View
67
Download
1
Category
Preview:
Citation preview
A/Prof Neil OrfordDivisional Director ICUUniversity Hospital Geelonghttp://barwonhealthicu.com
Dying for person-centred care
UHG ICU
Surviving critical illness
K-M Kaukonen, e tal , JAMA. 2014;311(13);1308-1316
Is there a problem
Social and Political
Moral and Personal
Scientific
The questions
1. Can we identify people at high risk of dying in the next year due to long-term disease?
2. Can we identify these same people in the critical care setting?
3. Do we practice SDM / PCC in Australian ICU?4. Can we train our doctors and nurses to deliver SDM? 5. Will SDM improve health care utilisation, person-centred
outcomes?6. Do we want SDM all the time in all situations?
1. Can we identify people at high risk of dying in the next year due to long-term disease?
2. Can we identify these same people in the critical care setting?
Frailty
Cancer
NoneOrgan failure
Orford N, Milnes S, Lambert N, et al CCR Sep 2016;(18)3:181-8
3. Do we practice SDM / PCC in Australian ICU?
No LLI Organ failure
Frailty Cancer
No. (1024) 419 305 196 104
Pre-hospital ACP 3% 9% 14% 13%
Hospital GoC form 3% 24% 55% 40%
Discharge to independent living
78% 61% 25% 45%
1-year mortality 8% 24% 46% 60%
Orford N, Milnes S, Lambert N, et al CCR Sep 2016;(18)3:181-8
4. Can we train our doctors and nurses to deliver SDM?
Who should we train?
All* ED Ward ICU
Total GoC 223 14 150 47
MO completing GoC
Intern 2% 0% 3% 0%
Resident 18% 14% 19% 19%
Registrar 67% 86% 73% 53%
Consultant 8% 0% 4% 28%
Orford N, Milnes S, Lambert N, et al CCR Sep 2016;(18)3:181-8
4. Can we train our doctors and nurses to deliver SDM?
Effect of communication skills training on outcomes in critically ill patients with life-limiting illness referred for intensive care management – A before-and-after study
Orford N, Milnes S, Simpson N, et al, BMJSPC accepted
4. Can we train our doctors and nurses to deliver SDM?
Before (n=119) After (n=103) P-value
Age 72.6 (+13.6) 73.9 (+12.4) 0.47
Pre-hospital living at home 81% 78% 0.62
LLI Criteria
Cancer 24% 22% 0.83
CCF 29% 12% 0.16
COPD 23% 21% 0.68
Renal failure 11% 6% 0.18
Frailty / dementia / stroke 45% 48% 0.74
Nursing home 13% 13% 1.00
Neurological disease 3 % 5% 0.35
4. Can we train our doctors and nurses to deliver SDM?
Before (n=119) After (n=103) P-value
Patent-centred discussion documented 50% 69% 0.004
Competence and surrogate 31% 48% 0.01
Values and goals discussed 17% 42% <0.0001
Medical advice provided 49% 61% 0.08
PCD in cohort deceased by day-90 43% 94% <0.0001
(Documented by 48 hrs post ICU referral)
5. Will SDM improve health care utilisation, person-centred outcomes?
5. Will SDM improve health care utilisation, person-centred outcomes?
Survival for cancer before and after
5. Will SDM improve health care utilisation, person-centred outcomes?
Survival for organ failure before and after
5. Will SDM improve health care utilisation, person-centred outcomes?
Frailty Before (n=48) After (n=43) P-value
ICU/HDU admission 15% 21% 0.4
MET incidence 94% 79% 0.04
Palliative care referral 13% 21% 0.3
90-day readmission 48% 19% 0.003
90-day mortality 35% 44% 0.4
The questions
1. Can we identify people at high risk of dying in the next year due to long-term disease?
2. Can we identify these same people in the critical care setting?
3. Do we practice SDM / PCC in Australian ICU?4. Can we train our doctors and nurses to deliver SDM? 5. Will SDM improve health care utilisation, person-centred
outcomes?6. Do we want SDM all the time in all situations?
Sep Oct Nov Dec Jan Feb Mar Apr0
2
4
6
8
10
12
14
16
18
20
GoM for Patients with LLI in ICU
GoM in ICU No GoM
50%
70%
61% 58%
33%
UHG ICU 2017
New registrars
IvalCourse
IvalCourse
“90% of adults in the US have no or limited knowledge of palliative care, but after reading a definition, more than 90% would want it for them or their family” Amy Kelley, NEJM 2015
“Everyone dies. Death is not an inherent failure. Neglect, however, is.”(Atul Gawande, JAMA 2016)
http://barwonhealthicu.com
Recommended