Research Article
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Published Online: 1 April 2017

Developing a Research Agenda for Integrating Palliative Care into Critical Care and Pulmonary Practice To Improve Patient and Family Outcomes

Publication: Journal of Palliative Medicine
Volume 20, Issue Number 4

Abstract

Background: Palliative care is a medical specialty and philosophy of care that focuses on reducing suffering among patients with serious illness and their family members, regardless of disease diagnosis or prognosis. As critical illness or moderate to severe pulmonary disease confers significant disease-related symptom burdens, palliative care and palliative care specialists can aid in reducing symptom burden and improving quality of life among these patients and their family members.
Objective: The objective of this article is to review the existing gaps in evidence for palliative care in pulmonary disease and critical illness and to use an interdisciplinary working group convened by the National Institutes of Health and the National Palliative Care Research Center to develop a research agenda to address these gaps.
Methods: We completed a narrative review of the literature concerning the integration of palliative care into pulmonary and/or critical care. The review was based on recent systematic reviews on these topics as well as a summary of relevant articles identified through hand search. We used this review to identify gaps in current knowledge and develop a research agenda for the future.
Results: We identified key areas of need and knowledge gaps that should be addressed to improve palliative care for patients with pulmonary and critical illness. These areas include developing and validating patient- and family-centered outcomes, identifying the key components of palliative care that are effective and cost-effective, developing and evaluating different models of palliative care delivery, and determining the effectiveness and cost-effectiveness of palliative care interventions.
Conclusions: The goal of this research agenda is to encourage researchers, clinicians, healthcare systems, and research funders to identify research that can address these gaps and improve the lives of patients with pulmonary and critical illness and their family members.

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References

1.
Kelley AS, Morrison RS: Palliative care for the seriously ill. NEJM 2015;373:747–755.
2.
Quill TE, Abernethy AP: Generalist plus specialist palliative care—Creating a more sustainable model. NEJM 2013;368:1173–1175.
3.
Institute of Medicine: Dying in America: Improving the Quality and Honoring Individual Preferences Near the End of Life. Washington, DC: National Academies Press, 2014.
4.
Nelson JE, Bassett R, Boss RD, et al.: 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). Crit Care Med 2010;38:1765–1772.
5.
Smith AK, White DB, Arnold RM: Uncertainty—the other side of prognosis. NEJM 2013;368:2448–2450.
6.
Christakis NA, Lamont LB: Extent and determinants of error in doctors' prognoses in terminally ill patients: Prospective cohort study. BMJ 2000;320:469–472.
7.
Center to Advance Palliative Care: “What is Palliative Care?” http://getpalliativecare.org/whatis. (Last accessed June 18, 2016).
8.
Lanken PN, Terry PB, Delisser HM, et al.: An official American Thoracic Society clinical policy statement: Palliative care for patients with respiratory diseases and critical illnesses. Am J Respir Crit Care Med 2008;177:912–927.
9.
Selecky PA, Eliasson CA, Hall RI, et al.: Palliative and end-of-life care for patients with cardiopulmonary diseases: American College of Chest Physicians position statement. Chest 2005;128:3599–3610.
10.
Truog RD, Campbell ML, Curtis JR, et al.: Recommendations for end-of-life care in the intensive care unit: A consensus statement by the American College [corrected] of Critical Care Medicine. Crit Care Med 2008;36:953–963.
11.
Carlet J, Thijs LG, Antonelli M, et al.: Challenges in end-of-life care in the ICU. Statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003. Intensive Care Med 2004;30:770–784.
12.
Nelson JE, Puntillo KA, Pronovost PJ, et al.: In their own words: Patients and families define high-quality palliative care in the intensive care unit. Crit Care Med 2010;28:808–818.
13.
Angus DC, Barnato AE, Linde-Zwirble WT, et al.: Use of intensive care at the end of life in the United States: An epidemiologic study. Crit Care Med 2004;32:638–643.
14.
Goodman DC, Esty AR, Fisher ES, et al.: Trends and variation in end-of-life care for Medicare beneficiaries with severe chronic illness. The Dartmouth Institute for Health Policy & Clinical Practice. 2011. www.dartmouthatlas.org/downloads/reports/EOL_Trend_Report_0411.pdf. (Last accessed June 18, 2016).
15.
Teno JM, Gozalo PL, Bynum JP, et al.: Change in end-of-life care for Medicare beneficiaries: Site of death, place of care, and health care transitions in 2000, 2005, and 2009. JAMA 2013;209:470–477.
16.
Wunsch H, Guerra PL, Barnato AE, et al.: Three-year outcomes for Medicare beneficiaries who survive intensive care. JAMA 2010;202:849–856.
17.
Moitra VK, Guerra C, Linde-Zwirble WT, Wunsch H: Relationship between ICU length of stay and long-term mortality for elderly ICU survivors. Crit Care Med 2016;44:655–662.
18.
Cox CE, Docherty SL, Brandon DH, et al.: Surviving critical illness: Acute respiratory distress syndrome as experienced by patients and their caregivers. Crit Care Med 2009;37:2702–2708.
19.
Choi J, Hoffman LA, Schulz R, et al.: Self-reported physical symptoms in intensive care unit (ICU) survivors: Pilot exploration over four months post-ICU discharge. J Pain Symptom Manage 2014;47:257–270.
20.
Cox CE, Martinu T, Sathy SJ, et al.: Expectations and outcomes of prolonged mechanical ventilation. Crit Care Med 2009;37:2888–2894.
21.
Cox CE, Carson SS, Lindquist JH, et al.: Differences in one-year health outcomes and resource utilization by definition of prolonged mechanical ventilation: A prospective cohort study. Crit Care 2007;11:R9.
22.
Puntillo KA, Arai S, Cohen NH, et al.: Symptoms experienced by intensive care unit patients at high risk of dying. Crit Care Med 2010;38:2155–2160.
23.
Nelson JE, Meier DE, Oei EJ, et al.: Self-reported symptom experience of critically ill cancer patients receiving intensive care. Crit Care Med 2001;29:277–282.
24.
Herridge MS, Tansey CM, Matte A, et al.: Canadian critical care trials group: Functional disability 5 years after acute respiratory distress syndrome. NEJM 2011;364:1293–1304.
25.
Dowdy DW, Eid MP, Sedrakyan A, et al.: Quality of life in adult survivors of critical illness: A systematic review of the literature. Intensive Care Med 2005;31:611–620.
26.
Iwashyna TJ, Ely EW, Smith DM, et al.: Long-term cognitive impairment and functional disability among survivors of severe sepsis. JAMA 2010;304:1787–1794.
27.
Davydow DS, Gifford JM, Desai SV, et al.: Posttraumatic stress disorder in general intensive care unit survivors: A systematic review. Gen Hosp Psychiatry 2008;30:421–434.
28.
Davydow DS, Gifford JM, Desai SV, et al.: Depression in general intensive care unit survivors: A systematic review. Intensive Care Med 2009;35:796–809.
29.
Nelson JE, Meier DE, Litke A, et al.: The symptom burden of chronic critical illness. Crit Care Med 2004;32:1527–1534.
30.
Needham DM, Davidson J, Cohen H, et al.: Improving long-term outcomes after discharge from intensive care unit: Report from a stakeholders' conference. Crit Care Med 2012;40:502–509.
31.
De Miranda S, Pochard F, Chaise M, et al.: Postintensive care unit psychological burden in patients with chronic obstructive pulmonary disease and informal caregivers: A multicenter study. Crit Care Med 2011;29:112–118.
32.
Swoboda SM, Lipsett PA: Impact of a prolonged surgical critical illness on patients' families. Am J Crit Care 2011;11:459–466.
33.
Van Pelt DC, Milbrandt EB, Qin L, et al.: Informal caregiver burden among survivors of prolonged mechanical ventilation. Am J Respir Crit Care Med 2007;175:167–173.
34.
Choi J, Donahoe MP, Zullo TG, et al.: Caregivers of the chronically critically ill after discharge from the intensive care unit: Six months' experience. Am J Crit Care 2011;20:12–22.
35.
Pochard F, Darmon M, Fassier T, et al.: Symptoms of anxiety and depression in family members of intensive care unit patients before discharge or death. A prospective multicenter study. J Crit Care 2005;20:90–96.
36.
Anderson WG, Arnold RM, Angus DC, et al.: Posttraumatic stress and complicated grief in family members of patients in the intensive care unit. J Gen Intern Med 2008;23:1871–1876.
37.
Siegel MD, Hayes E, Vanderwerker LC, et al.: Psychiatric illness in the next of kin of patients who die in the intensive care unit. Crit Care Med 2008;36:1722–1728.
38.
Cameron JI, Chu LM, Matte A, et al.: One-year outcomes in caregivers of critically ill patients. NEJM 2016;374:1831–1841.
39.
[No authors listed]: Optimum care for hopelessly ill patients—A report of the clinical care committee of the Massachusetts General Hospital. NEJM 1976;295:362–364.
40.
Fried C: Terminating life support: Out of the closet! NEJM 1976;195:390–391.
41.
Prendergast TJ, Luce JM: Increasing incidence of withholding and withdrawal of life support from the critically ill. Am J Respir Crit Care Med 1997;155:15–20.
42.
Pefoyo AJ, Bronskill SE, Gruneir A, et al.: The increasing burden and complexity of multimorbidity. BMC Public Health 2015;15:415.
43.
Aslakson R, Cheng J, Vollenweider D, et al.: Evidence-based palliative care in the intensive care unit: A systematic review of interventions. J Palliat Med 2014;17:219–235.
44.
Campbell ML, Guzman JA: A proactive approach to improve end-of-life care in a medical intensive care unit for patients with terminal dementia. Crit Care Med 2004;32:1839–1843.
45.
Curtis JR, Treece PD, Nielsen EL, et al.: Integrating palliative and critical care: Evaluation of a quality-improvement intervention. Am J Respir Crit Care Med 2008;178:269–275.
46.
Lautrette A, Darmon M, Megerbane B, et al.: A communication strategy and brochure for relatives of patients dying in the ICU. NEJM 2007;356:469–478.
47.
Norton SA, Hogan LA, Holloway RG, et al.: Proactive palliative care in the medical intensive care unit: Effects on length of stay for selected high risk patients. Crit Care Med 2007;35:1530–1535.
48.
Carlson RW, Devich L, Frank RR: Development of a comprehensive supportive care team for the hopelessly ill on a university hospital medical service. JAMA 1988;259:378–383.
49.
Penrod JD, Luhrs CA, Livote EE, et al.: Implementation and evaluation of a network-based pilot program to improve palliative care in the intensive care unit. J Pain Symptom Manage 2011;42:672–675.
50.
Schneiderman LJ, Gilmer T, Teetzel HD, et al.: Effects of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting: A randomized controlled trial. JAMA 2003;290:1166–1172.
51.
Scheunemann LP, McDevitt M, Carson SS, et al.: Randomized, controlled trials of interventions to improve communication in intensive care: A systematic review. Chest 2011;139:543–554.
52.
Khandelwel N, Kross EK, Engelberg RA, et al.: Estimating the effect of palliative care interventions and advance care planning on ICU utilization: A systematic review. Crit Care Med 2015;43:1102–1111.
53.
Aslakson RA, Curtis JR, Nelson JE: The changing role of palliative care in the ICU. Crit Care Med 2014;42:2418–2428.
54.
Schaefer KG, Block SD: Physician communication with families in the ICU: Evidence-based strategies for improvement. Curr Opin Crit Care 2009;15:569–577.
55.
Andereck WS, McGaughey JW, Schneiderman LJ, Jonson AR: Seeking to reduce nonbeneficial treatment in the ICU: An exploratory trial of proactive ethics intervention. Crit Care Med 2014;42:824–830.
56.
Schneiderman LJ, Gilmer T, Teetzel HD: Impact of ethics consultations in the intensive care setting: A randomized, controlled trial. Crit Care Med 2000;28:3920–3924.
57.
Curtis JR, Treece PD, Nielsen EL, et al.: Randomized trial of communication facilitator to reduce family distress and intensive of end-of-life care. Am J Crit Care Med 2016;193:154–162.
58.
Carson SS, Cox CE, Wallenstein S, et al.: Effect of palliative care-led meetings for families of patients with chronic critical illness: A randomized controlled trial. JAMA 2016;316:51–62.
59.
Brown CE, Jecker NS, Curtis JR: Inadequate palliative care in chronic lung disease: An issue of healthcare inequality. Ann Am Thorac Soc 2016;13:311–316.
60.
Organization WH: Global atlas of palliative care at the end of life. 2016. www.thewhpca.org/resources/global-atlas-on-end-of-life-care. (Last accessed June 30, 2016).
61.
Diaz-Guzman E, Mannino DM: Epidemiology and prevalence of chronic obstructive pulmonary disease. Clin Chest Med 2014;35:7–16.
62.
Murray SA, Kendall M, Boyd K, Sheikh A: Illness trajectories and palliative care. BMJ 2005;330:1007–1011.
63.
Steer J, Gibson J, Bourke SC: The DECAF Score: Predicting hospital mortality in exacerbations of chronic obstructive pulmonary disease. Thorax 2012;67:970–976.
64.
Hajizadeh N, Goldfeld K, Crothers K: What happens to patients with COPD with long-term oxygen treatment who receive mechanical ventilation for COPD exacerbation? A 1-year retrospective follow-up study. Thorax 2015;70:294–296.
65.
Weingaertner V, Scheve C, Gerdes V, et al.: Breathlessness, functional status, distress, and palliative care needs over time in patients with advanced chronic obstructive pulmonary disease or lung cancer: A cohort study. J Pain Symptom Manage 2014;48:569.e1–581.e1.
66.
Joshi M, Joshi A, Bartter T: Symptom burden in chronic obstructive pulmonary disease and cancer. Curr Opin Pulm Med 2012;18:97–103.
67.
Brown CE, Engelberg RA, Nielsen EL, Curtis JR: Palliative care for patients dying in the ICU with chronic lung disease compared to metastatic cancer. Ann Am Thorac Soc 2016;13:684–689.
68.
Lindell KO, Liang Z, Hoffman LA, et al.: Palliative care and location of death in decedents with idiopathic pulmonary fibrosis. Chest 2015;147:423–429.
69.
Bajwah S, Higginson IJ, Ross JR, et al.: The palliative care needs for fibrotic interstitial lung disease: A qualitative study of patients, informal caregivers and health professionals. Palliat Med 2013;27:869–876.
70.
Swetz KM, Shanafelt TD, Drozdowicz LB, et al.: Symptom burden, quality of life, and attitudes toward palliative care in patients with pulmonary arterial hypertension: Results from a cross-sectional patient survey. J Heart Lung Transplant 2012;31:1102–1108.
71.
Batzlaff CM, Karpman C, Afessa B, Benzo RP: Predicting 1-year mortality rate for patients admitted with an acute exacerbation of chronic obstructive pulmonary disease to an intensive care unit: An opportunity for palliative care. Mayo Clin Proc 2014;89:638–643.
72.
Boland J, Owen J, Ainscough R, Mahdi H: Developing a service for patients with very severe chronic obstructive pulmonary disease (COPD) within resources. BMJ Support Palliat Care 2014;4:196–201.
73.
Boland J, Martin J, Wells AU, Ross JR: Palliative care for people with non-malignant lung disease: Summary of current evidence and future direction. Palliat Med 2013;27:811–816.
74.
Gardiner C, Gott M, Small N, et al.: Living with advanced chronic obstructive pulmonary disease: Patients concerns regarding death and dying. Palliat Med 2009;23:691–697.
75.
Walke LM, Byers AL, Tinetti ME, et al.: Range and severity of symptoms over time among older adults with chronic obstructive pulmonary disease and heart failure. Arch Intern Med 2007;167:2503–2508.
76.
Mularski RA, Reinke LF, Carrieri-Kohlman V, et al.: An official American Thoracic Society workshop report: Assessment and palliative management of dyspnea crisis. Ann Am Thorac Soc 2013;10:S98–S106.
77.
Mahler DA, O'Donnell DE: Recent advances in dyspnea. Chest 2015;147:232–241.
78.
Mularski RA, Rocker G: Managing dyspnea in advanced chronic obstructive pulmonary disease: Balancing all the evidence. Ann Am Thorac Soc 2015;12:978–980.
79.
Rochester CL, Vogiatzis I, Halland AE, et al.: An official American Thoracic Society/European Respiratory Society policy statement: Enhancing implementation, use, and delivery of pulmonary rehabilitation. Am J Respir Crit Care Med 2015;192:1373–1386.
80.
Benzo R, Vickers K, Novotny PJ, et al.: Health coaching and COPD re-hospitalization: A randomized study. Am J Respir Crit Care Med 2016;194:672–680.
81.
Courtright KR, Madden V, Gabler NB, et al.: Rationale and Design of the Randomized Evaluation of Default Access to Palliative Services (REDAPS) Trial. Ann Am Thorac Soc 2016;13:1629–1639.
82.
Benzo R, Vickers K, Novotny PJ, et al.: Health coaching and chronic obstructive pulmonary disease rehospitalization. A randomized study. Am J Respir Crit Care Med 2016;194:672–680.
83.
Higginson IJ, Bausewein C, Reilly CC, et al.: An integrated palliative and respiratory care service for patients with advanced disease and refractory breathlessness: A randomised controlled trial. Lancet Respir Med 2014;2:979–987.
84.
Barnes H, McDonald J, Smallwood N, et al.: Opioids for the palliative of refractory breathlessness in adults with advanced disease and terminal illness. Cochrane Database Syst Rev 2016;3:CD011008.
85.
Abernethy AP, Currow DC, Frith P, et al.: Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnoea. BMJ 2003;327:523–528.
86.
Currow DC, McDonald C, Oaten S, et al.: Once-daily opioids for chronic dyspnea: A dose increment and pharmacovigilance study. J Pain Symptom Manage 2011;42:388–399.
87.
Au DH, Udris EM, Engelberg RA, et al.: A randomized trial to improve communication about end-of-life care among patients with COPD. Chest 2012;141:726–735.
88.
Detering KM, Hancock AD, Reade MC, Silvester W: The impact of advance care planning on end of life care in elderly patients: Randomised controlled trial. BMJ 2010;340:c1345.
89.
Daly K, Kleinpell RM, Lawinger S, Casey G: The effect of two nursing interventions on families of ICU patients. Clin Nurs Res 1994;3:414–422.
90.
Medland JJ, Ferrans CE: Effectiveness of a structured communication program for family members of patients in an ICU. Am J Crit Care 1998;7:24–29.
91.
Lilly CM, De Meo DL, Sonna LA, et al.: An intensive communication intervention for the critically ill. Am J Med 2000;109:469–475.
92.
Lilly CM, Sonna LA, Haley KJ, Massaro AF: Intensive communication: Four-year follow-up from a clinical practice study. Crit Care Med 2003;31:S394–S399.
93.
Azoulay E, Pochard F, Chevret S, et al.: Impact of a family information leaflet on effectiveness of information provided to family members of intensive care unit patients: A multicenter, prospective, randomized, controlled trial. Am J Respir Crit Care Med 2002;165:438–442.
94.
Burns JP, Mello MM, Studdert DM, et al.: Results of a clinical trial on care improvement for the critically ill. Crit Care Med 2003;31:2107–2117.
95.
Jacobowski NL, Girard TD, Mulder JA, Ely EW: Communication in critical care: Family rounds in the intensive care unit. Am J Crit Care 2010;19:421–430.
96.
Ahrens T, Yancey V, Kollef M: Improving family communications at the end of life: Implications for length of stay in the intensive care unit and resource use. Am J Crit Care 2003;12:317–323.
97.
Shelton W, Moore CD, Socaris S, et al.: The effect of a family support intervention on family satisfaction, length-of-stay, and cost of care in the intensive care unit. Crit Care Med 2010;38:1315–1320.
98.
Holloran SD, Starkey GW, Burke PA, et al.: An educational intervention in the surgical intensive care unit to improve ethical decisions. Surgery 1995;118:294–298.
99.
Villarreal D, Restrepo MI, Healy J, et al.: A model for increasing palliative care in the intensive care unit: Enhancing interprofessional consultation rates and communication. J Pain Symptom Manage 2011;42:676–679.
100.
Treece PD, Engelberg RA, Crowley L, et al.: Evaluation of a standardized order form for the withdrawal of life support in the intensive care unit. Crit Care Med 2004;32:1141–1148.
101.
Hall RI, Rocker GM, Murray D: Simple changes can improve conduct of end-of-life care in the intensive care unit. Can J Anaesth 2004;51:631–636.
102.
Field BE, Devich LE, Carlson RW: Impact of a comprehensive supportive care team on management of hopelessly ill patients with multiple organ failure. Chest 1989;96:353–356.
103.
Dowdy MD, Robertson C, Bander JA: A study of proactive ethics consultation for critically and terminally ill patients with extended lengths of stay. Crit Care Med 1998;26:252–259.
104.
Campbell ML, Guzman JA: Impact of a proactive approach to improve end-of-life care in a medical ICU. Chest 2003;123:266–271.
105.
Curtis JR, Nielsen EL, Treece PD, et al.: Effect of a quality-improvement intervention on end-of-life care in the intensive care unit: A randomized trial. Am J Respir Crit Care Med 2011;183:348–355.
106.
Lamba S, Murphy P, McVicker S, et al.: Changing end-of-life care practice for liver transplant service patients: Structured palliative care intervention in the surgical intensive care unit. J Pain Symptom Manage 2012;44:508–519.
107.
Rocker GM, Verma JY: ‘INSPIRED’ COPD outreach program: Doing the right things right. Clin Invest Med 2014;37:E311–E319.
108.
Currow DC, Agar M, Smith J, Abernethy AP: Does palliative home oxygen improve dyspnoea? A consecutive cohort study. Palliat Med 2009;23:309–316.
109.
Currow DC, Quinn S, Greene A, et al.: The longitudinal pattern of response when morphine is used to treat chronic refractory dyspnea. J Palliat Med 2013;16:881–886.
110.
Abernethy AP, McDonald CF, Frith PA, et al.: Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: A double-blind, randomised controlled trial. Lancet 2010;376:784–779.
111.
Rabow M, Kvale E, Barbour L, et al.: Moving upstream: A review of the evidence of the impact of outpatient palliative care. J Palliat Med 2013;16:1540–1549.
112.
Gomes B, Cakanzanu N, Curiale V, et al.: Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers. Sao Paulo Med J. 2016;134:93–94.
113.
Barnes H, McDonald J, Smallwood N, Manser R: Opioids for the palliation of refractory breathlessness in adults with advanced disease and terminal illness. Cochrane Database Syst Rev 2016;3:CD011008.

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cover image Journal of Palliative Medicine
Journal of Palliative Medicine
Volume 20Issue Number 4April 2017
Pages: 329 - 343
PubMed: 28379812

History

Published in print: April 2017
Published online: 1 April 2017
Accepted: 3 January 2017

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Rebecca A. Aslakson
Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins School of Medicine, Baltimore, Maryland.
Department of Oncology and Palliative Care Program in the Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, Maryland.
Department of Health, Behavior and Society, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
Lynn F. Reinke
Department of Veterans Affairs, Puget Sound Healthcare System, Seattle, Washington.
Department of Biobehavioral Nursing and Health Systems, University of Washington, Seattle, Washington.
Christopher Cox
Department of Medicine, Duke University, Durham, North Carolina.
Erin K. Kross
Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, Washington.
Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington.
Roberto P. Benzo
Mindful Breathing Laboratory, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota.
J. Randall Curtis
Division of Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, Washington.
Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington.

Notes

Address correspondence to:Rebecca A. Aslakson, MD, PhD, FAAHPM, FCCMDepartment of Anesthesiology and Critical Care MedicineThe Johns Hopkins Hospital1800 Orleans Street, Meyer 289Baltimore, MD 21287E-mail: [email protected]

Author Disclosure Statement

No competing financial interests exist.

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