Online Letters to the Editor

Letter to the Editor Korea; Joo Myung Lee, MD, MPH, Division of Cardiology, Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Jongno-gu, Seoul, South Korea

ACKNOWLEDGMENTS We thank Soyeon Ahn, PhD, Medical Research Collaborating Center, Seoul National University Bundang Hospital; Kyung Hwa Seo, MBA, Research Institute for Healthcare Policy, Korean Medical Association; and Dr. Ein Soon Shin, PhD, Department of Preventive Medicine, EWHA Woman’s University School of Medicine, for statistical review and independent comment on this response letter.


1. Iftikhar IH, Donley MA, Owens WB: Prone Positioning in Acute Respiratory Distress Syndrome. Crit Care Med 2015; 43:e55–e56 2. Lee JM, Bae W, Lee YJ, et al: The efficacy and safety of prone positional ventilation in acute respiratory distress syndrome: Updated study-level meta-analysis of 11 randomized controlled trials. Crit Care Med 2014; 42:1252–1262 3. Deeks JJ: Issues in the selection of a summary statistic for meta-analysis of clinical trials with binary outcomes. Stat Med 2002; 21:1575–1600 4. Hu SL, He HL, Pan C, et al: The effect of prone positioning on mortality in patients with acute respiratory distress syndrome: A metaanalysis of randomized controlled trials. Crit Care 2014; 18:R109 5. Sud S, Friedrich JO, Adhikari NK, et al: Effect of prone positioning during mechanical ventilation on mortality among patients with acute respiratory distress syndrome: A systematic review and meta-analysis. CMAJ 2014; 186:E381–E390 6. Chan MC, Hsu JY, Liu HH, et al: Effects of prone position on inflammatory markers in patients with ARDS due to community-acquired pneumonia. J Formos Med Assoc 2007; 106:708–716 7. Lee JM, Cho YJ: The authors reply. Crit Care Med 2014; 42: e599–e601 8. Guérin C, Reignier J, Richard JC, et al; PROSEVA Study Group: Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013; 368:2159–2168 9. Guerin C, Baboi L, Richard JC: Mechanisms of the effects of prone positioning in acute respiratory distress syndrome. Intensive Care Med 2014; 40:1634–1642 10. Richards JM, Deboisblanc BP: Over easy: An updated recipe for acute respiratory distress syndrome. Crit Care Med 2014; 42:1318–1319 DOI: 10.1097/CCM.0000000000000830

Chronic Critical Illness Should Be Considered in Long-Term Mortality Study Among Critical Illness Patients

outcome. The determination for long-term outcome of patients who survived from critical illness is still unknown. In another recent study by Allan Garland et al (2), it is suggested that shortterm mortality was mainly determined by the acute illness and the long-term mortality was mainly determined by age and comorbidity. However, in the study by Linder et al (1), acute critical illness contributes a lot to the long-term mortality, which is inconsistent with the study by Garland et al (2). We speculate that the different conclusion of those two studies is due to the varied percentage of patients with chronic critical illness (CCI). CCI is a nebulous term for the patients who survive a catastrophic illness or surgical procedure but are left with a prolonged need for mechanical ventilation (3). Of mechanically ventilated critical patients, CCI develops in 5–10% depending on the definition (4). Compared with non-CCI patients, the mortality of CCI patients is relatively high. Although patients with comorbidity are thought to be prior to CCI, the exact reasons for those acute illness patients for developing into CCI are still unknown. In their study, Linder et al (1) compared the long-term mortality between septic patients without underlying commodities and the age and gender comparable general population and concluded that sepsis contribute to the long-term mortality. In our view, we should take the impact of CCI into consideration. The author may make a comparison without CCI patients to see whether CCI is the main factor associated with long-term mortality or not. For this reason, we believe that studies with the numbers of patients with CCI will add confidence to their dataset. The authors have disclosed that their institutions received grant support from the National Natural Science Foundation of China (81270478). Qin Wu, MD, Dong Hu, MD, Jianan Ren, MD, FACS, Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China


1. Linder A, Guh D, Boyd JH, et al: Long-Term (10-Year) Mortality of Younger Previously Healthy Patients With Severe Sepsis/Septic Shock Is Worse Than That of Patients With Nonseptic Critical Illness and of the General Population. Crit Care Med 2014; 42:2211–2218 2. Garland A, Olafson K, Ramsey CD, et al: Distinct determinants of long-term and short-term survival in critical illness. Intensive Care Med 2014; 40:1097–1105 3. Lamas D: Chronic critical illness. N Engl J Med 2014; 370:175–177 4. Maguire JM, Carson SS: Strategies to combat chronic critical illness. Curr Opin Crit Care 2013; 19:480–487 DOI: 10.1097/CCM.0000000000000762

To the Editor:


n a recent issue of Critical Care Medicine, we read with interest the article by Linder et al (1). In the study, the authors found that previously healthy patients suffering an episode of severe sepsis have increased long-term mortality compared with patients with nonseptic critical illness and a general population. With the development of life support techniques, more patients could survive from critical illness. Growing individuals place more value on long-term outcome than short-term Critical Care Medicine

The authors reply:


e would like to thank Wu et al (1) for their insightful comments regarding our study. We appreciate the importance of the impact of chronic critical illness (CCI) on outcome after critical illness. We did acknowledge that lack of information on cause of death, new comorbidities, and quality of life were weaknesses of our study (2). We did do some adjusted analyses to increase the robustness of our findings.


Online Letters to the Editor

CCI is still not universally defined (3). We adjusted for CCI as much as possible by adjusting for factors believed to be associated with CCI. The authors refer to Garland et al (4) who focused on short-term outcome and defined long-term outcome as starting after 90-day survival. Similar to Garland et al (4), we found a marked increase in mortality within the first 90 days. However, some have reported that patients with CCI have a 1-year mortality rate of approximately 50% (3). To correct for this altered outcome, we chose to evaluate only patients surviving at least 1 year after the episode of critical illness. CCI is present in approximately 5–10% of critically ill (4) and that age had a significant impact on more than 90-day mortality. We investigated three age groups and found the greatest negative impact of critical illness among the younger patients (< 70 yr) not the older, who may be more susceptible to CCI, suggesting CCI may not be a huge impact in our study. These two observations and the finding that 1-year mortality was 50% suggest that CCI was not as common in our study as Garland et al (4). In the Canadian study by Garland et al (4), although they did not subgroup different age groups, extrapolating the data from their Figure 1 shows that the general population had a 1- to 10-year mortality of approximately 20%, comparable to our mortality rate of 15%, and the 1- to 10-year mortality of approximately 30% in critically ill patients is also very similar to the 30% we found when combining the patients with and without comorbidities. These observations suggest that the two different Canadian study results are similar, and the study populations were similar. The different conclusions may hence be due to the fact that the two articles defined the cutoff for long-term survival differently (after 90 d [4] vs after 1 yr [2]) and also focused on different age groups. Nonetheless, we agree that the impact of CCI on outcome is important and should be assessed in future studies. Dr. Russell served as a board member for Cyon Therapeutics; consulted for Cubist, Ferring, Leading Bioscience, La Jolla Pharmaceutical, and Grifols; has patents with PCSK9 in sepsis; and has stock in Cyon Therapeutics and Sirius Genomics. His institution received grant support from Ferring, AstraZeneca, and Sirius Genomics. Dr. Linder has disclosed that he does not have any potential conflicts of interest. Adam Linder, MD, Centre for Heart Lung Innovation, Division of Critical Care Medicine, St. Paul’s Hospital, University of British Columbia, Vancouver, BC, Canada, and Division of Infection Medicine, Department of Clinical Sciences, Lund University, Lund, Sweden; James A. Russell, MD, Centre for Heart Lung Innovation, Division of Critical Care Medicine, St. Paul’s Hospital, University of British Columbia, Vancouver, BC, Canada


1. Wu Q, Hu D, Ren J: Chronic Critical Illness Should Be Considered in Long-Term Mortality Study Among Critical Illness Patients. Crit Care Med 2015; 43:e57 2. Linder A, Guh D, Boyd JH, et al: Long-term (10-year) mortality of younger previously healthy patients with severe sepsis/septic shock is worse than that of patients with nonseptic critical illness and of the general population. Crit Care Med 2014; 42:2211–2218


3. Lamas D: Chronic critical illness. N Engl J Med 2014; 370:175–177 4. Garland A, Olafson K, Ramsey CD, et al: Distinct determinants of long-term and short-term survival in critical illness. Intensive Care Med 2014; 40:1097–1105 DOI: 10.1097/CCM.0000000000000809

Of Course, Futile Care Is Wasteful—Are We Ready to Act on This Knowledge? To the Editor:


e applaud Huynh et al (1) for their article, describing the opportunity costs of futile care. We specifically thank them for not limiting their analysis to simply exploring financial impacts of futile care or the vague complexity of “resource allocation” but for instead evaluating futile care’s direct impact on the care of other patients. The study clearly illustrates that providing ongoing care to patients without possibility for meaningful recovery is not only costly but can be directly detrimental to other patients’ care. This is not a shocking conclusion. Providing care to patients who are not going to survive is inefficient and wasteful. As the authors recognize, it is antithetical to the clinician’s responsibility. However, the unanswered question is what to do with this information. When a patient’s care is deemed futile, but their family still finds meaning with an extremely poor quality of life, we continue their care. Is it time to take a harsher stance on futile care and tell families their loved one is being transitioned to comfort care rather than asking? “The family wants everything done” is a common response to the question of goals of care, translating to “the family does not consent to withdrawal of care.” Why ask this question at all? We never ask the patient or family when starting antibiotics or ordering IV fluid. These are our areas of expertise, and there is an understanding that we will use our expertise to make the best medical decision. However, when it comes to end-of-life care, we suddenly ask the family to make decisions that are the most complex. Multisystem organ failure, respiratory insufficiency, and need for hemodialysis are topics that take years to understand; how can it be expected that a family without medical training can make an informed decision on what is appropriate for the patient? Why do we cede our professional responsibility to make a treatment decision at the very point our patients and their families most need us to make this decision objectively? In a well-written editorial, Clark (2) recognizes the limitations of the article by Huynh et al (1) but uses these limitations to wholly discount the conclusions it reaches and, as might be expected, devolves into the typical quagmire of “who’s to say?” We, on the other hand, disagree with the authors of this excellent article on a single point: further multicenter studies are not necessary. No more studies need to be done on this topic. Future studies will also show that futile care is inefficient and wasteful. These are uncomfortable topics, and derogatory terms like “death panels” are often used when describing those who advocate attempts to control end-of-life costs. Presumably, it is this taboo February 2015 • Volume 43 • Number 2

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