Rita N. Bakhru

The recently published Society of Critical Care Medicine Guidelines on Adult End-of-Life Care in the ICU provide a detailed and well-thought-out approach to a vital component of critical care, although they explicitly refrain from discussing how they may apply to organ donation. As representatives of the Donor Care Unit Network for Optimizing Recovery (DONOR), a group of intensivists experienced in managing donation after circulatory death (DCD), we wish to endorse equal delivery of high-quality end-of-life (EOL) care for organ donors. Although some logistical differences must be addressed, the EOL recommendations outlined in the Guidelines are still applicable to patients being evaluated for or undergoing DCD. Recent accounts of unacceptable patient care in the setting of DCD highlight a critical threat to patient welfare and public trust. Our mandate is clear: implement and audit protocols that guarantee dignity and symptom control while demonstrating that DCD remains wholly consistent with a compassionate, honorable, and fulfilling EOL.

Rationale: Survivors of critical illness are at high risk for poor long-term outcomes, including readmissions, reduced quality of life, and mortality. A post-ICU telehealth care model may improve outcomes. Objectives: We sought to evaluate the cost-effectiveness and clinical efficacy of a post-ICU telehealth care model. Methods: We performed a single-center randomized controlled trial of 400 ICU patients with sepsis and/or acute respiratory failure, who had two or fewer hospital admissions in the past year, and who were not admitted from or discharged to hospice, a skilled nursing facility, or a long-term acute care hospital. The intervention group had scheduled telehealth visits at 1 and 2 weeks after ICU discharge and as needed for 6 months with a clinician trained in post-ICU recovery. The primary outcome is the cost-effectiveness of the intervention. Measurements and Main Results: Overall healthcare spending on emergency room (ER) visits and hospitalizations were a mean (SD, in U.S. dollars) $7,801.10 ($15,461.03) in the attention control group versus $8,086.50 ($17,464.87) in the intervention group, with a calculated incremental net benefit of $1,958.29 (−$5,779.56 to $9,696.14). ER visits to our healthcare system were the same between groups, but patient-reported ER visits to outside hospitals were different (0.97 per 100 patients per month in the attention control group vs. 2.43 in the intervention group; P = 0.03). Readmissions, mortality, quality-of-life scores, and overall patient satisfaction scores were similar between groups. Conclusions: This randomized controlled trial of a post-ICU telehealth intervention demonstrated wide variation but no clear incremental net benefit compared with standard care. Clinical trial registered with www.clinicaltrials.gov (NCT 04576065).