMID: 22339793
12.  Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: A report from the IPAL-ICU Project (Improving Palliative Care in the ICU)* 
Critical Care Medicine  2010;38(9):1765-1772.
Objective
To describe models used in successful clinical initiatives to improve the quality of palliative care in critical care settings.
Data Sources
We searched the MEDLINE database from inception to April 2010 for all English language articles using the terms “intensive care,” “critical care,” or “ICU” and “palliative care”; we also hand-searched reference lists and author files. Based on review and synthesis of these data and the experiences of our interdisciplinary expert Advisory Board, we prepared this consensus report.
Data Extraction and Synthesis
We critically reviewed the existing data with a focus on models that have been used to structure clinical initiatives to enhance palliative care for critically ill patients in intensive care units and their families.
Conclusions
There are two main models for intensive care unit–palliative care integration: 1) the “consultative model,” which focuses on increasing the involvement and effectiveness of palliative care consultants in the care of intensive care unit patients and their families, particularly those patients identified as at highest risk for poor outcomes; and 2) the “integrative model,” which seeks to embed palliative care principles and interventions into daily practice by the intensive care unit team for all patients and families facing critical illness. These models are not mutually exclusive but rather represent the ends of a spectrum of approaches. Choosing an overall approach from among these models should be one of the earliest steps in planning an intensive care unit–palliative care initiative. This process entails a careful and realistic assessment of available resources, attitudes of key stakeholders, structural aspects of intensive care unit care, and patterns of local practice in the intensive care unit and hospital. A well-structured intensive care unit–palliative care initiative can provide important benefits for patients, families, and providers.
doi:10.1097/CCM.0b013e3181e8ad23
PMCID: PMC3267548  PMID: 20562699
intensive care; critical care; palliative care
13.  Patients Rate Physician Communication About Lung Cancer 
Cancer  2011;117(22):5212-5220.
BACKGROUND
High-quality lung cancer care includes physician-patient communication about the disease and treatment, patient needs/preferences, and care goals. In this study, the authors evaluated communication with patients at all stages across multiple topics.
METHODS
A standardized questionnaire asked patients with lung cancer to rate (on 5-point, verbal descriptor scale) the extent of communication with physicians on symptoms, spiritual concerns, practical needs, proxy appointment, living will preparation, prognosis, care goals, potential complications of therapy, life support preferences, and hospice. Communication was defined as inadequate if the patient reported discussing ≥5 of 11 questionnaire topics “not at all” or “a little bit.” Multivariate logistic regression was used to evaluate the factors associated with inadequate communication.
RESULTS
In total, 276 of 348 (79%) eligible patients were enrolled (mean age [±standard deviation], 65 ± 10 years; 55% white, 21% black, and 19% Hispanic; all disease stages). For most topics, the majority of respondents reported that physicians communicated “not at all” or “a little bit.” Low ratings were frequent for discussion of emotional symptoms (56%; 95% confidence interval [CI], 49%–62%), practical needs (71%; 95% CI, 65%–76%), spiritual concerns (80%; 95% CI, 75%–85%), proxy appointment (63%; 95% CI, 57%–69%), living will preparation (90%; 95% CI, 85%–93%), life support preferences (80%; 95% CI, 75%–84%), and hospice (88%; 95% CI, 86%–94%). Communication was inadequate for patients of different ages, stages, and races, although Hispanics were less likely than non-Hispanic whites and blacks to report inadequate communication (odds ratio, 0.31; 95% CI, 0.15–0.65).
CONCLUSIONS
Across all stages, patients with lung cancer reported low rates of physician-patient communication on key topics, which may increase patient distress, impair decision-making, and compromise clinical outcomes and use patterns.
doi:10.1002/cncr.26152
PMCID: PMC3267549  PMID: 21495028
lung neoplasms; communication; physician-patient relations; quality of health care; symptoms; palliative care
14.  In their own words: Patients and families define high-quality palliative care in the intensive care unit* 
Critical Care Medicine  2010;38(3):808-818.
Objective
Although the majority of hospital deaths occur in the intensive care unit and virtually all critically ill patients and their families have palliative needs, we know little about how patients and families, the most important “stakeholders,” define high-quality intensive care unit palliative care. We conducted this study to obtain their views on important domains of this care.
Design
Qualitative study using focus groups facilitated by a single physician.
Setting
A 20-bed general intensive care unit in a 382-bed community hospital in Oklahoma; 24-bed medical–surgical intensive care unit in a 377-bed tertiary, university hospital in urban California; and eight-bed medical intensive care unit in a 311-bed Veterans’ Affairs hospital in a northeastern city.
Patients
Randomly-selected patients with intensive care unit length of stay ≥5 days in 2007 to 2008 who survived the intensive care unit, families of survivors, and families of patients who died in the intensive care unit.
Interventions
None.
Measurements and Main Results
Focus group facilitator used open-ended questions and scripted probes from a written guide. Three investigators independently coded meeting transcripts, achieving consensus on themes. From 48 subjects (15 patients, 33 family members) in nine focus groups across three sites, a shared definition of high-quality intensive care unit palliative care emerged: timely, clear, and compassionate communication by clinicians; clinical decision-making focused on patients’ preferences, goals, and values; patient care maintaining comfort, dignity, and personhood; and family care with open access and proximity to patients, interdisciplinary support in the intensive care unit, and bereavement care for families of patients who died. Participants also endorsed specific processes to operationalize the care they considered important.
Conclusions
Efforts to improve intensive care unit palliative care quality should focus on domains and processes that are most valued by critically ill patients and their families, among whom we found broad agreement in a diverse sample. Measures of quality and effective interventions exist to improve care in domains that are important to intensive care unit patients and families.
PMCID: PMC3267550  PMID: 20198726
intensive care; critical care; palliative care; quality assessment; health care; quality indicators; qualitative research
15.  Surgical intensive care unit clinician estimates of the adequacy of communication regarding patient prognosis 
Critical Care  2010;14(6):R218.
Introduction
Intensive care unit (ICU) patients and family members repeatedly note accurate and timely communication from health care providers to be crucial to high-quality ICU care. Practice guidelines recommend improving communication. However, few data, particularly in surgical ICUs, exist on health care provider opinions regarding whether communication is effective.
Methods
To evaluate ICU clinician perceptions regarding adequacy of communication regarding prognosis, we developed a survey and administered it to a cross section of surgical ICU nurses, surgical ICU physicians, nurse practitioners (NPs), and surgeons.
Results
Surgeons had a high satisfaction with communication regarding prognosis for themselves (90%), ICU nurses (85%), and ICU physicians and NPs (85%). ICU nurses noted high satisfaction with personal (82%) and ICU physician and NP (71%) communication, but low (2%) satisfaction with that provided by surgeons. ICU physicians and NPs noted high satisfaction with personal (74%) and ICU nurse (88%) communication, but lower (23%) satisfaction with that provided by surgeons. ICU nurses were the most likely (75%) to report speaking to patients and patient families regarding prognosis, followed by surgeons (40%), and then ICU physicians and NPs (33%). Surgeons noted many opportunities to speak to ICU nurses and ICU physicians and NPs about patient prognosis and noted that comments were often valued. ICU physicians and NPs and ICU nurses noted many opportunities to speak to each other but fewer opportunities to communicate with surgeons. ICU physicians and NPs thought that their comments were valued by ICU nurses but less valued by surgeons. ICU nurses thought that their comments were less valued by ICU physicians and NPs and surgeons.
Conclusions
ICU nurses, surgeons, and ICU intensivists and NPs varied widely in their satisfaction with communication relating to prognosis. Clinician groups also varied in whether they thought that they had opportunities to communicate prognosis and whether their concerns were valued by other provider groups. These results hint at the nuanced and complicated relationships present in surgical ICUs. Further validation studies and further evaluations of patient and family member perspectives are needed.
doi:10.1186/cc9346
PMCID: PMC3220002  PMID: 21114837
16.  Deciding in the Dark: Advance Directives and Continuation of Treatment in Chronic Critical Illness 
Critical care medicine  2009;37(3):919-925.
doi:10.1097/CCM.0b013e31819613ce
PMCID: PMC2947202  PMID: 19237897
prolonged mechanical ventilation; prolonged critical illness; do not resuscitate; decision making; withholding treatment; withdrawing treatment

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