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Deep Dive in Delirium
7 Plays6 years ago
In this episode of Critical Matters, we take a deep dive in delirium with Wesley Ely, MD. Dr. Ely is a professor of medicine at Vanderbilt University School of Medicine and the co-director of the Center for Critical Illness, Brain dysfunction, and Survivorship (CIBS Center), which has enrolled thousands of patients into clinical trials answering vital questions about ICU acquired brain disease and other components of ICU survivorship. His team developed the CAM-ICU, and he has published extensively on the topic.
Additional Resources:
Link to the CIBS Center website, which contains a wealth of resources for intensivists on the topic of delirium: https://bit.ly/2HfdQ0n
The MIND-USA trial evaluated haloperidol and ziprasidone in ICU patients with delirium: https://bit.ly/2OQ5gIE
Caring for Critically Ill Patients with the ABCDEF Bundle: Results of the ICU Liberation Collaborative in Over 15,000 Adults: https://bit.ly/2VWLUlm
Books Mentioned in This Episode:
The Boys in the Boat: Nine Americans and Their Epic Quest for Gold at the 1936 Berlin Olympics by Daniel James Brown: https://amzn.to/2RMmcRe
Solzhenitsyn: A soul in exile by Joseph Pearce: https://amzn.to/2RPhpi0
Man’s Search for Meaning by Viktor E. Frankl: https://amzn.to/2VZ2ZLb
Being Mortal: Medicine and What Matters in the End by Atul Gawande: https://amzn.to/2HfeQ4D
Music Mentioned in This Episode:
The Chronic by Dr. Dre: https://amzn.to/2HffeA7
Recommended
Transcript
Introduction to Critical Matters Podcast
00:00:09
Speaker
Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:17
Speaker
And now, your host, Dr. Sergio Zanotti.
00:00:22
Speaker
In previous episodes of Critical Matters, we have discussed the A to F bundle and the most recent guidelines for the prevention and management of pain, agitation, delirium, immobility and sleep disruption in patients in the ICU, also known as the PATIS guideline.
00:00:36
Speaker
Today, we will
Focus on Delirium
00:00:37
Speaker
take a deeper dive into delirium.
00:00:39
Speaker
Marcus Aurelius, the Roman emperor and stoic philosopher, said that the quality of our thoughts determines the quality of our life.
00:00:45
Speaker
If our mind plays such a critical role in our well-being during health, it is reasonable to believe that our minds are also critical in our recovery from critical illness.
00:00:55
Speaker
Understanding the effects of critical illness on our minds has been a focal point of our guest academic career.
Guest Introduction: Dr. E. Wesley Ely
00:01:00
Speaker
Dr. E. Wesley Illy is a professor of medicine at Vanderbilt University School of Medicine with subspecialty training in pulmonary and critical care medicine.
00:01:09
Speaker
Dr. Ily's research has focused on improving the care and outcomes of critically ill patients with ICU-acquired brain disease, manifested acutely as delirium and chronically as acquired dementia.
00:01:20
Speaker
He is the co-director of the Center for Critical Illness, Brain Dysfunction, and Survivorship, CIBS Center, which has enrolled thousands of patients into clinical trials answering vital questions about ICU-acquired brain disease and other components of ICU survivorship.
00:01:35
Speaker
His team developed the CAM ICU, the primary tool used to measure delirium in ICU-based trials and clinically at the bedside.
00:01:42
Speaker
The CAM ICU has been translated into over 30 languages and is utilized in ICUs all over the world.
00:01:48
Speaker
Dr. Ely has published extensively with over 400 peer-reviewed publications and over 50 published book chapters and editorials.
00:01:55
Speaker
It is a real honor to welcome him to the podcast to discuss a topic he is passionate about and has been instrumental in advancing our understanding for our field.
00:02:04
Speaker
Wes, welcome to Critical Matters.
00:02:07
Speaker
Thank you, Sergio.
00:02:08
Speaker
It's my pleasure to be here.
Understanding Delirium in ICU
00:02:09
Speaker
So I think a good place to start would be with defining what delirium really is.
00:02:13
Speaker
And I think that people use sometimes definitions very loosely.
00:02:18
Speaker
But from your perspective, if you were to find somebody who's outside of medicine, what is delirium?
00:02:24
Speaker
Right.
00:02:25
Speaker
That is a good place to start.
00:02:26
Speaker
And by the way, I love that you gave the intro, including Marcus Aurelius.
00:02:30
Speaker
who is a great thinker and somebody that we can all emulate and try and be like to some degree.
00:02:38
Speaker
If Marcus Aurelius was sick and in the hospital back in the day and somebody went up to him and tried to figure out if he was delirious, what the most important thing for them to do would be to see how long he can pay attention.
00:02:54
Speaker
So delirium is really an inability to pay attention or in attention.
00:03:01
Speaker
Aurelius would not have to be hallucinating or delusional.
00:03:04
Speaker
He could just not have the ability to pay attention to a 10 to 15 second command.
00:03:08
Speaker
And that would be a very sensitive barometer of the brain not working.
00:03:13
Speaker
So when we're in the ICU and we're testing with the CAM ICU, we try to find out if somebody can, for example, squeeze my hand on a certain letter, the letter A, for example, and we can spell out the word Casablanca or save a heart.
00:03:31
Speaker
or a bad, bad day, or even abracadabra.
00:03:35
Speaker
And all of these 10 letter phrases actually have a mixture of consonants and vowels.
00:03:44
Speaker
Whenever the patient squeezes on the A, they're following the command.
00:03:46
Speaker
When they don't squeeze on the A, they're following the command.
00:03:49
Speaker
And if they do either of the opposite, it's kind of a sin of omission or commission.
00:03:55
Speaker
And if they cannot, if they can get eight out of 10 correct, they're paying attention.
Impact of Delirium on Outcomes
00:04:01
Speaker
If they can't get eight out of 10 correct, they're unable to pay attention and then therefore might be delirious.
00:04:10
Speaker
Let's start with that.
00:04:12
Speaker
And I think to follow up, I think there's two very important points that come up to mind immediately.
00:04:17
Speaker
On one hand, is that this is a very broad syndrome.
00:04:21
Speaker
And I think that a lot of things that people call otherwise would fall in that category.
00:04:26
Speaker
So is this just kind of a very vast umbrella of brain dysfunction?
00:04:30
Speaker
Or is it a distinct entity that might have a different pathophysiology of something like we would call acute metabolic encephalopathy?
00:04:38
Speaker
Yeah.
00:04:40
Speaker
Right.
00:04:40
Speaker
Well, the definition I gave you a second ago isn't the complete definition.
00:04:43
Speaker
It's part of it.
00:04:44
Speaker
A delirious patient is also unable to organize their thinking.
00:04:48
Speaker
They have fluctuations in the level of consciousness, and those wouldn't be attributable to, for example, sleep.
00:04:55
Speaker
Somebody might not be able to pay attention if they were having a stroke, for example, if they were having a bleed inside their head.
00:05:01
Speaker
So you have to make sure that they're not having an organized neuronal catastrophe at a macro level, like a stroke or a bleed or a
00:05:09
Speaker
head trauma.
00:05:10
Speaker
In the absence of those things, a pneumonia patient or a sepsis patient, for example, might have microclots in their body and get a downstream difficulty neurologically, and then it would manifest as delirium, disorganized thinking and attention, et cetera.
00:05:26
Speaker
So encephalopathy is another great word, more of a neurologist's term for delirium.
00:05:33
Speaker
Most patients who are encephalopathic are delirious, and they could be
00:05:36
Speaker
encephalopathic from hepatic dysfunction, from Tylenol overdose, from acid in their blood, from an overdose, etc.
00:05:44
Speaker
And those patients would be CAM positive and also delirious.
00:05:47
Speaker
What we have done is use the literature that we collected, the data to drive our understanding of whether or not this problem, this broad syndrome is important.
00:05:58
Speaker
And what we know, and I'll stop after I say this, is that the days that you spend delirious, inattentive,
00:06:06
Speaker
not organizing your thinking, et cetera, the days you spend like that as a patient contribute or are predictive of, independently predictive of four major outcomes.
00:06:19
Speaker
And those are higher likelihood of dying, longer likelihood of staying in the hospital, more cost of care, and an accelerated form of dementia, acquired dementia, which doesn't necessarily get better in the upcoming weeks and months.
00:06:37
Speaker
And I think that that is obviously a great point in terms that people talk about delirium.
00:06:42
Speaker
We've been talking about it for several years now and recognizing more and more regarding the impact it has on patients.
00:06:48
Speaker
But that's the answer of why we should care, because the days that you spend delirious in the ICU have a tremendous impact on the short term in terms of outcomes, but also on the long term.
00:06:59
Speaker
Can you explain?
00:07:01
Speaker
expand a little bit on the long-term effects of being delirious?
00:07:04
Speaker
Because I think that as ICU providers, we're very focused on getting people out of the ICU, but we haven't done a very good job as a group in understanding what happens to an ICU patient maybe six months later after they've survived their septic shock.
Research on Long-term Effects of Delirium
00:07:20
Speaker
Yes, that's a great question.
00:07:22
Speaker
And, you know, imagine if you were sick in the ICU and you
00:07:27
Speaker
you couldn't think well and you were delirious.
00:07:29
Speaker
So it might be confusing to you, might be scary to you.
00:07:31
Speaker
It's a form of suffering for sure.
00:07:35
Speaker
But in the old days, we would say, you know what, daddy's confused, but he will get better.
00:07:39
Speaker
But now we say, you know, this confusion he has, this delirium is a predictor of this long term problem of not being able to think clearly when you get out of the hospital.
00:07:51
Speaker
And I was just sitting yesterday with a 27 year old woman who got out of the ICU after ARDS
00:07:56
Speaker
and rhabdomyolysis and kidney failure.
00:07:58
Speaker
And she said, you know, my brain just doesn't work the way it used to.
00:08:02
Speaker
And I can't I can't remember people's names.
00:08:05
Speaker
I can't do my job.
00:08:07
Speaker
I used to work in Excel spreadsheets and that sort of thing.
00:08:10
Speaker
And I can't do that anymore very well.
00:08:12
Speaker
What is going on?
00:08:14
Speaker
And I said, you know, maybe maybe you feel like your brain is swimming in molasses or you have cobwebs in your brain.
00:08:21
Speaker
And that's exactly she started nodding her head.
00:08:23
Speaker
Yes.
00:08:23
Speaker
That is a form of neuropsychological dysfunction, which is clinically a manifestation of problems with memory, executive function, and visuospatial function, all these things that we know can go awry after critical illness.
00:08:40
Speaker
And we've now studied, Sergio, thousands of patients and found that delirium duration is a predictor of that problem.
00:08:48
Speaker
We don't want to claim cause and effect yet because we're still studying all that.
00:08:52
Speaker
But actually we're about to start an investigation to couple with the previous New England Journal paper we published here from the Sibs Center at Vanderbilt University, which showed that dementia occurred after the ICU stay.
00:09:05
Speaker
And what we're going to do next is we're going to redo the whole cohort.
00:09:08
Speaker
And it's going to be called BRAIN2, the previous study BRAIN1.
00:09:12
Speaker
This BRAIN-ICU2 study is actually going to collect the brains of our patients once they die
00:09:18
Speaker
whether it be months or years later, and try and determine exactly what kind of dementia is this and what can we do to help prevent and mitigate the deficit.
00:09:26
Speaker
And I think that
00:09:27
Speaker
recognizing the short-term impacts on outcome obviously is extremely important.
00:09:32
Speaker
I think that was what we identified first, and there's still a lot of room for trying to improve that.
00:09:39
Speaker
But also, I think as we understand more and more of what happens downstream in those survivors, it seems, Wes, that we're almost like finding parallel findings to what we have in a traumatic brain injury that we would see in our trauma units.
00:09:52
Speaker
I mean, I've had
00:09:53
Speaker
family members and patients who've had, I mean, even not as severe traumatic brain injuries, but they will describe that for months afterwards, they have, I mean, those cow webs and difficulty getting back to where they were before.
00:10:07
Speaker
And really, it seems like critical illness is just another form of traumatic brain injury almost.
Recognition and Assessment of Delirium
00:10:14
Speaker
It very much is.
00:10:15
Speaker
In fact, we are doing a study, an NIH-sponsored study right now called Insight ICU, which
00:10:22
Speaker
where we're studying delirium and these long term cognitive outcomes in trauma patients.
00:10:27
Speaker
So the overlap between what a neurologically injured patient like a trauma or a stroke patient experiences and what a medical ICU or surgical ICU patient experiences is much greater than we once thought.
00:10:42
Speaker
We used to think these were totally different worlds, but now we know through the advent of our epidemiological studies and even interventional trials that they're what
00:10:52
Speaker
Patients have in common across ICUs is this form of an acquired brain injury, even though you might have come in with a problem in your lung or your gallbladder or something neck down.
00:11:05
Speaker
And I think that it's fascinating just, I mean, to see over the span of my career from residency to where we are right now, how we have really evolved in understanding this and what it seems that we really identified in the late 90s and early 2000s is the tip of the iceberg.
00:11:22
Speaker
And that there really is a lot of consequences that perhaps we didn't appreciate as well before, but are becoming more and more apparent with all the work that your group and other colleagues are doing.
00:11:35
Speaker
Let me ask you.
00:11:36
Speaker
Go ahead.
00:11:36
Speaker
Sorry.
00:11:37
Speaker
No, go ahead.
00:11:38
Speaker
Let me go with your next question.
00:11:39
Speaker
So I think that one of the things that I see commonly in critical care when I talk with providers is we have a lot of syndromes and that we always argue about definitions.
00:11:49
Speaker
But one of the things that I often have heard clinicians say is that, well, I can recognize it if I see it.
00:11:55
Speaker
And I think that when it applies to delirium, that is not necessarily true, right?
00:11:59
Speaker
Because we seem to see it all the time and not recognize it.
00:12:03
Speaker
Can you dive a little bit more into the development of the CAM-ICU, how to really implement it, and how you would actually recommend somebody who's never done anything formally in their ICU to identify patients with delirium, how you would guide them in that direction?
00:12:20
Speaker
Sure.
00:12:21
Speaker
Let's talk about that.
00:12:22
Speaker
So first off, delirium, most of it will be invisible to you as a clinician because the vast majority of delirium is hypoactive delirium.
00:12:31
Speaker
Think of an old lady sitting in the bed with pneumonia who can tell you not a yes or no if you ask her yes or no questions, but she may have no idea what you're asking.
00:12:42
Speaker
And so you have to do something a little bit more objective to figure out if she's actually following your conversation.
00:12:49
Speaker
And there's a lot of times where I'm sitting there looking at somebody, they're nodding, and then I test them with the cam and they're very delirious.
00:12:55
Speaker
And I think, wow, what a dummy I am to not have tested with the cam first because the cam saves you a ton of time.
00:13:04
Speaker
Imagine having like some five-minute conversation with somebody and they're totally delirious.
00:13:08
Speaker
They're never gonna remember it anyway.
00:13:09
Speaker
The answers you got don't mean anything.
00:13:11
Speaker
And it was just a total waste of everybody's time.
00:13:14
Speaker
So start with the cam in the ICU.
00:13:17
Speaker
And that means just walk up to the bedside,
00:13:19
Speaker
hold the patient's hands.
00:13:21
Speaker
And this is a beautiful thing is that delirium monitoring actually gets you to the bedside in a beautiful way to hold hands.
00:13:28
Speaker
So they have them squeeze on a certain letter that I showed you.
00:13:32
Speaker
We have videos on our website.
00:13:34
Speaker
Our website is ICU delirium.org.
00:13:37
Speaker
And those videos will show you how to measure delirium.
00:13:41
Speaker
And it takes about 30 to 40 seconds on average.
00:13:44
Speaker
We actually used a computer to test it.
00:13:46
Speaker
It was 37 seconds on average.
00:13:48
Speaker
And
00:13:50
Speaker
That's hundreds of patients, 37 seconds.
00:13:52
Speaker
That's a small price to pay for the amount of information you get from that exam.
00:13:57
Speaker
But still, when you start this, you will find that patients, excuse me, that healthcare professionals don't want to do it at first because it's something that they're not used to doing.
00:14:09
Speaker
So we have to make it appealing to them, make them realize that it's easy.
00:14:15
Speaker
And the way to do that is just to have good nurses in your hospital
00:14:20
Speaker
demonstrate to the other nurses, have a train the trainer session in your in your ICU.
00:14:25
Speaker
And the second big thing to do is that you have to make sure you're talking about this on rounds so that on rounds, there is absolutely a conversation taking place where the nurse presents the delirium data and the team entertains what to do with that with those data.
00:14:43
Speaker
If you don't have that conversation, I guarantee you, you will never get delirium monitoring implemented in
Implementing Delirium Data in Clinical Rounds
00:14:48
Speaker
a meaningful way.
00:14:50
Speaker
And I think that one of the things that I find very often, and it applies to the CAM ICU, it applies to RAS scores, but also might apply to the A to F bundles, is that you might ask an ICU, and it's overdoing that.
00:15:05
Speaker
And then when you start really digging a little bit deeper or watch them in rounds, it might be that they're documenting somewhere in the chart, but it's not really integrated into the care of that patient itself.
00:15:18
Speaker
in a consolidated way.
00:15:19
Speaker
Can you talk a little bit about how you would push teams that, okay, you don't do anything, you're not measuring the CAMICU, learn how to do it well, what's the next step?
00:15:29
Speaker
The next step is that you're right, just because you're doing it on paper doesn't mean you're using the information.
00:15:36
Speaker
Just like if you put a SWAN in and you sat there and looked at the SWAN all day long but didn't look up at the monitor to see what the wedge was, then what's the point, what the mean arterial pressure was?
00:15:46
Speaker
So if you're doing, if you're collecting, if the nurse is collecting this information and enters it into the chart, but on rounds, nobody uses the information to affect the patient's care, then what was the point of all of that?
00:15:58
Speaker
So the way to make it useful and productive and helpful is to, on rounds, at the beginning of every patient's presentation is for the nurse out loud to say to the rest of the team, the patient's
00:16:14
Speaker
you know, they don't have to say A, B, C, D. They don't have to say the letters like that.
00:16:18
Speaker
You could, you could say A is assessment treatment management of pain and the CPOT today is.
00:16:23
Speaker
But our nurses don't even say the letters.
00:16:25
Speaker
They just say the pain scale rating today for CPOT is a four.
00:16:29
Speaker
The patient got an SAT, which is a spontaneous awakening trial.
00:16:34
Speaker
And we stopped all the medications and she woke up to verbal command.
00:16:38
Speaker
And then we moved on to the SBT and the SBT was failed.
00:16:43
Speaker
So we couldn't take her off the ventilator because she failed the SVT.
00:16:47
Speaker
We started thinking about the choice of drugs and she was still on benzodiazepines.
00:16:51
Speaker
So we stopped the benzodiazepines.
00:16:53
Speaker
We tested her with the cam and the RAS.
00:16:55
Speaker
Her target RAS was a zero, but her actual RAS was a minus two.
00:17:02
Speaker
So we judged that she was deeper than she should have been and her cam was positive.
00:17:06
Speaker
So we went ahead, as we said earlier, and stopped the benzos.
00:17:09
Speaker
And then in terms of E for early mobility,
00:17:13
Speaker
We we've decided since she's delirious and she was a little overstated, we let her wake up a little bit more and she now has off the drugs.
00:17:20
Speaker
And now we're going to get her out of the bed and do range of motion exercises.
00:17:23
Speaker
And we're actually going to walk her around her room.
00:17:26
Speaker
We got the physical therapist coming or you could say the physical therapist isn't here, but we're going to do it as nurses.
00:17:31
Speaker
And then F the family is at the bedside this morning and they're they're going to actually help us get this patient moving around because engaging with the family obviously is a delirium reducer.
00:17:41
Speaker
We know that from literature.
00:17:43
Speaker
So that was maybe a one minute, 30 second, one minute presentation.
00:17:47
Speaker
Think of how much information I just gave you about this patient.
00:17:52
Speaker
And that is the way that the bundle has to take place is it actually has to generate a conversation.
00:17:57
Speaker
And then once I say that stuff, I stop talking and then rest of the team members chime in, disagree, agree, modify what I said and so on.
00:18:05
Speaker
And that conversation is good patient management.
00:18:07
Speaker
It's just that we organized what used to be chaos
00:18:11
Speaker
into a structured, evidence-based way of taking care of people.
00:18:17
Speaker
And I think that that's really the difficult part, right?
00:18:19
Speaker
I mean, everybody can do it on paper, but to really integrate it into your care in a way that's meaningful is the harder part.
00:18:27
Speaker
And like I think I've heard you say at your presentation last year at SCCM, even ICUs that are doing a great job have room for improvement.
00:18:36
Speaker
So I think that we should always be trying to improve what we're doing because this is truly something that can make a difference for our patients and their lives.
00:18:44
Speaker
in a way that maybe 20 years ago we didn't even understand.
00:18:48
Speaker
Yeah.
Improving ICU Practices with ABCDEF Bundle
00:18:49
Speaker
Well, in fact, we just published a paper in October of Critical Care Medicine, came out in the paper form in January of 2019, that have data on 15,000 people demonstrating that at the end of the day, after implementing the ABCDEF bundle at 70 hospitals in the United States, that we have shown very nice dose response
00:19:14
Speaker
curves for reductions in mortality, length of stay, bounce backs to the ICU, more transfers to home rather than nursing homes, and of course, reductions in delirium and coma.
00:19:29
Speaker
So those are some pretty great outcomes that all of us would agree are target items for patients for us in medicine.
00:19:36
Speaker
Absolutely.
00:19:37
Speaker
So I want to ask you a couple more questions around the CAMICU, Wes.
00:19:41
Speaker
And specifically, do you have any tips that you can share with our audience in terms of
00:19:48
Speaker
getting it rolling or I think that one of the complaints that I always hear is that physicians or providers might say, oh, they just don't know how to do it, but we don't teach them.
00:19:58
Speaker
On the other hand, when they're doing it, sometimes we don't actually bring it up in rounds and specifically ask them, what is it?
00:20:05
Speaker
I might see you would have a discussion about that.
00:20:07
Speaker
But any other tips you can give us or your insight and how to really make it a fabric of our rounds?
00:20:13
Speaker
Yeah, I think I would use what's called the brain roadmap.
00:20:15
Speaker
And we use this term brain roadmap.
00:20:18
Speaker
We made it up to be a shorthand for four things that we want every nurse to say on every patient at the bedside with their attending physician.
00:20:26
Speaker
And those four things are the target RAS, the actual RAS, the CAM, and the drugs that the patient is on.
00:20:36
Speaker
So if I tell you the target is minus one and the actual is minus three,
00:20:42
Speaker
and the cam is positive, and the patient is on a fentanyl versus a drip, you automatically hear in five seconds, that I want the patient basically alert to mildly calm, that I've got the patient way over sedated, I know which drugs they're on, and they're delirious.
00:21:00
Speaker
And that little brain roadmap, if you just say that it takes five to 10 seconds max, it just provides so much useful information and fodder for patient management decisions.
00:21:11
Speaker
And
00:21:12
Speaker
When the doctors don't know how to do the CAM, I actually don't really care that much that they don't know how to use it.
00:21:18
Speaker
As long as they know that a CAM positive means a predictor of brain dysfunction that leads, that is a predictor of death, length of stay, cost of care and dementia.
00:21:29
Speaker
Well, that's enough for them to know.
00:21:32
Speaker
And they say, well, if they're CAM positive, I need to do something about it.
00:21:34
Speaker
What do I do?
00:21:36
Speaker
Well, I got to, I got to stop sedation.
00:21:38
Speaker
I got to get them out of the bed.
00:21:39
Speaker
I got to incorporate their family.
00:21:41
Speaker
Cause those are the three biggest things right there.
00:21:43
Speaker
Uh, incorporation of family, getting them out of the bed and, and stopping sedation.
00:21:48
Speaker
Uh, they have to do other good things like, is there a new sepsis here?
00:21:51
Speaker
Does the patient need a chest X-ray or white count?
00:21:54
Speaker
Um, is the patient gotten sicker for some reason?
00:21:56
Speaker
Is there CHF?
00:21:57
Speaker
The two most important medical maladies would be blood flow problems like CHF, too much volume, you know, whatever, or, um, or any type of infection.
00:22:09
Speaker
So the good intensivists will have a short list on the differential diagnosis of what to do when they hear that the patient is CAM positive.
00:22:20
Speaker
Sergio, have you ever heard of the Dr. Dre?
00:22:23
Speaker
I have not.
00:22:24
Speaker
Well, I mean, I actually have.
00:22:25
Speaker
I mean, I've heard of one Dr. Dre, but he's a rapper.
00:22:28
Speaker
I don't know if that's the one.
00:22:29
Speaker
Yeah, yeah, that's who I'm talking about.
00:22:31
Speaker
The Dr. Dre is a rapper, and he has the earbuds, you know, the big earbuds.
00:22:34
Speaker
Yep, yep, yep.
00:22:35
Speaker
Well, we made up a mnemonic called the Dr. Dre and we use it every day at every bedside.
00:22:40
Speaker
So it stands for diseases, drug removal and environment to D DRE.
00:22:49
Speaker
Doctor could be disease remediation if you want for a D R disease remediation.
00:22:53
Speaker
And then the Dre is DRE drug removal environment.
00:22:57
Speaker
So when the patient is delirious, we just say to the nurse, run the doctor, Dr. Dre.
00:23:01
Speaker
And she says, OK, let's think of what diseases we need to solve disease remediation.
00:23:06
Speaker
CHF infection in the main two ones, COPD, hypoxemia, think of all that.
00:23:10
Speaker
And then drugs to be removed.
00:23:11
Speaker
So we run the list of medicines.
00:23:13
Speaker
And then environment.
00:23:14
Speaker
So eyeglasses, hearing aids, sleep, ambulation, family, all that stuff.
00:23:21
Speaker
And if you run the Dr. Dre, you will get at the vast majority of things that could be creating the delirium.
00:23:26
Speaker
And
Strategies for Delirium Treatment
00:23:27
Speaker
I think that this is probably worth, I mean, reemphasizing because I think this is just gold here, Wes, in terms that a lot of the...
00:23:35
Speaker
the complaints I might hear from some of our clinicians is that, well, there's nothing really I can do about it, which is not true, right?
00:23:42
Speaker
We'll get to treatment.
00:23:43
Speaker
I just gave you a whole list.
00:23:44
Speaker
A little later, but this, Dr. Dre, is exactly what I think people need to understand.
00:23:48
Speaker
So if you have a patient who was CAM negative and now is CAM positive,
00:23:53
Speaker
or they're still CAM positive, you should think about these three things.
00:23:58
Speaker
And I think that in terms of emphasizing just a couple of questions.
00:24:02
Speaker
So I've seen, for example, disease removal recovery.
00:24:06
Speaker
I've seen historically that patients who severe ARDS or septic shock, when we used to blast them with fluids, that a lot of times, I mean, they were very, I mean, unresponsive or very
00:24:19
Speaker
And with diuresis over time, their mental status improves.
00:24:25
Speaker
I mean, is that something that you have encountered?
00:24:27
Speaker
Yeah, absolutely.
00:24:28
Speaker
Any comments on that?
00:24:32
Speaker
It totally does.
00:24:33
Speaker
I just said a minute ago that the two most common medical maladies that lead to delirium are infections of any type and fluid problems, flow problems.
00:24:43
Speaker
CHF is the best example.
00:24:46
Speaker
And what you just said supports that.
00:24:48
Speaker
I absolutely think that's the case.
00:24:50
Speaker
And also when you diurese somebody, they're more able to be mobile.
00:24:53
Speaker
They can get out of the bed better.
00:24:54
Speaker
They can move better.
00:24:56
Speaker
There's just lots of things that we need to think about medically and then physically for our loved ones, for our patients and their families to get them on the right road.
00:25:05
Speaker
It's just brain health, you know?
00:25:08
Speaker
Absolutely.
00:25:08
Speaker
And I think with drug removal, I think that
00:25:12
Speaker
Even though this has been well published and discussed, I still find people not recognizing the perils of benzodiazepines, especially in elderly people.
00:25:24
Speaker
That seems to be, from what I read the literature, the single most dangerous risk factor from a drug perspective.
00:25:31
Speaker
Any comments on that, Wes?
00:25:33
Speaker
Yeah, listen to this.
00:25:36
Speaker
There are about 30 randomized controlled trials of benzos up against some other
00:25:43
Speaker
medicine, about 30 in critical care.
00:25:46
Speaker
And if you look at all of them, whether the benzo is compared to propofol, dexamidatomidine, a narcotic, whatever it is, I don't know of a single one that the benzo one out.
00:26:00
Speaker
It loses every time.
00:26:01
Speaker
It's either neutral or loses every time to the comparator.
00:26:04
Speaker
So the benzo is evidence-based wise the worst choice for lots of different outcomes, whether it be length of stay,
00:26:13
Speaker
delirium, time on vent, you name it, it loses over and over again.
00:26:18
Speaker
So the other day, we had a nurse who needed to give a benzo because it's part of a study protocol, a rescue protocol.
00:26:26
Speaker
And she looked scared.
00:26:27
Speaker
I said, what's the matter?
00:26:28
Speaker
She says, I've never given a benzo.
00:26:30
Speaker
She's been up in our ICU for four years, had never given a benzo.
00:26:33
Speaker
So we rarely use them anymore.
00:26:35
Speaker
And I think that that is something that in ICUs throughout the country, I still see, unfortunately, benzodrips and there's better options and definitely something that we can push for.
00:26:46
Speaker
The third component of the Dr. Dre is the environment.
00:26:50
Speaker
And I used to joke when I was a fellow, but we would used to say that if you want the patient to look better, put their glasses on and they immediately look 10 times better.
00:26:59
Speaker
So when the attending comes, put the glasses on, they'll look much better.
00:27:02
Speaker
But they also look
00:27:03
Speaker
look better probably because it helps them in many other ways that now are linked to delirium.
00:27:08
Speaker
So any comments, I mean, on the importance of us asking glasses, hearing aids?
00:27:14
Speaker
I had a guy in the hospital recently that came in for an in-stemmy, and then he got aspiration, but he got so much better.
00:27:22
Speaker
He's all the way better.
00:27:23
Speaker
He was on the downhill of his critical illness.
00:27:26
Speaker
And then out of nowhere, he got profoundly delirious.
00:27:28
Speaker
And long story short, because we're short on time here, it was his glasses.
00:27:32
Speaker
He needed his glasses.
00:27:34
Speaker
He needed to read.
00:27:35
Speaker
He hadn't read in days.
00:27:36
Speaker
He was used to reading a lot every day.
00:27:37
Speaker
And so I gave him the glasses out of my out of my lab coat.
00:27:40
Speaker
And the next day I walked in, he was totally fine.
00:27:42
Speaker
He was sitting there reading like crazy one of his biographies.
00:27:44
Speaker
And it was a beautiful thing.
00:27:46
Speaker
And it was such a I just kicking myself.
00:27:48
Speaker
I was like, why didn't I think of that two days earlier?
00:27:51
Speaker
But we have to realize that people need to do sensory deprivation is a huge delirogenic situation.
00:27:58
Speaker
And it's not benign.
Delirium Care Post-ICU
00:28:00
Speaker
And I think that, again, this mnemonic, I mean, Dr. Dre, the single thing that I, one thing you're going to learn from this podcast is just apply that every time you have a count positive and will probably make a big, big impact on our patients.
00:28:14
Speaker
Now, I have another question, and this is something that has been bothering me for some time, and I just want to know what your experience is and how you have looked at this.
00:28:22
Speaker
So I feel that we're very focused on the patients in the ICU, right?
00:28:27
Speaker
And we do the A to F bundle.
00:28:31
Speaker
But I think there's a huge voltage drop when people leave our ICUs.
00:28:34
Speaker
And we're not doing a good job for our patients.
00:28:37
Speaker
And maybe sharing information that might be helpful elsewhere.
00:28:41
Speaker
So, for example, I have never seen somebody be transferred from an ICU to a step down a floor or a LTAC.
00:28:50
Speaker
And in the report, somebody include the CAM status.
00:28:54
Speaker
Because it seems that a lot of people might leave with some delirium or might get them when they leave the ICU.
00:29:00
Speaker
Is that something that you have looked at or any comments on that, Wes?
00:29:05
Speaker
That's really – it was around 2005 that we here at Vanderbilt, we started teaching delirium to every single nurse who got – who came on at faculty – say on staff at Vanderbilt.
00:29:21
Speaker
And the reason we did that was on purpose to take care of the problem you just outlined.
00:29:25
Speaker
We wanted the floor nurses and the ICU nurses all to know about delirium so that when the ICU nurse checked out a patient to go to the floor, she said the patient's scanned positive.
00:29:34
Speaker
And then the floor nurse would say, oh, I know what that means.
00:29:36
Speaker
I learned about that when I was initiated here at Vanderbilt.
00:29:39
Speaker
And so, yes, we make that part of our regular warm handoff of information.
00:29:45
Speaker
And I think it's something that for our group, which is a large group, I mean, that deals with a lot of impatience.
00:29:50
Speaker
That's something probably that we should work on because I think that's very inconsistent, I mean, from program to program, from hospital to hospital.
00:29:57
Speaker
Absolutely.
Prevention of Delirium
00:29:58
Speaker
So let's talk a little bit about –
00:30:01
Speaker
treatment in terms of prevention and actual treatment.
00:30:04
Speaker
And I know that when people think of prevention, you talked about some of the things that can help, obviously, but there's non-pharmacological and pharmacological things that people have looked at in terms of prevention.
00:30:15
Speaker
Can you kind of summarize the way you think of, okay, this is a high-risk patient for delirium.
00:30:19
Speaker
What are the things I can do before their CAM ICU becomes positive to try to avoid it becoming positive?
00:30:28
Speaker
I think about the elements of the ABCDF bundle.
00:30:31
Speaker
Let me let me take you through it.
00:30:33
Speaker
If somebody's in pain, it's delirogenic.
00:30:35
Speaker
I need to take care of that.
00:30:36
Speaker
That's A. B is both SATs and SBTs.
00:30:40
Speaker
So I want to make sure that every day the patient has the opportunity to be taken off whatever sedatives they're on.
00:30:45
Speaker
That's a spontaneous awakening trial, stopping the drugs and then to be taken off the ventilator, which is very sensory depriving because it locks them down with a tube down their throat.
00:30:56
Speaker
So we need an SBT as soon as they wake up to verbal stimulation.
00:30:59
Speaker
C is choice of drugs, which gets you to avoid benzos and other delirogenic agents.
00:31:04
Speaker
D is measuring the delirium just to know that it's there or not.
00:31:08
Speaker
E is the early mobility and it's getting somebody out of the bed.
00:31:11
Speaker
We know that the Schweikert study and Lancet cut delirium in half.
00:31:16
Speaker
And F, family involvement in the great Brazil study by Rose, we found that the patient's delirium was also cut in half by expanding
00:31:25
Speaker
family visitation.
00:31:26
Speaker
So these are really a great list of things that help you prevent delirium.
00:31:33
Speaker
It's not rocket science.
00:31:34
Speaker
It's basic stuff.
00:31:36
Speaker
But you need a checklist kind of like when you're reading an EKG, you don't jump all around.
00:31:40
Speaker
You go rate, rhythm, axis, and you go down a certain order.
00:31:44
Speaker
When you're reading an X-ray, you go patient position, rotation, inspiration, lines, bones, soft tissues, lungs.
00:31:50
Speaker
Same order every day.
00:31:52
Speaker
Same thing.
00:31:53
Speaker
And that way you don't skip any steps.
00:31:57
Speaker
What about any other interventions?
00:32:00
Speaker
I mean, we talked about making sure patients have their glasses, their hearing aids.
00:32:04
Speaker
Any comments on, and this isn't the PADIS guideline, but from your experience on sleep protocols, other things that we can do to improve the environment?
00:32:16
Speaker
Yes, I think that, for one thing, as soon as the sun comes up,
00:32:21
Speaker
We begin to open windows, turning lights on, getting the patient out of the bed.
00:32:25
Speaker
It's daytime.
00:32:26
Speaker
Let's let's act like it's daytime.
00:32:28
Speaker
When the night comes, we can try and have them tired enough that they will fall asleep.
00:32:33
Speaker
Not not chemically, but naturally.
00:32:36
Speaker
And to do that, we want to get the patient walking, get them tired.
00:32:39
Speaker
So rather than chemically get them to go to sleep, we'll try and get them physically to fall asleep.
00:32:44
Speaker
These things, plus the environment of reduction of noise at night so they can sleep.
00:32:49
Speaker
And then, of course,
00:32:52
Speaker
hearing aids and eyeglasses during the day.
00:32:53
Speaker
So all of these things we think improve the environment quite a bit.
00:32:57
Speaker
And in terms of pharmacological prevention, one thing I think that you've covered very clearly is that one way of pharmacologically preventing delirium is avoiding benzos.
00:33:10
Speaker
But what about, there's been some small studies recently in the Blue Journal about low-dose dexmetomidine in elderly patients for sleep.
00:33:18
Speaker
Any comments on where we stand there right now and what would be the current recommendations, Wes?
00:33:23
Speaker
Sure.
00:33:23
Speaker
And I would disclose that I have received honoraria for giving talks that were sponsored by the companies that make Dix Metatomini like Orion and Pfizer.
00:33:34
Speaker
I don't have any stock in those companies, and I will tell you right now what I'm about to say is evidence-based.
00:33:39
Speaker
So evidence-based-wise, there's no sedative agent that has even remotely the amount of data behind it
00:33:48
Speaker
that alpha 2 agonists specifically dex has in terms of delirium reduction whether it be the men's study m-e-n-d-s in jama sedcom prodex mydex the uh the studies by yaya shahabi in australia which are the spice studies um the low dose dexamontomany study by joanna scrobic and john devlin all of these investigations have pushed us in the same direction was it which is that
00:34:15
Speaker
Alpha-2 agonists are a safer, kinder, gentler way to provide sedation in the ICU, which is associated with less delirium, less brain dysfunction, shorter time on the ventilator, et cetera.
00:34:26
Speaker
This is a much evidence-based evolution of data over the past five to 10 years.
00:34:33
Speaker
And I think that any clinician can stand firm on those data.
00:34:40
Speaker
Any other, there's been some comments in the PADIS guidelines about melatonin and other drugs that might be utilizing the ICU.
00:34:50
Speaker
Any comments on your part?
00:34:53
Speaker
I think all of those other agents are potential, you know, good ways to go, but the evidence is way, way thinner.
00:35:00
Speaker
So I'm interested in melatonin, but does melatonin work because it helps or because it gets out of your hand a more dangerous agent that you might have given like Ambien or Benzo?
00:35:10
Speaker
I don't know the answer to that question.
00:35:11
Speaker
And if melatonin works, is it because of sleep?
00:35:13
Speaker
We don't have good data showing that the sleep
Reconsidering Antipsychotic Use for Delirium
00:35:16
Speaker
works.
00:35:16
Speaker
Like the data we have from the RCTs doesn't actually show a benefit to sleep.
00:35:20
Speaker
So what's the mechanism in that sort of thing?
00:35:23
Speaker
Excellent.
00:35:23
Speaker
So let's dive a little bit now into treatment of patients who are actually delirious.
00:35:30
Speaker
And I think that it was made electronically available in October, but I think published in the last...
00:35:39
Speaker
edition of December of the New England Journal of Medicine, the Haloperidol and Ciprasidone for Treatment of Delirium and Critical Illness, or the MIND USA study, which you're a senior author on.
00:35:52
Speaker
The first thing that I noticed that actually struck me, which is always interesting, is what you already said at the beginning, that 89% of the patients in this study had hypoactive delirium.
00:36:03
Speaker
So we're not seeing it unless we look for it.
00:36:07
Speaker
And the other thing that struck me, which I think just illustrates the enormous complexity and difficulties in pulling through these studies, was the percent of people who were approached for the study and the family said, do not want to participate.
00:36:21
Speaker
That was really a little bit of a downer for me.
00:36:24
Speaker
But I think it just illustrates the amount of work that your team had to do to get this study off the ground and working.
00:36:30
Speaker
Why don't you walk us through the study and tell us how you interpret it, Wes?
00:36:35
Speaker
Sure.
00:36:36
Speaker
Well, for 40 years, four decades, people have been giving antipsychotics for delirium.
00:36:40
Speaker
It all started with Ned Kasim at MGH back in 78.
00:36:46
Speaker
And for the last four decades, we've been doing this as usual care.
00:36:50
Speaker
And our question was, hey, you know, is this helping or hurting or is it neutral or what's going on?
00:36:56
Speaker
And so we went to the NIH and we did get a large multimillion dollar grant.
00:37:02
Speaker
We set up a multicenter trial and
00:37:06
Speaker
We wanted all comers who were delirious.
00:37:08
Speaker
That's hypo and hyperactive delirium or mixed delirium because all of those patients get antipsychotics.
00:37:15
Speaker
Now, you might say, Sergio, in my unit, I only give antipsychotics for hyperactive delirium.
00:37:20
Speaker
That may be true, but in plenty of units, people give them for hypoactive delirium.
00:37:25
Speaker
We have good, solid epidemiological data that say that patients who are delirious in the ICU, whether hyper or hypoactive, get antipsychotics all over the world.
00:37:35
Speaker
for delirium.
00:37:36
Speaker
So the scientific question was, is that right or is it wrong?
00:37:39
Speaker
And while 89% had hypoactive delirium at the beginning, a higher percentage of them eventually had mixed or hyper over time.
00:37:49
Speaker
But still the majority were hypoactive.
00:37:52
Speaker
And it really didn't matter whether you were hyperactive or hypoactive, the receipt of a set of a intravenous form of Haldol or the praesadone
00:38:05
Speaker
didn't do anything to the duration of delirium.
00:38:08
Speaker
So the amount of hours you spent delirious was the same whether you got those antipsychotics or placebo, which I think is a really important thing for us to know moving forward.
00:38:21
Speaker
It doesn't mean it's not practice to give an antipsychotic, but you should give it for a reason that you think you're going to accomplish, like perhaps sedation in a hyper agitated patient.
00:38:32
Speaker
not giving it in order to say we are treating the delirium.
00:38:38
Speaker
And I think that's an important point because, like you said, a lot of ICUs, if they had a CAM positive patient, whether they're agitated or not, might start these medications on a kind of around-the-clock basis.
00:38:53
Speaker
And that seems to be answered with this study as something that... And after those are started, about a third of them
00:39:02
Speaker
sometimes 20 to 30 percent of them will leave the hospital still on that drug that was started in the ICU.
00:39:08
Speaker
So what you think is just going to be a day or two of it can end up being months and months of antipsychotics.
00:39:14
Speaker
Yeah, I think a very important lesson.
00:39:15
Speaker
So let me ask you, Wes, in 2019, when do you use haloperidol in the ICU?
00:39:22
Speaker
I use haloperidol or another antipsychotic in the ICU mainly for things like this.
00:39:28
Speaker
My patient is having respiratory failure.
00:39:31
Speaker
and they need to tolerate BiPAP, but their anxiety level is too great and they won't tolerate BiPAP.
00:39:36
Speaker
So CHF, asthma, COPD, I might give them dexmedetomidine, but if I don't want to give the person an intravenous drip, I might just give them bolus doses of an antipsychotic because it doesn't suppress the respiratory drive and allows them to tolerate the claustrophobia circumstance of a BiPAP mask.
00:39:54
Speaker
Another circumstance will be a patient in DTs, which is hyperactive delirium.
00:40:00
Speaker
and they're withdrawing from a benzo or a narcotic or something, either again, either dex or an antipsychotic is an excellent choice because all you're really trying to do is calm the patient's safety situation down to the point that they're not dangerous to the self or others and do it in a way that doesn't make them stop breathing so that they land on a ventilator.
00:40:22
Speaker
And Haldol or dex or even clonidine are great choices in that circumstance.
00:40:29
Speaker
And those are times I think
00:40:30
Speaker
that I still use these agents.
00:40:32
Speaker
And I think it's important because, like you said, it's not malpractice if you use it for a specific reason, but we shouldn't be using it routinely for treating delirium where it's hyperactive or hypoactive unless we have those compelling reasons like you explained.
00:40:44
Speaker
And again, I think that over and over again, we find that dogma or what we do on a regular basis when evaluated more critically is
00:40:52
Speaker
It might not be helping our patients, and I think that we have to have that flexibility to practice at the best available evidence, understanding that as we learn more, things might change.
00:41:03
Speaker
Fantastic.
Future Research and Holistic Care
00:41:04
Speaker
Thank you for that summary.
00:41:05
Speaker
What are you most excited about looking forward to the next year, two years in the field of delirium?
00:41:14
Speaker
I am very excited about the results of our just recently completed MENDS-2 study, MENDS-2.
00:41:21
Speaker
because there is a there's a ton of propofol use in the world.
00:41:25
Speaker
And we are trying to find out if the pilot if the pilot data from our MENS-1 MENDS-1 study published in JAMA and later intensive care medicine and critical care, some sub studies were were real, where we saw a potential survival advantage to getting an alpha two agonist over a GABAergic drug like propofol.
00:41:48
Speaker
And that's going to be very interesting for us.
00:41:51
Speaker
So we've just completed randomization of propofol versus dexmedetomidine.
00:41:58
Speaker
And we are very interested to see if there's any advantage to one drug or the other.
00:42:03
Speaker
That'll be coming out hopefully by the end of 2019, early 2020.
00:42:08
Speaker
And I'm also then the second thing will be I'm very excited for our brain two study where we're going to be getting these brains out and trying to determine what kind of dementia the patients are experiencing.
00:42:19
Speaker
And let me ask you a question related to the men's two.
00:42:22
Speaker
In patients who need heavy sedation, let's say they're paralyzed, ARDS, prone, what would you do, I mean, if dexmatomidine was not enough?
00:42:34
Speaker
Well, first of all, I would never use dex by itself with a paralytic agent.
00:42:37
Speaker
No way.
00:42:38
Speaker
It's not a deep enough sedative.
00:42:39
Speaker
If you're going to be paralyzed, you've got to be deep enough.
00:42:42
Speaker
So propofol or even a benzo has got to happen for those patients.
00:42:46
Speaker
You cannot risk.
00:42:48
Speaker
Somebody feeling like they're buried alive, paralyzed, and not able to communicate.
00:42:54
Speaker
So DEX is a total no-go there.
00:42:57
Speaker
And that was a contraindication in our study, an exclusion.
00:43:00
Speaker
If you're on paralytics, you could not be on the study drug.
00:43:04
Speaker
So you have to have a deeper sedative agent, and propofol will be a very appropriate one of the choices.
00:43:09
Speaker
Excellent.
00:43:10
Speaker
So I think that it's been a wonderful conversation, Wes.
00:43:14
Speaker
I want to be very respectful of your time.
00:43:15
Speaker
But one of the things that we like to do at Critical Matters is also tap into the wisdom of our guest and talk about some couple topics that might not be related directly to delirium.
00:43:25
Speaker
Sure.
00:43:26
Speaker
Would that be okay?
00:43:27
Speaker
Sure.
00:43:27
Speaker
Sure.
00:43:28
Speaker
Whatever.
00:43:29
Speaker
So my first question is, what book or books have influenced you the most or what books have you gifted most often to others?
00:43:37
Speaker
Yeah.
00:43:37
Speaker
That's a great question.
00:43:38
Speaker
It's a broad question.
00:43:39
Speaker
It's a good one.
00:43:42
Speaker
I'm looking on my bookshelf right here in my office here.
00:43:44
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I usually keep a few extra books in my office.
00:43:47
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And when I meet with people, students especially, once I see what kind of person they are, what they're interested in, I might gift them a different book.
00:43:54
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One of them sitting on the shelf here is Boys in the Boat, which is a great story of life and work and success from the famous 1936 Olympic
00:44:07
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rowing team.
00:44:08
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Another one sitting here staring at me is the is a biography of Alexander Solzhenitsyn, which was a beautiful book by Joseph Pierce called a soul in exile.
00:44:18
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Solzhenitsyn represents a soul who obviously was in exile for many years in the Russian gulag.
00:44:26
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He wrote the gulag archipelago.
00:44:28
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And that's a great story of his life.
00:44:30
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We can learn a lot from from him.
00:44:31
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Another bog another book that that is one of my favorite books of all time
00:44:36
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is by Viktor Frankl, Man's Search for Meaning.
00:44:40
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He was a physician in Auschwitz who survived and wrote about those struggles.
00:44:47
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And I'll give you one last one.
00:44:49
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I'll give you two last ones.
00:44:51
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Atul Gawande's Being Mortal is a great book about end of life and growing old in the United States.
00:44:57
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And one I recently read last year, which is just a beautiful book, it's called Just Mercy by Bryan Stevenson.
00:45:03
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about, basically about prejudice and the problems within the American justice system.
00:45:10
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So those are a few titles that I give out a lot and that have helped me in my struggle to become a better person.
00:45:17
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And I think that a lot of them obviously are books that are wonderful that I have read.
00:45:23
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I have not read Soul in Exile, so I definitely would have to look that up.
00:45:26
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And we'll put links to all these books in the show notes.
00:45:30
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But I think that Boys in the Boat, I would imagine Soul in Exile, and especially Viktor Frankl's book, I think really talk a lot about finding purpose, right?
00:45:39
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Finding purpose as a guidance.
00:45:41
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for succeeding.
00:45:43
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In fact, the Solzhenitsyn book is very important because Joseph Pierce is the only person who has ever written a biography of Solzhenitsyn that actually Solzhenitsyn asked him to come to his house in Russia and gave him in-person interviews.
00:45:59
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Wow.
00:45:59
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So that's the only biography we have of Solzhenitsyn where the biographer had contact with him in person at his own house over a long period of time.
00:46:08
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So we'll definitely have to look into that and that we will put all these in the show notes alongside the address to the website for delirium and some of the studies that we've mentioned.
00:46:19
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So the second question, Wes, is what do you believe to be true in medicine or in life that most other people don't believe?
00:46:30
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I don't know if it's that most people don't believe it, but especially a lot of people in medicine now believe that
00:46:37
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that of all of the bioethical principles that autonomy is the kingpin and that nothing else can compete with autonomy.
00:46:46
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But I just recently watched one doctor do the exact opposite with regard to patient autonomy.
00:46:53
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The patient wanted to be one patient of this doctor wanted end of life and specifically physician assisted suicide.
00:47:02
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And the patient was in California.
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So I was told the story by this doctor.
00:47:06
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that they provided physician assisted dying.
00:47:09
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And then that same doctor told me that they had a patient who wanted everything done in the ICU, but they judged that it was inappropriate.
00:47:19
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So they went against the patient's autonomous wishes.
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The answer to your question is that I think that all life is totally priceless and that I don't have the right to take it.
00:47:32
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So I will do everything I can
00:47:34
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at the end of life in the ICU to relieve human suffering and and to provide the best palliative care I can.
00:47:41
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But in no way, shape or form would I ever feel comfortable to deliberately intentionally shorten the life of a patient.
00:47:49
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I remove life support all of the time.
00:47:52
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And that is in keeping with whenever something has been judged disproportionate or extraordinary care.
00:47:57
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And that's a that allows the patient's life to take its natural course.
00:48:01
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But I wrote a piece in CNN last year.
00:48:04
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You could put a link to that on from CNN.org about approach I took to a patient's life when they asked me to end it.
00:48:12
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And that's just a patient story that kind of represents what I think is my calling as a physician.
00:48:20
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Excellent.
00:48:20
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And we'll definitely put that link in there as well.
00:48:23
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And finally, the last question is, what would you want every provider intensivist who's listening to us in this podcast to know?
00:48:30
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It could be a quote, a fact, or just a reflection.
00:48:36
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I would want every intensivist to know this and to remind me of it too, so that I can do a better job with this, that when the patient is in that ICU room, look in their eyes.
00:48:47
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and realize that that is a deep well of of of a complicated individual human being that is not just about our decision of what antibiotic to use what mean or to a pressure to use whatever and we have to ask the patients about themselves.
00:49:06
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I want to know the name of their dog.
00:49:08
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I want to know how long they've been married.
00:49:10
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I want to know how they met their wife or husband or you know what their problems have been in life and the things
00:49:17
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And then when I say to that person, not here is what's the matter with you, I want to say what matters to you.
00:49:25
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Flip that around, not what's the matter with you, but what matters to you.
00:49:29
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And in so doing that, that is the way that I can serve that patient to the best of my ability.
00:49:36
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And I think this is a perfect place to stop, Wes.
00:49:38
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Again, I want to thank you for your generosity with your time, with your knowledge.
00:49:43
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Always a pleasure to hear what's new in the world of delirium, to talk with you.
00:49:48
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And look forward to having you on the podcast soon again as a guest.
00:49:52
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Thank you, Sergio.
00:49:53
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I greatly appreciate it.
00:49:54
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Bye-bye now.
00:49:57
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Thanks again for listening to Critical Matters.
00:50:00
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Make sure to subscribe to this podcast on iTunes or Google Play.