How to say…..

Craig HoreIntensive Care UnitLiverpool Hospital

The ICU in 2023?

1. If you want everything done, we’re always open! 2. ECMO is always the answer, no matter the question

Remember our philosophy:

Bring out your dead!

“Refusal”???

Appropriateness?

- appropriate referrals

- appropriate admissions

- appropriate management in wards and ICU

- appropriate communications

A better prospect for 2023!

ICU triage

When evaluating a patient with a severe When evaluating a patient with a severe acute illness for ICU admission determine:acute illness for ICU admission determine:

(i)(i) the the diagnosisdiagnosis, prognosis, and treatment;, prognosis, and treatment;

(ii)(ii)patient characteristics and co-morbidities;patient characteristics and co-morbidities;

(iii)(iii)whether the patient, if competent, (or whether the patient, if competent, (or surrogate) consents to ICU admission;surrogate) consents to ICU admission;

(iv)(iv)and if they do, whether or not ICU and if they do, whether or not ICU admission is warranted.admission is warranted.

ICU triage

The number of beds The number of beds available in ICU!available in ICU!

Do some patients deserve an automatic

?

What ICU referrals commonly make you go

hmmmm… Which ones make you instinctively think

“NO”?

ICU consultant considers another referral….

Patients with cancer in the ICU

“These patients never do well….”

“The ‘cures’ are worse than the disease..”

VS

21st Century!!!

Advances in management in ICU as well as oncology and haematology

Patients with cancer in the ICU

So what exactly are the outcomes?

Cancer and mechanical ventilation – the past

Authors Journal Patients

(N)

Malignancy ICU

Mortality

Hospital

Mortality

Snow JAMA 1979 180 Solid tumors 74 87

Ewer JAMA 1986 46 Lung cancer 85 87

Peters Chest 1988 119 Hematologic / 82

Dees NJM 1990 49 Both 67 76

Lee JAMA 1995 115 Both 77 97

Tremblay CIM 1995 32 AML 99 99

Epner J I M 1996 157 Hematologic / 83

Cancer patients needing ICU in 2013

Improved survival rates reported in cancer patients requiring mechanical ventilation, CRRT and vasopressors

But limitations – heterogeneity; single centres; retrospective; short-term outcomes (rarely 3 or 6 month survival)

Cancer patients needing ICU in 2013

Some sub-groups continue to have a high and unchanged mortality:

- bedridden patients

- allogeneic BMT recipients with severe GVHD not responsive to chemotherapy

- multiple organ failure (“delayed ICU admission”?)

- specific vignettes (eg pulmonary carcinomatosis lymphangitis; carcinomatous meningitis with coma)

- not on “life-span expanding therapy”(Azoulay et al Annals Intensive Care 2011)

Cancer patients in the ICU

““Only cancer patients with a chance of Only cancer patients with a chance of being cured, who agree to undergo being cured, who agree to undergo

supportive therapy, and those with best supportive therapy, and those with best chances of benefiting from intensive chances of benefiting from intensive

care should be admitted by priority”.care should be admitted by priority”.

Sculier Sculier Curr Opin OncolCurr Opin Oncol 1991;3:656-662 1991;3:656-662

As true now as in 1991!

Cancer patients in ICU – admit or not?

“Full active management” newly diagnosed malignancies and malignancies in “complete remission”

3 day ICU trial as an alternative to ICU refusal in other cancer patients?

The nature and extent of organ dysfunctions at ICU admission, and especially after day 3, are good predictors of mortality

Those in sub-groups mentioned earlier – comfort cares

(Azoulay et al Annals Intensive Care 2011)

Elderly patients in the ICU “ICU care provided to younger patients is more

effective and more likely to be successful….they’re more resilient and able to recover”

“If ICU care is successful and the patient recovers, a young person gains more years of life to live….whole life ahead of them rather than behind them”

“Where I worked before we would never admit anyone over (insert random number here) years of age…”

Elderly patients in the ICU “But he’s a good 81 year old……”

The oldest man to climb Mt Everest is Yuichiro Miura (Japan, b. 12 October 1932), who reached the summit on 23 May 2013 at the age of 80 years 223 days. This is the third time that he has held this record: he previously reached the highest point on Earth as the world's oldest summiteer in 2003 and again at 2008.

Elderly patients in the ICU ANZICS CORE (2000 – 2005): 15,640 patients aged ≥

80yrs (13.0%)

Age ≥ 80 years:

- higher ICU and hospital death compared with younger cohorts

- more likely to be discharged to rehabilitation / long-term care

Factors associated with lower survival included: admission from a chronic care facility, co-morbid illness, nonsurgical admission, greater illness severity, mechanical ventilation, and longer stay in the ICU.

Bagshaw, Webb et al. Crit Care, 2009.

Elderly patients in the ICU Netherlands

129 people 80+ years old vs 620 people <80 years

Admitted to ICU for >48 hours

Elderly patients: mean age 83; median APACHE II of 18; median ventilator days 3

Primary outcome was health-related quality of life HRQOL before and after ICU admission.

Hofhuis, Spronk et al: CHEST 2008

Elderly patients in the ICU Main conclusion: HRQOL recovered to pre-ICU

baseline by 6 months, and in fact were close to age-matched controls.

“Denying admission to the ICU should not just rely on old age.”

VERY TRUE!

But…….

- 49 of 129 octogenarians survived to be analysed at 6 months (62% mortality rate)

- the younger (~67 year old) cohort did better at six months, although still poorly (43% mortality rate)

Elderly patients in the ICU Elderly cohort relatively healthy pre-ICU - likely

bias toward admitting healthier elderly patients to the ICU

Isn’t this the real point?

Elderly patients in the ICU

“Age…represents an additive factor when coupled with frailty, physiologic reserve, burden of co-morbid illness, primary diagnosis, and illness severity……”

“……important bearing not only on short- term survival but also on long-term survival, neurocognitive performance, functional autonomy, and quality of life.”

Bagshaw, Webb et al. Crit Care, 2009.

Similar conclusions

Patients with cancer are a heterogeneous group

The elderly are a heterogenous group

Similar conclusions for any patient group!

Appropriate patient selection not routine denial!

ICU triage

When evaluating a patient with a severe When evaluating a patient with a severe acute illness for ICU admission determine:acute illness for ICU admission determine:

(i) the (i) the diagnosisdiagnosis, prognosis, and treatment;, prognosis, and treatment;

(ii) whether the patient, if competent, (or (ii) whether the patient, if competent, (or surrogate) consents to ICU admission;surrogate) consents to ICU admission;

(iii) and if they do, whether or not ICU (iii) and if they do, whether or not ICU admission is warranted.admission is warranted.

Some common reasons raised to stop you

saying

“….but this is REVERSIBLE!”

Reversible ≠ must treat Context!

“….but the family want EVERYTHING done!”

Was the right question asked?

“… but this is IATROGENIC…”

Iatrogenic ≠ must treat Context!

A reminder on medical futility Medical Board of Australia 2012:

- “you do not have a duty of care to prolong life at all cost. However, you have a duty to know when not to inititiate and when to cease attempts at prolonging life.”

- as Intensivists, this is part of our specialist expertise – embrace it!

So the time has come……how do I say

General principles Knowledge!

Consider risks and benefits of different modalities of treatment

Consider risks and benefits of ICU admission

Involve the patient (where able)!

Involve the surrogate decision-maker

Involve the family

Involve the admitting team

Suggestions if conflict

Clarify goals of treatment – cure; prolong survival; symptom relief

- consider interests of patient first (but don’t ignore interests of the family)

- consider biases that may be influencing your decision (fear of litigation; fear of conflict; bullying; lack of knowledge)

- seek expert advice (senior colleague or other expert) when needed

Adapted from Koczwara: MJA, 2013

Suggestions if conflict Communicate with patient and significant others

and clarify any areas of disagreement

Use clear, consistent communication. Consultant level.

Involve a third party if necessary

Support the patient, his or her family and the staff

Offer alternatives (“not for ICU but this is what we can do…”)

Adapted from Koczwara: MJA, 2013

Suggestions if conflict

The ICU in 2023?

Remember our philosophy: