***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND Formal family meetings have been recommended as a useful approach to assist in goal setting , facilitate decision making , and reduce use of ineffective re sources in the ICU . We examined patient outcomes before and after implementation of an intensive communication system ( ICS ) to test the effect of regular , structured formal family meetings on patient outcomes among long-stay ICU patients . METHODS One hundred thirty-five patients receiving usual care and communication were enrolled as the control group , followed by enrollment of intervention patients ( n = 346 ) , from five ICUs . The ICS included a family meeting within 5 days of ICU admission and weekly thereafter . Each meeting discussed medical up date , values and preferences , and goals of care ; treatment plan ; and milestones for judging effectiveness of treatment . RESULTS Using multivariate analysis , there were no significant differences between control and intervention patients in length of stay ( LOS ) , the primary end point . Similarly , there were no significant differences in indicators of aggressiveness of care or treatment limitation decisions ( ICU mortality , LOS , duration of ventilation , treatment limitation orders , or use of tracheostomy or percutaneous gastrostomy ) . Exploratory analysis suggested that in the medical ICUs , the intervention was associated with a lower prevalence of tracheostomy among patients who died or had do-not-attempt-resuscitation orders in place . CONCLUSIONS The negative findings of the main analysis , in combination with preliminary evidence of differences among types of unit , suggest that further examination of the influence of patient , family , and unit characteristics on the effects of a system of regular family meetings may be warranted . Despite the lack of influence on patient outcomes , structured family meetings may be an effective approach to meeting information and support needs . TRIAL REGISTRY Clinical Trials.gov ; No. : NCT01057238 ; URL : www . clinical trials.gov Objective : To provide a focused , detailed assessment of the symptom experiences of intensive care unit patients at high risk of dying and to evaluate the relationship between delirium and patients ' symptom reports . Design : Prospect i ve , observational study of patients ' symptoms . Setting : Two intensive care units in a tertiary medical center in the western United States . Patients : One hundred seventy-one intensive care unit patients at high risk of dying . Interventions : None . Measurements and Main Results : Patients were interviewed every other day for up to 14 days . Patients rated the presence , intensity ( 1 = mild ; 2 = moderate ; 3 = severe ) , and distress ( 1 = not very distressing ; 2 = moderately distressing ; 3 = very distressing ) of ten symptoms ( that is , pain , tired , short of breath , restless , anxious , sad , hungry , scared , thirsty , confused ) . The Confusion Assessment Method -Intensive Care Unit was used to ascertain the presence of delirium . A total of 405 symptom assessment s were completed by 171 patients . Patients ' average age was 58 ± 15 yrs ; 64 % were males . Patients were mechanically ventilated during 34 % of the 405 assessment s , and 22 % died in the hospital . Symptom prevalence ranged from 75 % ( tired ) to 27 % ( confused ) . Thirst was moderately intense , and shortness of breath , scared , confusion , and pain were moderately distressful . Delirium was found in 34.2 % of the 152 patients who could be evaluated . Delirious patients were more acutely ill and received significantly higher doses of opioids . Delirious patients were significantly more likely to report feeling confused ( 43 % vs. 22 % , p = .004 ) and sad ( 46 % vs. 31 % , p = .04 ) and less likely to report being tired ( 57 % vs. 77 % , p = .006 ) than nondelirious patients . Conclusions : Study findings suggest that unrelieved and distressing symptoms are present for the majority of intensive care unit patients , including those with delirium . Symptom assessment in high-risk intensive care unit patients may lead to more focused interventions to avoid or minimize unnecessary suffering BACKGROUND Ten percent to 20 % of trauma patients admitted to the intensive care unit ( ICU ) will die from their injuries . Providing appropriate end-of-life care in this setting is difficult and often late in the patients ' course . Patients are young , prognosis uncertain , and conflict common around goals of care . We hypothesized that early , structured communication in the trauma ICU would improve end-of-life care practice . METHODS Prospect i ve , observational , prepost study on consecutive trauma patients admitted to the ICU before and after a structured palliative care intervention was integrated into st and ard ICU care . The program included part I , early ( at admission ) family bereavement support , assessment of prognosis , and patient preferences , and part II ( within 72 hours ) interdisciplinary family meeting . Data on goals of care discussion s , do-not-resuscitate ( DNR ) orders and withdrawal of life support ( W/D ) were collected from physician rounds , family meetings , and medical records . RESULTS Eighty-three percent of patients received part I and 69 % part II intervention . Discussion of goals of care by physicians on rounds increased from 4 % to 36 % of patient-days . During intervention , rates of mortality ( 14 % ) , DNR ( 43 % ) , and W/D ( 24 % ) were unchanged , but DNR orders and W/D were instituted earlier in hospital course . ICU length of stay was decreased in patients who died . CONCLUSIONS Structured communication between physician and families result ed in earlier consensus around goals of care for dying trauma patients . Integration of early palliative care alongside aggressive trauma care can be accomplished without change in mortality and has the ability to change the culture of care in the trauma ICU IMPORTANCE A recent Centers for Disease Control and Prevention report found that more persons die at home . This has been cited as evidence that persons dying in the United States are using more supportive care . OBJECTIVE To describe changes in site of death , place of care , and health care transitions between 2000 , 2005 , and 2009 . DESIGN , SETTING , AND PATIENTS Retrospective cohort study of a r and om 20 % sample of fee-for-service Medicare beneficiaries , aged 66 years and older , who died in 2000 ( n = 270,202 ) , 2005 ( n = 291,819 ) , or 2009 ( n = 286,282 ) . A multivariable regression model examined outcomes in 2000 and 2009 after adjustment for sociodemographic characteristics . Based on billing data , patients were classified as having a medical diagnosis of cancer , chronic obstructive pulmonary disease , or dementia in the last 180 days of life . MAIN OUTCOME MEASURES Site of death , place of care , rates of health care transitions , and potentially burdensome transitions ( eg , health care transitions in the last 3 days of life ) . RESULTS Our r and om 20 % sample included 848,303 fee-for-service Medicare decedents ( mean age , 82.3 years ; 57.9 % female , 88.1 % white ) . Comparing 2000 , 2005 , and 2009 , the proportion of deaths in acute care hospitals decreased from 32.6 % ( 95 % CI , 32.4%-32.8 % ) to 26.9 % ( 95 % CI , 26.7%-27.1 % ) to 24.6 % ( 95 % CI , 24.5%-24.8 % ) , respectively . However , intensive care unit ( ICU ) use in the last month of life increased from 24.3 % ( 95 % CI , 24.1%-24.5 % ) to 26.3 % ( 95 % CI , 26.1%-26.5 % ) to 29.2 % ( 95 % CI , 29.0%-29.3 % ) . ( Test of trend P value was < .001 for each variable . ) Hospice use at the time of death increased from 21.6 % ( 95 % CI , 21.4%-21.7 % ) to 32.3 % ( 95 % CI , 32.1%-32.5 % ) to 42.2 % ( 95 % CI , 42.0%-42.4 % ) , with 28.4 % ( 95 % CI , 27.9%-28.5 % ) using a hospice for 3 days or less in 2009 . Of these late hospice referrals , 40.3 % ( 95 % CI , 39.7%-40.8 % ) were preceded by hospitalization with an ICU stay . The mean number of health care transitions in the last 90 days of life increased from 2.1 ( interquartile range [ IQR ] , 0 - 3.0 ) to 2.8 ( IQR , 1.0 - 4.0 ) to 3.1 per decedent ( IQR , 1.0 - 5.0 ) . The percentage of patients experiencing transitions in the last 3 days of life increased from 10.3 % ( 95 % CI , 10.1%-10.4 % ) to 12.4 % ( 95 % CI , 12.3%-2.5 % ) to 14.2 % ( 95 % CI , 14.0%-14.3 % ) . CONCLUSION AND RELEVANCE Among Medicare beneficiaries who died in 2009 and 2005 compared with 2000 , a lower proportion died in an acute care hospital , although both ICU use and the rate of health care transitions increased in the last month of life CONTEXT Although hospital mortality has decreased over time in the United States for patients who receive intensive care  , little is known about subsequent outcomes for those discharged alive . OBJECTIVE To assess 3-year outcomes for Medicare beneficiaries who survive intensive care . DESIGN , SETTING , AND PATIENTS A matched , retrospective cohort study was conducted using a 5 % sample of Medicare beneficiaries older than 65 years . A r and om half of all patients were selected who received intensive care and survived to hospital discharge in 2003 with 3-year follow-up through 2006 . From the other half of the sample , 2 matched control groups were generated :  hospitalized patients who survived to discharge ( hospital controls ) and the general population ( general controls )  , individually matched on age , sex , race , and whether they had surgery ( for hospital controls ) . MAIN OUTCOME MEASURE Three-year mortality after hospital discharge . RESULTS There were 35,308 intensive care unit ( ICU ) patients who survived to hospital discharge . The ICU survivors had a higher 3-year mortality ( 39.5 % ; n = 13,950 ) than hospital controls ( 34.5 % ; n = 12,173 ) ( adjusted hazard ratio [ AHR ] , 1.07 [ 95 % confidence interval { CI } , 1.04 - 1.10 ] ; P < .001 ) and general controls ( 14.9 % ; n = 5266 ) ( AHR , 2.39 [ 95 % CI , 2.31 - 2.48 ] ; P < .001 ) . The ICU survivors who did not receive mechanical ventilation had minimal increased risk compared with hospital controls ( 3-year mortality , 38.3 % [ n = 12,716 ] vs 34.6 % [ n=11,470 ] , respectively ; AHR , 1.04 [ 95 % CI , 1.02 - 1.07 ] ) . Those receiving mechanical ventilation had substantially increased mortality ( 57.6 % [ 1234 ICU survivors ] vs 32.8 % [ 703 hospital controls ] ; AHR , 1.56 [ 95 % CI , 1.40 - 1.73 ] ) , with risk concentrated in the 6 months after the quarter of hospital discharge ( 6-month mortality , 30.1 % ( n = 645 ) for those receiving mechanical ventilation vs 9.6 % ( n = 206 ) for hospital controls ; AHR , 2.26 [ 95 % CI , 1.90 - 2.69 ] ) . Discharge to a skilled care facility for ICU survivors ( 33.0 % ; n = 11,634 ) and hospital controls ( 26.4 % ; n = 9328 ) also was associated with high 6-month mortality ( 24.1 % for ICU survivors and hospital controls discharged to a skilled care facility vs 7.5 % for ICU survivors and hospital controls discharged home ; AHR , 2.62 [ 95 % CI , 2.50 - 2.74 ] ; P < .001 for ICU survivors and hospital controls combined ) . CONCLUSIONS There is a large US population of elderly individuals who survived the ICU stay to hospital discharge but who have a high mortality over the subsequent years in excess of that seen in comparable controls . The risk is concentrated early after hospital discharge among those who require mechanical ventilation STUDY OBJECTIVES To assess the impact of a proactive case finding approach to end-of-life care for critically ill patients experiencing global cerebral ischemia ( GCI ) after cardiopulmonary resuscitation and multiple organ system failure ( MOSF ) in comparison to historical control subjects . DESIGN Comparative study of retrospective and prospect i ve cohorts . SETTING Medical IC 
    Output:
    
Most of the interventions result ed in a decrease in hospital and ICU LOS .
Few interventions significantly affected satisfaction .
With one exception , the interventions decreased or had no effect on mortality .
There was no evidence of harm from any intervention .
However , existing evidence suggests proactive palliative care in the ICU , using either consultative or integrative palliative care interventions , decrease hospital and ICU LOS , do not affect satisfaction , and either decrease or do not affect mortality