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Todd Fraser wrote 12-14-2011 06:34:59 pm
There was an interesting editorial in an online journal recently by Ken Hillman from Sydney. Designed for the layperson, this review eloquently describes the cold and unsympathetic "medical conveyerbelt" that traps so many unnecessary victims. Why is it that so many people need a "trial of ICU" before they die?

Check it out here - bit.ly/w2Iyy5

Cameron Knott wrote 04-11-2011 11:26:29 am
Selection bias is no doubt part of it. With the rise of the Baby-Boomer generation into, ICU will be need more access to advanced directives and advanced care planning. It this something that should be mandated?

Also, the increasing recognition of outcomes from ICU should be further studied to allow better selection of patients. How are we to manage a larger, older population with a smaller tax-paying population coming through beneath - the distributive justice question. Do we need to think about QALYs and 'value for functional integrated return to the community' in our role as ICU gatekeepers?

Todd Fraser wrote 04-11-2011 12:59:45 pm
These are all very good points Cameron.

The issue of Advanced Care Directives seems a generalised one. I know that I, along with many colleagues, are frustrated at the lack of implementation of this important tool. The time to be undertaking this process is certainly not at 2am in an emergency situation, which it often seems to be.

There was a fascinating podcast on the SCCM website by Robert Truog. He's a professor of medical ethics and anesthesia at Harvard and writes a bit on this topic. The podcast talks about rationing of care, and raises the concern that we should be declaring such rationing decisions to the patient and/or caregivers. In the absence of that declaration, he suggests we need rationing, but this should be legislative (ie out of the hands of clinicians at the bedside). This seems to me highly unlikely - no politician is going within 10 miles of it. Until then, I suspect the decision making process will continue to default to on-call intensivists....

Alex McKenzie wrote 06-08-2011 10:37:03 pm
We're going to have to work out a solution to this fast - there's a tidal wave a-comin' and we're all gunna drown.

andrew stapleton wrote 06-13-2011 04:21:14 pm
In my short career to date I have worked in 4 different countries with public health systems and none come close to Australia in terms of the (high) number of elderly patients admitted to ICU (in Australia). Also none come close in terms of the money available within the public health system - I suspect a correlation. Rationing is only the beginning, overcoming the moral cowardice of doctors (that's us) will be harder.

Alex McKenzie wrote 06-17-2011 10:16:56 pm
I couldn't agree more Andrew. Its getting to the point where no one dies without a trial of ICU.

There has to be some limit to this. Surely we have to consider this on a social justice basis - we have to do the most good for the most people (having said that, should we abandon ICU altogether and all go work in primary care?)

I've heard this line from UK docs many times - have we lost our way in Australasia?

Robyn Cooke wrote 06-21-2011 08:57:02 pm
Lets try looking at this slightly differently. The criteria for entry should be quality of life (before) and physiological age - NOT chronological age. We have all seen young patients who seriously are not long for the world, and "old" patients who do fabulously well and go home to meaningful lives. To restrict on age alone is an error. I think we need to be mindful of age - realise that physiologically speaking the older we are the less reserve and the chances that one has more comorbidities and this means that we simply have to be cleverer in our approach in ICU and tailor the treatment and admission to these factors.

Oliver Arkell wrote 06-22-2011 04:09:51 pm
That's fair enough Robyn, but I don't thing the pendulum has been swinging away from elderly admissions. I get the feeling that we are admitting them based on the criteria you mention, but there is an increasing gap between the number of beds required and the number available. I heard once we are 100 beds short of accepted benchmark numbers across Australia - not sure where this figure is from.

So don't we need to have a discussion about this? Is it acceptable that a 30 year old with severe pneumonia sits in ED all night because the beds are full of 90 year olds?

Robyn Cooke wrote 06-22-2011 09:21:31 pm
That's a good point Oliver and a discussion worth having. What concerns me is that there are those in policy making decisions that look at restricting access rather than creating the beds to meet the demands. And as age use to be the criteria - it has been suggested in some places by some people (obviously NOT all and certainly not the current trend) that this be considered again. Very interesting to hear everyone's thoughts - perhaps we should base access of age + serverity of illness markers and prognosis based on diagnosis at admission. Does anyone know if there have been any studies looking at this particular combination? If we could predict this then perhaps that would be an interesting way to allocate resources? I personally belieive we need to create more beds with a flex up system and then run an acceptable 80% capacity knowing that in times of epidemics etc we can flex to 100%. But accountants don't like this idea.

stanley nikki wrote 06-27-2011 05:07:14 pm
can I add an extra comment (perhaps an inflammatory one) in that intensive care becomes the default decision making specialty most frequently in elderly cases. Yes we all know great colleagues in emergency, anaesthesia, and the medical and surgical specialties who advise their patients, families and registrars(who often become surrogate decision makers as the referral to icu happens) well.
But far too often the decision is made for resuscitation/intervention(eg vascular nightmare patients) or surgery, before we are involved and our anaesthetists can get them through the case, just not the lingering multi-organ failure afterwards (or people are too afraid to say no or pull the tube). The "good eighty" declines.
There needs to be leadership from other specialties as well as our own, with recognition of end of life issues bought into the public realm of thought in Australia, which if you chat to the average emergency patient/medical with a chronic illness, has never been bought up by their team, gp or family. The horse may have already bolted and the bubble will burst when we simply don't have the beds to "GIve them a go" .

Todd Fraser wrote 06-27-2011 09:23:01 pm
Lots of interesting comments there.

Andrew's entry intrigues me. I've spoken to many UK practitioners who say ward staff rarely refer these elderly patients because they know they'd simply be refused. Is this because of even greater bed restriction than here? Or is there a better understanding of end of life care issues there? Why is it so different from what we experience down here?

I guess the question is how to progress from here. I suspect many of us share the frustration that end of life planning should already be in place long before it gets to the point of ICU admission. Do we need more leadership from CICM, or perhaps ANZICS, perhaps by engaging other colleges, to improve awareness and skills training in end of life care at grass roots level?