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Is Intensive Care becoming an out-of-hours acute palliative care service?

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It's hard to die without passing through MET-calling criteria; if you try to do so on a hospital ward, chances are you'll have an Intensivist next to you. By designing systems to detect patient deterioration, we've inadvertently invented acute palliative care. How did we move from resuscitators to out-of-hours death doulas so rapidly? Is death the future of Intensive Care Medicine?

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Is Intensive Care becoming an out-of-hours acute palliative care service?

  1. 1. DONATING INTENSIVISTS’ R.E.M. SLEEP alex psirides @psirides 26th march 2019 TO PALLIATIVE CARE COLLEAGUES
  2. 2. “ First I will define what I conceive medicine to be. In general terms, it is to do away with the sufferings of the sick, to lessen the violence of their diseases, and to refuse to treat those who are overmastered by their disease, realising that in such cases medicine is powerless. Hippocrates 400 BC
  3. 3. “Most clinicians felt strongly that end-of-life care should be part of their core business, but it appears that this is not always usual practice. Outsourcing end-of-life care to the medical emergency team, the palliative care team or the intensive care team appears to be common practice.”
  4. 4. 50% of Australians will die in hospital despite most wanting to die at home Risk factors associated with in-hospital death include advanced age, history of severe organ failure, immunosuppression, abnormal vital signs & severe electrolyte derangement
  5. 5. Works with awesome team James Bond Iron Man Crime Scene Investigator Cool gadgets Deals with death regularly Mostly Works Office Hours PALLIATIVE CARE Adapted from tweet by @Anaesthesia_AGB INTENSIVISTINTENSIVIST
  6. 6. Being healthy means dying as slowly as possible
  7. 7. 6 I think it’s clinicians’ fear. As my oncologist said, ‘We’re here to keep you alive.’ When I asked him some years ago, ‘Look realistically, what’s my time frame?’, he didn’t like that question. Death is everyone’s business, it’s our common lot. It’s not a medical problem. Dying isn’t a failure of medicine: it just is. PATIENT DIRECTOR OF PALLIATIVE CARE
  8. 8. sick person with a reversible process who would benefit most from intensive care dying person with an irreversible process who would benefit most from palliative care
  9. 9. the rise of the SOD & the fall of the MOD
  10. 10. Barnett, Lancet 2012 Patients and doctors are moving in opposite directions
  11. 11. Old Medical Model Current Medical Practice Single acute pathology Multiple chronic pathologies Short term conditions predominate Long term conditions predominate Diagnose, treat, cure Ameliorate, listen, explain, advise, console Survival dependent upon skills of paramedical, medical & nursing staff Survival dependent upon patient’s lifestyle choices Smith, BMJ 2015
  12. 12. You can’t die without mee0ng the MET
  13. 13. 6 SUPPORT THEM, THEIR FAMILY & YOUR COLLEAGUES WHILE THEY DIE YES Are you sure? NO DO MEDICAL STUFF YES NO YES TELL THEM then ask them what they would like Go you! High fives all round & go to Pub NO YES NO ‘Everything’ ‘Comfort’ Review patient Are they dying? MET or ICU REFERRAL Are you sure they’re not just actually dying? Did you make them better?
  14. 14. DO MEDICAL STUFF •DIAGNOSE •TREAT •CURE MAKE A DECISION
  15. 15. dying doesn’t have a biomarker
  16. 16. CRITICAL CARE CONVEYOR BELT
  17. 17. 4 the bad death •Occurs on bedroom floor or in an acute hospital bed •Nurses or doctors present, not family or friends •Occurs during or immediately after a treatment or procedure that doesn’t change outcome •Patient may have been unaware they were dying •Monitors & alarms •Lack of dignity •Ignorance of cultural/ spiritual needs •THE DEFAULT
  18. 18. “ To answer your question very directly, you asked ‘Do people die well in this hospital?’ They absolutely do not. People are allowed to linger for far too long, in far too much pain, and causing far too much distress to themselves and their family and the people who care for them… The current situation, to speak frankly, is completely unacceptable. Intensive Care Consultant, Australian Public Hospital
  19. 19. 3 how can we change things? •encourage palliative care exposure for ICU trainees •talk to patients about not doing stuff & why •ask your patients what they want •ask your hospital to employ more palliative care clinicians then invite them into your ICU •always consider ‘is this patient actually dying?’
  20. 20. “Sometimes patients know they are dying and just hope that someone actually mentions it at some point. Chaplain, Australian Public Hospital
  21. 21. @psirides AlliconsfromTheNounProject Thank you wellingtonicu.com

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