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Adaptive coping after critical illness: a novel
mobile patient-centered intervention
Christopher Cox
Duke University Pulmonary, Critical Care, and Palliative Medicine
Mike: 48yo with ARDS from pneumonia.
Gets home—weak, PTSD. Why am I like this?
Patient-centered
care…dimensions &
concepts
Open information access
Collaborative management
Family & friends involved
Non-medical & spiritual needs
Respect for patient preferences
Physical / emotional
symptoms
1
Balint 1969
Picker Institute/Commonwealth 1993
Curtis, Rubenfeld, Angus, Herridge, Needham, Carson, Hopkins PCORI 2011
Patient-centered
care…dimensions &
concepts
information access
collaborative management
family & friends involved
non-medical & spiritual needs
respect for patient preferences
1
physical / emotional symptoms
2
Balint 1969
Picker Institute/Commonwealth 1993
Curtis, Rubenfeld, Angus, Herridge, Needham, Carson, Hopkins PCORI 2011
Challenges of
patient-centered
outcomes
Define, prioritize, measure, ask?
How to engage patients in research?
When you have a hammer…aligning
patient interests & research capacity
Patient – provider translator?
Gabriel SE 2012
Past and current: the impact of critical
illness is profound and persistent
ADL
difficulties
50-70%
daily
informal
caregiving
50-75%
not back to
work
50%
psych.
distress
50-75%
life savings
lost
60%
Herridge, Stelling, Covinsky, Carson, Nelson, Cox, Bienvenu, Needham, 1990s-2000s
Psychological distress symptoms
are serious among ICU survivors
Distress = depression, anxiety, PTSD
40% saw a mental health provider
50% using psych meds after discharge
Many patients describe in their own words:
“People sometimes do not know what you go through.
They think that because you are in one piece, everything is
fine. But inside I’m all screwed up now.”
Weinert 2006; Cox 2009; Bienvenu 2013
Psychological distress: difficult to prevent,
complicated to treat
Delusional
memories
Treatment
(sedation,
PaO2, glucose)
Symptoms
Social
support
Cognit
ion
Caregi
ving
needs
Comorb
idities &
psych
history
Illness
severity
Communication
Davydow 2011, Azoulay 2005, Bienvenu 2013
Trajectories of post-discharge health are
complicated and tough to predict
cancer
chemo
health
status
septic
shock
Trajectories of post-discharge health are
complicated and tough to predict
cancer
depression,
anxiety,
PTSD
chemo
septic
shock
And other
challenges…
Heterogeneous patients
Very disabled—hard to return to clinic
Logistical
challenges
Transient and permanent disability
Few targeted therapies
Gabriel SE 2012
How can I get my life back?
critical illness defining
sense of self
pervasive
traumatic
memories
inability to cope
with new
disability
Study 1
Cox 2009
patient-family
relationship
strain
day to day
impact of
critical illness
What is coping: thoughts and actions used
to manage stress…not a passive process
Stress
emotional
physical
psychological
etc
+
adaptive /
constructive
coping
maladaptive /
destructive
coping
Conceptual model of coping & distress
Problems Common to ICU Survivors
- Psychological distress
- Barriers to post-discharge care for distress
- Few treatment options perceived by patients
Coping Frequency & Quality
Self Efficacy
Psychological Distress
Quality of Life
Study 2: Poor coping ability is common
among ICU survivors
Significant depression
Patients
(n=21)
12 (58%)
Caregivers
(n= 23)
5 (22%)
Significant anxiety
14 (66%)
11 (48%)
Significant PTSD symptoms
12 (58%)
7 (30%)
Quality of life
70 (35, 75)
60 (29, 83)
Poor coping, general
21 (100%)
23 (100%)
Poor coping, global attributes
14 (66%)
12 (52%)
Cox, Porter, Keefe, et al. 2012
Study 2: Maladaptive coping is correlated
with psychological distress & QOL
Infrequent
coping
r = 0.39 - 0.66
Poor QOL
r = 0.30 - 0.75
r = 0.36 - 0.80
Anxiety
r = 0.32 - 0.72
PTSD
Depression
Cox, Porter, Keefe, et al. 2012
Study 3: Can we
develop a coping skills
intervention that is
feasible, acceptable, and
shows promise?
Development of coping skills intervention
Evaluation of coping skills intervention
Study 3: Can we
develop a coping skills
intervention that is
feasible, acceptable, and
shows promise?
Cox, Porter, Keefe, et al. 2012
Coping and
distress
assessment
Assessed for eligibility
34 patients
34 informal caregivers
Excluded
6 patients didn't meet inclusions
4 patients died
2 caregivers refused
1 patient refused
Enrolled & interviewed
6 weeks post-discharge
21 patients
23 informal caregivers
Derivation
of coping
skills
intervention
Prospective
evaluation
of coping
intervention
Assessed for eligibility
16 patients
16 informal caregivers
Excluded
4 patients didn't meet inclusions
2 caregivers refused
3 patients died
Enrolled
7 patients
7 informal caregivers
Interview 1
patients & caregivers
~2 weeks of arrival home
HADS, PTSS, COPE
Intervention
12 weekly
coping skills sessions
Interview 2
patients & caregivers
~1 week post-intervention
HADS, PTSS, COPE
acceptability
Study 3: Individualization, selfmanagement, collaborative care
Cox, White, Carson, Hough, Kahn, Porter, Keefe 2012
Study 3: Coping skills intervention
elements for specific distress targets
Day to
day
impact of
critical
illness
Inability to
cope with
post-ICU
disability
problem solving
activity-rest cycling
Patientcaregiver
relationship
strain
Critical
illness
defining
sense of
self
behavioral rehearsal
relaxation training
communication
techniques
maintenance planning
problem solving
activity-rest cycling
pervasive
traumatic
memories
cognitive restructuring
pleasant imagery
How does coping training work in
practice?
Mrs. Edwards says main stressor is post-ICU physical disability.
She also has troubling memories of the ICU.
Session 1 starts with activity-rest cycling, focusing on activities of
daily living that she values. She reviews the material in the
guidebook and discusses it with her daughter.
At Session 2, she is more confident in her ability to manage
distress. The next topic most relevant to her distress about
troubling memories is begun (cognitive restructuring).
This strategy of personalization, self-management, and feedback
continues through other phone sessions.
Study 3: Coping skills training
may reduce distress
Figure 8: CST pilot results. CST resulted in reductions in HADS
Cox, Porter,
Keefe,
al. 2012
(depression, anxiety)
and PTSS
(PTSD)et
scores,
as well as
Study 3: Conceptual model validated:
distress reduction correlates with enhanced
self-efficacy & adaptive coping
PSTD
Depression
Anxiety
r = 0.50 - 0.80
Selfefficacy
r = 0.40 - 0.76
Adaptive
Coping
Skills
Cox, Porter, Keefe, et al. 2012
Study 3: Evaluation: coping skills program
feasible & acceptable
Current RCT: adaptive coping skills vs.
education programs by phone & web
Problems Common to ICU Survivors
-
Psychological distress
Barriers to post-discharge care for distress
Informational needs that are not addressed
Few treatment options perceived by patients
EP
CST
Informational
Support
Coping Frequency
Self Efficacy
Self Efficacy
Psychological Distress
Quality of Life
Days at Home
I can get back on track faster
PS: challenges of
patient-centered
outcomes
Define, prioritize, measure, ask?
How to engage patients in research?
When you have a hammer…aligning
patient interests & research capacity
Patient – provider translator?
Gabriel SE 2012
What about the future of this and
similar interventions?
Choice & precision: Preference- and needsbased, individualizable treatment.
Self-management: Self-pacing, logic-based
content, non-professional interventionists, and
feedback on effect
Convenience & mobility: Balancing people
(human but more expensive) with mobile
devices (cheap, high tech, widely used).
Future?
Summary: coping skills training to reduce
distress using patient-centered methodology
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