Epidemiology of patients with poor prognosis at ICU admission – prevalence, outcomes and resource use.

1. Epidemiology of patients with poor prognosis
at ICU admission – prevalence, outcomes and
resource use & educating colleagues
Bala Venkatesh
College of Intensive Care Medicine
Professor of Intensive Care (UQ and UNSW)
Wesley and Princess Alexandra Hospitals
George Institute for Global Health

2. Scope of this presentation
• ICU focussed
• What categories of patients?
• Impact on the patient
• Impact on the caregivers
• Impact on ICU practice
• Economic costs
• Compliance with stated preferences
• Drivers for this change
• Current level of training
• How we as a specialty should take the lead in
education and making the change

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9. Categories of patients
• older age
• diagnosis of cancer
• lower performance status
• subjective prognosis of poor outcome
• length of hospitalization before ICU referral.

10. Older age
• Ageing population (> 65 has increased from
9% in 1961 to 13% in 2009 and predicted to
reach 20% in 2031)
• Therapeutic and technical advances have
improved and extended the lives of many
• A now older generation is living with more
complex disease

11. Impact of these demographic changes
on ICU practice
• A greater proportion of older people (age > 65
are now being admitted to intensive care.
• The proportion of patients aged >80 admitted
to ICU in Australia is rapidly increasing at a
rate of 5.6% per year
• In the US, 1 in 5 deaths use ICU services

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14. Consequences of these changes
• Place of death
• Quality of death
• Impact on carers and medical professionals
• Health care costs

15. Is it a quality finish?

17. Crit Care Med 2015; 43:1352–1360

18. Anesthesiology 2017; 126:882-9

19. In patients with cancer…

21. Quality of death

23. Impact on carers and medical
professionals

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Health care costs

28. Crit Care Med 2015; 43:1352–1360

30. $700,000

32. Compliance with EOL preferences

34. Modifying the MEPA

35. Challenges – EOL planning
• Training
• Communication
• Sub-specialisation
• Lack of an overall perspective of treatment
goals.
• Community expectations
• Medical Advances

36. • Patient related
• Physician related
Current deficits – EOL planning

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38. Inadequately
prepared or
trained to hold
these
conversations

41. At medical
student stage

43. During post
graduate
training….

46. Additonal drivers
• Loss of generalist physicians
• Sub-specialisation
• Responsibility frequently falls to the intensivist
How we manage end-of-life care is
everyone’s responsibility

48. All physicians have a responsibility to
effectively, collaboratively and respectfully
discuss choices regarding treatment
escalation and de-escalation at the end-of-
life with both patients and their families.
All physicians have a responsibility to
document the summary and outcome of
end of life discussions with patients and/or
their families

49. The debate on EOL also needs to be
balanced

50. Medical Advances
• ECMO
• ECMO CPR
• Surgical success in the elderly
• TAVR
• RRT

51. Evidence for the positive role of ICU in
EOL

52. Increasing public expectations

53. Miracle survivals reported in TV
shows, internet…..

54. Consultation with the community

55. Common thread – effective and
timely communication, education of
clinicians, raising awareness with the
community

56. Improved skills in conducting crucial
conversations
a) reduce unnecessary admission to ICU
b) reduce undesired treatment and poor deaths
c) alleviate distress for family and medical
professionals
d) result in very substantial cost savings

57. Why intensivists should lead this
• Conversations about prognosis and outcome
Withdrawal and withholding life support –
both within and outside of ICU
• Organ donation conversations
• Involved in EOL conversations even outside of
ICU

58. Take home message(s)
• EOL management is a challenging task.
• If poorly done, it can lead to poor quality of
death for patients and can have a significant
impact on families and caregivers
• Increased health care costs
• All physicians have a responsibility to deliver
appropriate EOL care plans for their patients
• However education/communication skills are
lacking across the breadth of the profession.

59. • Intensivists lead the delivery of education on EOL
for all specialities
• improve the communication skills of doctors in
training and fully trained specialists
• Mandatory for all trainees across all specialties
to undergo formal training in EOL
• Mandatory for CPD
• Module for medical students
• Changing community expectations
Take home message(s)

62. Being mortal is about the struggle to cope
with the constraints of our biology, with the
limits set by genes and cells and flesh and
bone. Medical science has given us
remarkable power to push against these
limits, and the potential value of this power
was a central reason I became a doctor. But
again and again, I have seen the damage
we in medicine do when we fail to
acknowledge that such power is finite and
always will be. We’ve been wrong about
what our job is in medicine. We think our job
is to ensure health and survival. But really it
is larger than that. It is to enable well-being.
And well-being is about the reasons one
wishes to be alive. Those reasons matter not
just at the end of life, or when debility