To take arms against a sea of troubles

Where is the sense in intensive care?Grand Round

Feb 2012

Dr. Dan NethercottConsultant in Intensive Care Medicine

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

Intensive care?

…is goodCan offer unique

treatmentsAllows terrible experiences

to be toleratedSaves lives

…is badExpensiveUndignifiedPainful and

frighteningDestroys autonomyProlongs death

‘Less is more’Ventilation

‘The opposite of breathing’

Intravenous fluidsTransfusionImmobilitySedation

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. Curr Opin Crit 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.

Infusions of Propofol are dangerous

Balancing uncertainty

Health Benefits

Burdens

Probability of treatment achieving goalLow High

Appendicectomy aged 19

Oesophagectomy aged 99

Crack on…

…hang on a minute

Will an intervention achieve the outcome?What is a worthwhile outcome?

30-day mortality

Hospital discharge

Many years of healthy life

Prolonging lifeReducing disability

Pain and fearAcute delirium

Cognitive declineWorsening disability and dependence

A bad death

Normal arterial pressure

Normal PaO2

Pain and fearAcute delirium

Cognitive declineWorsening disability and dependence

A bad death

…the thousand natural shocksthat flesh is heir to…

When we have shuffled off this mortal coil…

‘One in five Americans die using ICU services’

Terminal ICU hospitalizations

Length of Stay = 12.9 daysCosts $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

Crit Care Med. 2004;32:638–643

Quantifying the burden

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)

109 survivors of ARDS:18% loss of body weightDiffusion capacity still impaired at 12 monthsPhysical Quality of Life score only 25 out of possible 846 minute walk test only 422m (lower than predicted)

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

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 dischargeHopkins RO et al. Neuropsychological sequelae and impaired health status in survivors of severe acute

respiratory distress syndrome. Am J Respir Crit 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-upDavydow DS et al. Post-traumatic stress disorder in general intensive care unit survivors: A systematic

review. Gen Hosp Psychiatry 2008; 30:421–434

Carers and society

PsychologicalFinancial‘Spiritual’

CostsAcuteOngoing

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 Clin Nurs. 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 Respir Crit Care

Med. 2005 May 1;171(9):987-94

Predicting outcome

“Prediction is very difficult, especially about the future”

Niels Bohr

The self-fulfilling prophesy

‘Trial of therapy’

24-48 hrs of specific interventions/supportPre-defined criteria for success/failure

Honest communication

Improves sensitivity and specificity of decision(?)

‘Mission creep’

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

Futility

Defined treatmentDefined goal

Goal futilityValue futility

Mohindra RK. Medical futility: a conceptual model. J Med Ethics.

2007;33:71-75

Initial state

Time

Better

No change

Worse

99 year old with severe co-morbidities and high predicted mortality

Intervention

Septic shock

MAP 40 mmHg

Time

MAP Higher

MAP 40 mmHg

MAP Lower

Intervention

99 year old with severe co-morbidities and high predicted mortality

Septic shock

MAP 40 mmHg

Time

MAP Higher

Paracetamol

MAP 40 mmHg

MAP Lower

‘Goal futile’

Septic shock

MAP 40 mmHg

Time

MAP Higher

Noradrenaline

MAP 40 mmHg

MAP Lower

‘Value futile’

Septic shock

Time

Hospital discharge

Intervention

Severely ill and still in hospital

Death

Septic shock

Time

Hospital discharge

Noradrenaline

Severely ill and still in hospital

Death

‘Goal futile’

Goal futilitySchneiderman:

“…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.

Gabbay et al. The Empirical Basis for Determinations of

Medical Futility. J Gen Intern Med. 2010;25(10):1083–9

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

Value futility

‘Impossible equations’Lack of capacity/autonomyTime criticalSurrogates/‘next of kin’ – reliable?Cultural normsPersonal 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”

But that the dread of something after death,The undiscovered country from whose bourn

No traveller returns, puzzles the will,And makes us rather bear those ills we have

Than 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 the415 who answered the question about whether they would bewilling to undergo similar treatment again under the samecircumstances 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

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-yearsamong critically ill elderly patients. Crit Care Med 2006; 34:2120–2126

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”

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 = 12,93860-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)

Economics: The science of infinite demands and finite resources

Red Herrings1. Quality of life2. ‘Independence’ vs. physiological reserve3. “For everything”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.

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.”

Give me a doctor partridge-plump,

Short in the leg and broad in the rump,

An endomorph with gentle hands

Who'll never make absurd demands

That I abandon all my vices

Nor pull a long face in a crisis,

But with a twinkle in his eye

Will tell me that I have to die.

WH Auden