End of life care (EOL) and treatment ceilings

A session blog from Day 2 of State of the Art, London December 2015. See the full list

Blogger Jack Wong

Chair: Tim Evans

Integrating MET teams and palliative care

Judith Nelson, Palliative Medicine Service

Summary/Key messages

Paradox of Rapid Response Team (RRT)

  • Focus Group: RRT seems to pick up dying patients more and triggering end of life decision and palliative care consult rather than what it was intended for, ie identifying ill patient and intervene early to reduce incidence of deterioration.
  • Tan & Delaney CCR 2014 showed that EOL care is commonly delivered during MET calls, and should be emphasised in training for MET members.
  • Aim of Palliative Care – relieve symptoms, exchange information, align plan with values, support caregivers, smooth transitions.

Unique challenges for palliative care

  • Patient unable to participate
  • Advance care planning (ACP) not accessible / unavailable
  • Surrogate unavailable unidentified
  • Primary clinician unavailable
  • Crisis conversations / decision
  • Lack of decision re: escalation of care
    • No prognostic model
    • Controversy re: ICU admission criteria
    • System, clinician, patient level factors influence triage
    • Ethical challenges
  • ANZICS-CORE – Epidemiologic Data (Australia) 25% mortality for patients who has received RRT and end up in ICU (vs 5% control with no RRT )

Observations from field

  • Acute, time-pressured decision-making: View via Simulation. Barnato Crit Care Med 2008
    • Simulated case of patients with metastatic cancer with capacity to express wishes of not wanting invasive treatment presented with acute dyspnoea.
    • < 45% clinicians asked re: understanding of disease or discussed prognosis if survived acute illness
    • < 40% clinicians discuss more than 1 potential treatment options
    • < 5% clinicians discussed possible poor outcomes
    • > 80% clinicians focus on procedural interventions eg. intubation etc


Strengthening clinicals and systems


Screen Shot 2015-12-08 at 23.49.18

  • Quickly and skillfully – Assess, communicate, manage


References/Further reading

  • Nelson JE et al. Integration of palliative care in the context of rapid response. Chest 2015; 147:560-9
  • Sulistio M et al. Hospital rapid response team and patients with life-limiting illness: a multicentre retrospective cohort study. Palliat Med 2015; 29:302-9
  • Jones D et al. The rapid response system and end of life care. Curr Opin Crit Care 2013; 19:616-23
  • Jones DA et al. The role of the medical emergency team in the end of life care: A multicenter, prospective, observational study. Crit Care Med 2012; 40:98-103

Decision making in ICU

Dr Chris Bassford, University Hospital Coventry

Summary/Key messages



  • Who should we admit to ICU? – ICU causes harm and ICU doesn’t always work!
  • Are we admitting the right patients?
    • Type 1 Error : Give them a go
    • Type 2 Error: Let them go
  • Example: CAOS study – Prognostic pessimism in patients with COPD.


Trained in decision making for intensive care unit admission

  • Question to audience: Have you had any specific training in how to decide who should be admitted to ICU?
  • Audience answer: No formal training 90%


What influences decision to ICU admission?

  • Factors include
    • Severity of acute illness and co-morbidities, poor functional status
    • More controversial – advanced age, gender
    • Seniority of referrer, communication skills of referrer, religiosity of decision maker, intensivist base specialty (anaesthetist has higher denial rate), wish to avoid litigation
    • Time of day of assessment, assessment by junior or senior physician, medical or surgical condition, availability of ICU bed, presence of written criteria for admission
  • Question to audience: Do you believe bed availability influences whether or not a patient is admitted to critical care?
  • Audience answer: 58% sometimes, 24% often, 14% rarely, 4% never
  • 18 out of 21 cohort studies showed more chance of refusal to ICU referral when there is limited bed availability.


Ethically justified, patient centered decision making process for ICU admission

  • Question to Audience: Does your hospital have guideline on determining whether or not a patient should be admitted to ICU?
  • Audience answer: 62% No, 28% Yes.
  • There is a DOH 1996 guideline for ICU referral decision making flowchart  – crude and outdated.
  • We need an updated guideline regarding decision making in ICU admission
  • ICU clinicians are the “best” people to decide, however:
    • We need better methods for predicting outcome from ICU
    • We need better training in how to make decision for ICU admission
    • Identify how we are making these decisions
    • Needs to be able to show decision is made in an ethically justifiable, patient centered way
    • Need to be protected from consequences of health care rationing decision.
  • Current work in Conventry & Warwick – Understanding and improving the decision making process surrounding admission to the ICU. To be completed in 2018.

The bioethics of DNACPR

Zoe Fritz, Cambridge University Hospital

Summary/Key messages


Q = Speaker Question

A = Audience Answer


  • 80% of patients who dies in hospital die with DNACPR
  • Majority initiated by clinician
  • 50% of patients with DNAR in hospital are discharged home
  • Currently it is at the front of the notes and often red

Issue 1: Not routinely completed

  • Q: How often do you go to assess a patient who has been referred to ICU and think they should have a DNAR order?
  • A: Once a week 53% Once a shift 43%
  • NCEPOD report 78% of patients had no DNAR decision when indicated
  • Ethical implication: Is DNAR decision when indicated just a lottery ?

Issue 2: Inappropriate resuscitation attempts

  • Q: How often have you gone to a patient who has survived an attempted resuscitation and not admitted them to ICU because you don’t think they would benefit
  • A: 52% once a week 35% once a year
  • NCEPOD 11/202 patients who had survived resus were not admitted to ICU

Issue 3: No one likes discussing this

  • Q: How often do you wish a nice calm conversation had been had with a patient and their family in advance about what they would and wouldn’t want in the event of their deterioration and it was all beautifully documented?
  • A: One a shift 59% once a week 33% once a year 4%
  • Patients rarely initiate discussion, doctors don’t like to have discussions.
  • Recent judgments have made in illegal not to discuss a decision to withhold CPR.
  • The case of Tracey and Winspear
  • While patients can’t demand treatment which will not benefit them but they have the right to know and demand a decision made on them.

Issue 4: Misunderstanding

Issue 5: Difference in care

Screen Shot 2015-12-08 at 23.49.52

  • Discrimination and lack of equity:
    • Reluctance to write them
    • Reluctance to talk about them
  • Alternative approach – Universal Form of Treatment options
    • Before and after study aim to change the culture
    • Change in reasoning and nature of discussions
    • Discuss goal of patient’s’ care in various aspect rather than only on DNACPR.