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: