Edward T. Moseley

Background: Little is known about family member involvement, by relationship status, for patients treated in the intensive care unit (ICU). Objective: Using documentation of family interactions in clinical notes, we examined associations between child and spousal involvement and ICU patient outcomes, including goals of care conversations (GOCCs), limitations in life-sustaining therapy (LLST), and 3-month mortality. Methods: Using a retrospective cohort design, the study included a total of 858 adult patients treated between 2008 and 2012 in the medical ICU at a tertiary care center in northeastern United States. Clinical notes generated within the first 48 hours of admission to the ICU were used with standard machine learning methods to predict patient outcomes. We used natural language processing methods to identify family-related documentation and abstracted sociodemographic and clinical characteristics of the patients from the medical record. Results: Most of the 858 patients were White (n=650, 75.8%); 437 (50.9%) were male, 479 (55.8%) were married, and the median age was 68.4 (IQR 56.5-79.4) years. Most patients had documented GOCC (n=651, 75.9%). In adjusted regression analyses, child involvement (odds ratio [OR] 0.81; 95% CI 0.49-1.34; P=.41) and child plus spouse involvement (OR 1.28; 95% CI 0.8-2.03; P=.3) were not associated with GOCCs compared to spouse involvement. Child involvement was not associated with LLST when compared to spouse involvement (OR 1.49; 95% CI 0.89-2.52; P=.13). However, child plus spouse involvement was associated with LLST (OR 1.6; 95% CI 1.02-2.52; P=.04). Compared to spouse involvement, there were no significant differences in the 3-month mortality by family member type, including child plus spouse involvement (OR 1.38; 95% CI 0.91-2.09; P=.13) and child involvement (OR 1.47; 95% CI 0.9-2.41; P=.12). Conclusions: Our findings demonstrate that statistical models derived from text analysis in the first 48 hours of ICU admission can predict patient outcomes. Early child plus spouse involvement was associated with LLST, suggesting that decisions about LLST were more likely to occur when the child and spouse were both involved compared to the involvement of only the spouse. More research is needed to further understand the involvement of different family members in ICU care and its association with patient outcomes.

The COVID-19 pandemic has resulted in more than 800 000 deaths in the US, 77% of which were among people 65 years or older and 33% among African American and Hispanic individuals.¹ Many of these patients faced emergency decisions about the use of life-sustaining treatments, an eventuality for which they and their families were often unprepared.² Advance care planning (ACP) seeks to help patients receive care that reflects what matters most to them.³ This process anchors on educating patients about the medical care they may receive and elucidating their informed preferences through iterative conversations and discussions.^3,4 In addition, ACP often includes choosing and preparing another trusted person to make medical decisions in the event that an individual no longer can do so themselves.^3-5

BACKGROUND Little is known about family member involvement, by relationship status, for patients treated in the intensive care unit (ICU). OBJECTIVE Using documentation of family interactions in clinical notes, we examined associations between child and spousal involvement and ICU patient outcomes, including goals of care conversations (GOCCs), limitations in life-sustaining therapy (LLST), and 3-month mortality. METHODS Using a retrospective cohort design, the study included a total of 858 adult patients treated between 2008 and 2012 in the medical ICU at a tertiary care center in northeastern United States. Clinical notes generated within the first 48 hours of admission to the ICU were used with standard machine learning methods to predict patient outcomes. We used natural language processing methods to identify family-related documentation and abstracted sociodemographic and clinical characteristics of the patients from the medical record. RESULTS Most of the 858 patients were White (n=650, 75.8%); 437 (50.9%) were male, 479 (55.8%) were married, and the median age was 68.4 (IQR 56.5-79.4) years. Most patients had documented GOCC (n=651, 75.9%). In adjusted regression analyses, child involvement (odds ratio [OR] 0.81; 95% CI 0.49-1.34; P=.41) and child plus spouse involvement (OR 1.28; 95% CI 0.8-2.03; P=.3) were not associated with GOCCs compared to spouse involvement. Child involvement was not associated with LLST when compared to spouse involvement (OR 1.49; 95% CI 0.89-2.52; P=.13). However, child plus spouse involvement was associated with LLST (OR 1.6; 95% CI 1.02-2.52; P=.04). Compared to spouse involvement, there were no significant differences in the 3-month mortality by family member type, including child plus spouse involvement (OR 1.38; 95% CI 0.91-2.09; P=.13) and child involvement (OR 1.47; 95% CI 0.9-2.41; P=.12). CONCLUSIONS Our findings demonstrate that statistical models derived from text analysis in the first 48 hours of ICU admission can predict patient outcomes. Early child plus spouse involvement was associated with LLST, suggesting that decisions about LLST were more likely to occur when the child and spouse were both involved compared to the involvement of only the spouse. More research is needed to further understand the involvement of different family members in ICU care and its association with patient outcomes.

An antibody is not the antidote: An HIV therapeutic that would give long-term remission without sustained antiretroviral therapy (ART) is a long-term goal. Byrareddy et al. [ Science 354 , 197 (2016)] reported that treating simian immunodeficiency virus (SIV)–positive macaques with an antibody against integrin α ₄ β ₇ during and after ART results in sustained virologic control after stopping all treatment. Three studies in this issue question the reproducibility of that result. Di Mascio et al. sequenced the virus used in the 2016 study and found that it was a variant with a stop codon in the nef gene rather than a wild-type virus. Abbink et al. used the same antibody for α ₄ β ₇ as before but tested control of a more commonly used pathogenic virus. Iwamato et al. used the same nef -stop virus as in the earlier paper but combined the antibody against the integrin with an antibody against the SIV envelope glycoprotein, which also blocks viral binding of the integrin. None of these three new studies found that treating with the antibody had any effect on virologic control after stopping ART treatment. Science , this issue p. 1025 , p. 1029 , p. 1033

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