Craig Hore on How to Say No: Refusing ICU Admissions

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Craig Hore gives important advice at BCC4 on when it is appropriate to refuse ICU admissions and how we should do it.

Published in: Health & Medicine

Craig Hore on How to Say No: Refusing ICU Admissions

  1. 1. How to say….. Craig Hore Intensive Care Unit Liverpool Hospital
  2. 2. The ICU in 2023? Bring out your dead! Remember our philosophy: 1. If you want everything done, we’re always open! 2. ECMO is always the answer, no matter the question
  3. 3. “Refusal”???  Appropriateness? - appropriate referrals - appropriate admissions - appropriate management in wards and ICU - appropriate communications A better prospect for 2023!
  4. 4. ICU triage  When evaluating a patient with a severe acute illness for ICU admission determine: (i) the diagnosis, prognosis, and treatment; (ii) patient characteristics and co-morbidities; (iii)whether the patient, if competent, (or surrogate) consents to ICU admission; (iv)and if they do, whether or not ICU admission is warranted.
  5. 5. ICU triage  The number of beds available in ICU!
  6. 6. Do some patients deserve an automatic ?
  7. 7. What ICU referrals commonly make you go hmmmm…  Which ones make you instinctively think “NO”? ICU consultant considers another referral….
  8. 8. 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
  9. 9. Patients with cancer in the ICU  So what exactly are the outcomes?
  10. 10. Cancer and mechanical ventilation – the past Authors Journal Patients Malignancy ICU (N) Hospital Mortality 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
  11. 11. 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)
  12. 12. 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)
  13. 13. Cancer patients in the ICU “Only cancer patients with a chance of being cured, who agree to undergo supportive therapy, and those with best chances of benefiting from intensive care should be admitted by priority”. Sculier Curr Opin Oncol 1991;3:656-662 As true now as in 1991!
  14. 14. 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)
  15. 15. 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…”
  16. 16. 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.
  17. 17. Elderly patients in the ICU  ANZICS CORE (2000 – 2005): 15,640 patients aged ≥ 80yrs (13.0%) Bagshaw, Webb et al. Crit Care, 2009.  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.
  18. 18. 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
  19. 19. 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)
  20. 20. 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?
  21. 21. 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.
  22. 22. 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!
  23. 23. ICU triage  When evaluating a patient with a severe acute illness for ICU admission determine: (i) the diagnosis, prognosis, and treatment; (ii) whether the patient, if competent, (or surrogate) consents to ICU admission; (iii) and if they do, whether or not ICU admission is warranted.
  24. 24. Some common reasons raised to stop you saying
  25. 25. “….but this is REVERSIBLE!”  Reversible ≠ must treat  Context!
  26. 26. “….but the family want EVERYTHING done!”  Was the right question asked?
  27. 27. “… but this is IATROGENIC…”  Iatrogenic ≠ must treat  Context!
  28. 28. 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!
  29. 29. So the time has come……how do I say
  30. 30. 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
  31. 31. 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
  32. 32. 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
  33. 33. Suggestions if conflict
  34. 34. The ICU in 2023? Remember our philosophy:

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