TedTalk

http://ed.ted.com/on/5AD389V3#review

Dr Rob Fowler, Critical Care & General Medicine

Physician at Sunnybrook Hospital in Canada.

15/06/2015 0

15/06/2015 1

End-of-Life Care

in the Intensive Care Unit

Denis Casey

End-of-Life Care Coordinator

University of Limerick Hospital Group

denis.casey@hse.ie 087-6544070

The Intensive Care Unit

The Intensive care unit (ICU) caters for patients with

severe and life threatening illnesses and injuries, which

require constant, close monitoring and support from

specialist equipment and medications in order to

support and ensure normal bodily functions.

Typically have higher staff-to-patient ratio, usually 1:1

Nurse patient ratio.

Nature of the ICU

• Highly technological care

• Curative focus – primary goals are to help patients

survive acute threats to their lives while preserving and

restoring quality of life

• 60- 70% of ICU patients are not capable of making

decisions due to illness/sedation

• 1-2% of all hospital beds

• Costs €1,500- €3,000 per day depending on therapies

68%

20%

12%

Wards

ICU

A&E

Place of Death – in Irish Hospitals

68%

20%

12%

Wards

ICU

A&E

National Audit of End of Life Care (2010). Audit of 1,000 patients deaths (18+)

Deaths in ICU – international research

• Approx 20% of all hospital deaths occur in ICU (ICNARC 1999-2006, Billings et al 2006, Morgan 2008)

• 42% of patients who die in hospital have spent part of

their last 3 days of life in a specialist unit (Cybulski 2011, Canada )

• Death can be sudden/ unexpected

• 70 - 90% of patients who die in ICU do so after a

decision to limit or withdraw therapy (Truog 2001; USA, Carlet et al 2004; France)

Paediatric deaths in ICU

• 20% of all adults who die in hospital will die in an ICU.

Most patients die in ward settings.

• In children’s hospitals, it’s the opposite.

• Case study: Our Lady’s Children’s Hospital, Crumlin

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Paediatric deaths in ICU (Crumlin Hospital)

PICU 86%

Cardiac 7%

Wards 6%

HaemOncology 1%

2010 2011 2012 2013 2014 Total

2010-2014 % Deaths

PICU 51 54 52 45 64 266 85.8%

Cardiac 3 5 2 3 10 23 7.4%

Wards 7 2 4 2 2 17 5.5%

HaemOncology 1 1 1 1 0 4 1.3%

Total 62 62 59 51 76 310 100.0%

Limitation of Treatment

Where a treatment which might be beneficial is

continued to a predetermined upper limit, dose or time

period.

e.g. Limit of vasopressors, period of CVVH (Dialysis)

(CCaNNI 2009)

Withholding Treatment

A treatment which might be beneficial in a different

scenario or patient is not initiated. e.g. A decision is

made not to re-intubate a patient or not initiating CVVH (CCaNNI 2009)

Withdrawal of treatment

A treatment which might be beneficial in a different

scenario or patient is reduced and stopped.

e.g. Inotropes, DNaCPR (CCaNNI 2009 )

Decisions to withhold or withdraw life

support

53%

47% Intensive Care Unit

Other areas

4,248 ICU deaths in 17 European countries

Mater Hospital. ETHICUS study

1999/2000 – 70% of patients who died in ICU had a

decision made to withhold or withdraw life-sustaining

therapy but only 72% of decisions were documented.

(Collins, Phelan, Marsh & Spring 2006)

Withdrawal of care

Dialysis

↓

Diagnostic tests

↓

Vasopressors

↓

IV Fluids

↓

Monitoring

↓

Artificial feeding

↓

Ventilation (Faber-langendoen 2000)

Challenges in End-of-life care in ICU?

Curative Vs Comfort

Discussion

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References • Billings, J. A., Keeley, A., Baunam, J., Cist, A., Coakley, E., Dahlin, C., et al. (2006). Merging

Cultures:Palliative care specialists in the medical intensive care unit. Critical Care Medicine , s388-s393.

• Cartlet, J., Thijs, L. G., Antonelli, M., Cassell, J., Cox, P., Hill, N., et al. (2004). Challenges in end-of-life care in the ICU - statement of the 5th International Consensus conference in Criticcal care: Brussels, Belgium, April 2003. Intensive Care Medicine , 30, 770-784.

• Collins, N., Phelan, D., Marsh, B., & Sprung, C. (2006). End of life care in the intensive care unit:the Irish Ethicus Data. Critical Care and resuscitation , 8 (4), 315-320.

• Critical Care Network of Northern Ireland. (2009). End-of-life care fro all Critical Care Patients. Belfast: Northern Health and Social Care Trust.

• Cybulski, P. (2011). A critical care nurse's role in the provision of end-of-life care. Dynamics- Canadian Association of Critical Care Nurses , 22 (4), 7-8.

• Faber-Langendoen, K., & Lanken, P. N. (2000). Dying Patients in the Intensive Care unit: Forgoing Treatment, Maintaining Care. Annals of Internal Medicine , 133 (11).

• Morgan, J. (2008). End-of-life care in UK critical care units - a literature review. Nursing in Critical Care , 13 (3), 152-161.

• Sprung, C., Cohen, S., & Sjokvist, P. (2003). End-of-life practices in European intensive care units. the Ethicus study. JAMA , 290, 790-797.

• Truog, R. D., Cist, A. F., Brackett, S. E., Burns, J. P., Curley, M. A., Danis, M., et al. (2001). Recommendations for end-of-life care in the Intensive care unit: The Ethics Committee of the society of Critical care Medicine. Critical Care Medicine , 29 (12), 2332-2348.

• Irish Hospice Foundation (2010). National Audit of End-of-Life Care in Hospitals in Ireland.