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To take arms against a sea of troubles

To take arms against a sea of troubles. Where is the sense in intensive care ? Grand Round Feb 2012 Dr. Dan Nethercott Consultant in Intensive Care Medicine.

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To take arms against a sea of troubles

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  1. To take arms against a sea of troubles Where is the sense in intensive care? Grand Round Feb 2012 Dr. Dan Nethercott Consultant in Intensive Care Medicine

  2. To die, to sleep,No more; and by a sleep to say we endThe heart-ache, and the thousand natural shocksThat flesh is heir to: 'tis a consummationDevoutly to be wished. Hamlet; act 3, scene 1

  3. Intensive care? …is good …is bad Expensive Undignified Painful and frightening Destroys autonomy Prolongs death Can offer unique treatments Allows terrible experiences to be tolerated Saves lives

  4. ‘Less is more’ Pinhu L et al. Ventilator-associated lung injury. Lancet. 2003 ;361(9354):332-40 The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342:1301-1308 Bouchard et al. Fluid accumulation and acute kidney injury: consequence or cause. CurrOpinCrit Care. 2009;15(6):509-13. Pettilä et al. Age of red blood cells and mortality in the critically ill. Critical Care 2011, 15:R116 de Jonghe B et al. Intensive care unit-acquired weakness: risk factors and prevention. Crit Care Med.2009;37(10):S309-15. Kress JP et al. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342(20):1471-7. Ventilation ‘The opposite of breathing’ Intravenous fluids Transfusion Immobility Sedation

  5. Infusions of Propofol are dangerous

  6. Balancing uncertainty Burdens Health Benefits Low High Probability of treatment achieving goal

  7. Crack on… Appendicectomy aged 19 Oesophagectomy aged 99 …hang on a minute

  8. Prolonging life Reducing disability Pain and fear Acute delirium Cognitive decline Worsening disability and dependence A bad death Will an intervention achieve the outcome? What is a worthwhile outcome? Normal arterial pressure 30-day mortality Many years of healthy life Normal PaO2 Hospital discharge

  9. Pain and fear Acute delirium Cognitive decline Worsening disability and dependence A bad death …the thousand natural shocksthat flesh is heir to…

  10. When we have shuffled off this mortal coil… ‘One in five Americans die using ICU services’ Terminal ICU hospitalizations Length of Stay = 12.9 days Costs $24,541 Non-ICU terminal hospitalizations Length of Stay = 8.9 days Costs $8,548 Angus DC et al. Use of intensive care at the end of life in the United States: An epidemiologic study. Crit Care Med. 2004; 32:638 –643

  11. Crit Care Med. 2004;32:638–643

  12. Quantifying the burden

  13. The chronic burdens of intensive care…to grunt and sweat under a weary life… Relative risk of death in the first year after ICU discharge compared to a matched normal population: 3.4 (95% CI 2.7–4.2) Ridley S and Plenderleith L. Anaesthesia. 1994;49(11):933-5 Chronic ill-health after survival from intensive care: • Physical • Psychological • “No man is an island” (John Donne)

  14. 109 survivors of ARDS: 18% loss of body weight Diffusion capacity still impaired at 12 months Physical Quality of Life score only 25 out of possible 84 6 minute walk test only 422m (lower than predicted)

  15. After severe sepsis… “Patients with sepsis have ongoing mortality beyond short-term end points, and survivors consistently demonstrate impaired quality of life” Winters BD et al. Long-term mortality and quality of life in sepsis: A systematic review. Crit Care Med 2010; 38:1276 –1283

  16. O, what a noble mind is here o'erthrown! One third of ICU survivors had clinically significant depressive symptoms at follow-up interview… Davydow DS et al. Depression in general intensive care unit survivors: A systematic review. Intensive Care Med 2009; 35:796–809 …but this may resolve during the first year after ICU discharge Hopkins RO et al. Neuropsychological sequelae and impaired health status in survivors of severe acute respiratory distress syndrome. Am J RespirCrit Care Med 1999; 160:50–56 44% of ARDS survivors had a diagnosis of PTSD… Kapfhammer HP et al. Post-traumatic stress disorder and health-related quality of life in long-term survivors of acute respiratory distress syndrome. Am J Psychiatry 2004;161:45–52 …which may not resolve over longer follow-up Davydow DS et al. Post-traumatic stress disorder in general intensive care unit survivors: A systematic review. Gen Hosp Psychiatry 2008; 30:421–434

  17. Carers and society Psychological Financial ‘Spiritual’ Costs Acute Ongoing Pochard F et al. Symptoms of anxiety and depression in family members of intensive care unit patients: ethical hypothesis regarding decision making capacity. Crit Care Med. 2001;29(10):1893-7 Kentish-Barnes N et al. Assessing burden in families of critical care patients. Crit Care Med. 2009 Oct;37(10):S448-56 Verhaeghe S et al. Stress and coping among families of patients with traumatic brain injury: a review of the literature. J ClinNurs. 2005 Sep;14(8):1004-12 FAMIREA Study Group. Risk of post-traumatic stress symptoms in family members of intensive care unit patients. Am J RespirCrit Care Med. 2005 May 1;171(9):987-94

  18. Predicting outcome “Prediction is very difficult, especially about the future” Niels Bohr The self-fulfilling prophesy

  19. ‘Trial of therapy’ 24-48 hrs of specific interventions/support Pre-defined criteria for success/failure Honest communication Improves sensitivity and specificity of decision(?) ‘Mission creep’

  20. Futility “... 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 diseases, realizing that in such cases medicine is powerless.” Hippocratic texts

  21. Futility Defined treatment Defined goal Goal futility Value futility Mohindra RK. Medical futility: a conceptual model. J Med Ethics. 2007;33:71-75

  22. 99 year old with severe co-morbidities and high predicted mortality Intervention Better Initial state No change Worse Time

  23. 99 year old with severe co-morbidities and high predicted mortality Intervention MAP Higher Septic shock MAP 40 mmHg MAP 40 mmHg MAP Lower Time

  24. ‘Goal futile’ Paracetamol MAP Higher Septic shock MAP 40 mmHg MAP 40 mmHg MAP Lower Time

  25. ‘Value futile’ Noradrenaline MAP Higher Septic shock MAP 40 mmHg MAP 40 mmHg MAP Lower Time

  26. Intervention Hospital discharge Septic shock Severely ill and still in hospital Death Time

  27. ‘Goal futile’ Noradrenaline Hospital discharge Septic shock Severely ill and still in hospital Death Time

  28. Gabbay et al. The Empirical Basis for Determinations of Medical Futility. J Gen Intern Med. 2010;25(10):1083–9 Goal futility Schneiderman: “…when physicians conclude (either through personal experience, experiences shared with colleagues or consideration of reported empiric data) that in the last 100 cases, a medical treatment has been useless, they should regard that treatment as futile” “…the clinician can be 95% confident that no more than three successes would occur in every 100 comparable trials” Medical futility: its meaning and ethical implications. Ann Intern Med. 1990;112(12):949–54.

  29. Individual judgement Accuracy for a predicted good outcome was 63% (95% CI, 50%–74%) ..for poor outcome was 94% (95% CI, 85%–98%) Caulfield AF et al. Outcome prediction in mechanically ventilated neurologic patients by junior neurointensivists. Neurology 2010;74:1096–1101

  30. Value futility ‘Impossible equations’ Lack of capacity/autonomy Time critical Surrogates/‘next of kin’ – reliable? Cultural norms Personal bias Shalowitz DI et al. The accuracy of surrogate decision makers: a systematic review.Arch Intern Med. 2006;166(5):493-497 “Unreliable in one third of cases”

  31. But that the dread of something after death,The undiscovered country from whose bournNo traveller returns, puzzles the will,And makes us rather bear those ills we haveThan fly to others that we know not of? COPD patients having been ventilated for an acute exacerbation: “In spite of this burden of symptoms and disabilities, 96% of the 415 who answered the question about whether they would be willing to undergo similar treatment again under the same circumstances said that they would” Wildman MJ et al. Survival and quality of life for patients with COPD or asthma admitted to intensive care in a UK multicentre cohort: the COPD and Asthma Outcome Study (CAOS). Thorax. 2009 Feb;64(2):128-32

  32. Old age and intensive care 882 patients >65yrs 1,827 controls <65 yrs of age All elderly patients with day-1 Sequential Organ Failure (SOFA) scores >15 died during the ICU stay QALYs of the elderly respondents were 21% - 35% lower than age and gender-adjusted general population Kaarlola A et al. Long-term survival, quality of life, and quality-adjusted life-years among critically ill elderly patients. Crit Care Med 2006; 34:2120–2126

  33. Frailty “..a multidimensional syndrome characterized by the loss of physical and cognitive reserve that predisposes to the accumulation of deficits and increased vulnerability to adverse events.” Strongly correlated with age, functional limitation and co-morbid disease Decreased mobility, muscle mass, nutritional status, strength and endurance McDermid RC et al. Frailty in the critically ill: a novel concept. Critical Care 2011;15(1):301 “The critically ill patient may be analogous to the frail geriatric patient. …objective measurement of frailty may…support to clinicians confronted with end-of-life decisions and on the appropriateness of ICU”

  34. Nutritional status Hutalung R et al. The obesity paradox in surgical intensive care unit patients Intensive Care Med. 2011 Nov;37(11):1793-9 N = 12,938 60-day hospital mortality Underweight 17.8% Normal weight 11.1% Overweight vs. Normal HR 0.86 (95% CI = 0.74-0.99) Obese vs. Normal HR 0.83 (95% CI = 0.69-0.99)

  35. Economics: The science of infinite demands and finite resources

  36. Red Herrings If it be now, 'tis not to come; if it be not to come, it will be now; if it be not now, yet it will come: the readiness is all. 1. Quality of life 2. ‘Independence’ vs. physiological reserve 3. “For everything”

  37. McKeown A et al Unsuitable for the intensive care unit: what happens next? J Palliat Med. 2011 Aug;14(8):899-903 “The identification of the imminently dying should facilitate appropriate communication of this by clinical staff and allow the relevant social, psychological, and spiritual preparations for death that are the hallmark of good care of the dying.”

  38. Give me a doctor partridge-plump,Short in the leg and broad in the rump,An endomorph with gentle handsWho'll never make absurd demandsThat I abandon all my vicesNor pull a long face in a crisis,But with a twinkle in his eyeWill tell me that I have to die. WH Auden

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