706
| Correspondence
Difficult decisions P. A. Ward* London, UK *E-mail: [email protected]
have identified the potential for clinical decline and predict the need for escalation in treatment before the patient reaches extremis. This reluctance/failure of medical and surgical teams to make these decisions on limits of care/DNAR orders may reflect a failure to recognize clinical deterioration (critical care outreach were involved in only three of 22 patients referred in the audit), an unwillingness or unfamiliarity with making such difficult decisions (the referral teams were unaware of premorbid function in 36% of the patients referred), an over-reliance upon critical care colleagues, a fear of litigation, unrealistic expectations of critical care (only 45% of the patients referred were accepted for admission), or a desire to follow the path of least resistance where everyone is considered a candidate for ICU admission (and cardiopulmonary resuscitation). Regardless of the reason, our medical and surgical colleagues should be encouraged to take increased responsibility for these decisions and to consider carefully the appropriateness of these interventions themselves (with assistance/advice from the ICU where necessary) at the earliest possible juncture; ideally, before they are prompted to do so by their critical care colleagues at the inevitable cardiac arrest call!
Declaration of interest None declared.
References 1. Brindley PG, Beed M. Adult cardiopulmonary resuscitation: ‘who’ rather than ‘how’. Br J Anaesth 2014; 112: 777–9 doi:10.1093/bja/aev052
Do not resuscitate and the intensive care unit: time to talk P. G. Brindley1, * and M. Beed2 1
Alberta, Canada, and 2Nottingham, UK
*E-mail: [email protected]
Editor—We sincerely thank Dr Ward for his interest in our editorial1 and agree with his comments. For both intensive care unit (ICU) admission and cardiopulmonary resuscitation (CPR) there is an increasing presumption of maximal intervention ( just say ‘yes’), coupled with an increasing reliance on ICU practitioners to become responsible for many discussions, decisions, and deaths. Both cardiac arrest and ICU admission are usually (though not always) presaged by gradual, recognizable, and reversible physiological derangement. In-hospital cardiac arrest may not always be avoidable, but is often associated with the
following factors: failure to discuss, failure to document, failure to alert, failure to respond, failure to rescue, and even failure to stop. Consideration of both ICU escalation and CPR status should be considered earlier for deteriorating patients. Indeed, the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report goes further, and recommends that resuscitation status be considered upon hospital admission for all acutely ill patients.2 Resuscitation is central to modern acute care, and as such, all practitioners (not only ICU practitioners) need a better
Downloaded from http://bja.oxfordjournals.org/ at Lakehead University on March 18, 2015
Editor—I read with interest the recent editorial by Brindley and Beed1 on the importance of carefully considering the appropriateness of cardiopulmonary resuscitation (CPR) in each patient before attempting it. The authors draw a parallel between CPR and the intensive care unit (ICU) and the capacity of each of these interventions to cause more harm than good when employed inappropriately. A further parallel can be drawn from the relative absence of prior decision making in CPR/do not attempt resuscitation (DNAR) situations that is often mirrored in the ICU referral process. The decision whether to attempt CPR can be extremely difficult, not least because it is dependent upon a myriad of factors, much like the decision whether to admit a patient to the ICU. It is therefore hugely surprising how frequently both of these difficult decisions are considered for the first time when the patients are in extremis (in often rather stressful circumstances), and the decisions are invariably left to anaesthetists/intensivists to make (usually on their first encounter with the patient) rather than being made in advance in a timely, considered fashion by the surgical or medical team/ Consultant responsible for the patient’s’ care. Indeed, an audit of the ICU referral process at St Mary’s Hospital Adult Intensive Care Unit, London (October 2012–January 2013) demonstrated that none of the 22 patients (mean age 59 yr, range 23–88 yr) referred to the ICU during this period had DNAR orders completed by their responsible medical or surgical teams, and in only 9% of patients had the referring team considered any limits of care. Of course, there are some patients who experience a catastrophic decline or unexpected event that precludes such prior decision making, but it is often possible in the vast majority of patients requiring ICU admission/higher levels of care/CPR to
| Correspondence
Difficult decisions P. A. Ward* London, UK *E-mail: [email protected]
have identified the potential for clinical decline and predict the need for escalation in treatment before the patient reaches extremis. This reluctance/failure of medical and surgical teams to make these decisions on limits of care/DNAR orders may reflect a failure to recognize clinical deterioration (critical care outreach were involved in only three of 22 patients referred in the audit), an unwillingness or unfamiliarity with making such difficult decisions (the referral teams were unaware of premorbid function in 36% of the patients referred), an over-reliance upon critical care colleagues, a fear of litigation, unrealistic expectations of critical care (only 45% of the patients referred were accepted for admission), or a desire to follow the path of least resistance where everyone is considered a candidate for ICU admission (and cardiopulmonary resuscitation). Regardless of the reason, our medical and surgical colleagues should be encouraged to take increased responsibility for these decisions and to consider carefully the appropriateness of these interventions themselves (with assistance/advice from the ICU where necessary) at the earliest possible juncture; ideally, before they are prompted to do so by their critical care colleagues at the inevitable cardiac arrest call!
Declaration of interest None declared.
References 1. Brindley PG, Beed M. Adult cardiopulmonary resuscitation: ‘who’ rather than ‘how’. Br J Anaesth 2014; 112: 777–9 doi:10.1093/bja/aev052
Do not resuscitate and the intensive care unit: time to talk P. G. Brindley1, * and M. Beed2 1
Alberta, Canada, and 2Nottingham, UK
*E-mail: [email protected]
Editor—We sincerely thank Dr Ward for his interest in our editorial1 and agree with his comments. For both intensive care unit (ICU) admission and cardiopulmonary resuscitation (CPR) there is an increasing presumption of maximal intervention ( just say ‘yes’), coupled with an increasing reliance on ICU practitioners to become responsible for many discussions, decisions, and deaths. Both cardiac arrest and ICU admission are usually (though not always) presaged by gradual, recognizable, and reversible physiological derangement. In-hospital cardiac arrest may not always be avoidable, but is often associated with the
following factors: failure to discuss, failure to document, failure to alert, failure to respond, failure to rescue, and even failure to stop. Consideration of both ICU escalation and CPR status should be considered earlier for deteriorating patients. Indeed, the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report goes further, and recommends that resuscitation status be considered upon hospital admission for all acutely ill patients.2 Resuscitation is central to modern acute care, and as such, all practitioners (not only ICU practitioners) need a better
Downloaded from http://bja.oxfordjournals.org/ at Lakehead University on March 18, 2015
Editor—I read with interest the recent editorial by Brindley and Beed1 on the importance of carefully considering the appropriateness of cardiopulmonary resuscitation (CPR) in each patient before attempting it. The authors draw a parallel between CPR and the intensive care unit (ICU) and the capacity of each of these interventions to cause more harm than good when employed inappropriately. A further parallel can be drawn from the relative absence of prior decision making in CPR/do not attempt resuscitation (DNAR) situations that is often mirrored in the ICU referral process. The decision whether to attempt CPR can be extremely difficult, not least because it is dependent upon a myriad of factors, much like the decision whether to admit a patient to the ICU. It is therefore hugely surprising how frequently both of these difficult decisions are considered for the first time when the patients are in extremis (in often rather stressful circumstances), and the decisions are invariably left to anaesthetists/intensivists to make (usually on their first encounter with the patient) rather than being made in advance in a timely, considered fashion by the surgical or medical team/ Consultant responsible for the patient’s’ care. Indeed, an audit of the ICU referral process at St Mary’s Hospital Adult Intensive Care Unit, London (October 2012–January 2013) demonstrated that none of the 22 patients (mean age 59 yr, range 23–88 yr) referred to the ICU during this period had DNAR orders completed by their responsible medical or surgical teams, and in only 9% of patients had the referring team considered any limits of care. Of course, there are some patients who experience a catastrophic decline or unexpected event that precludes such prior decision making, but it is often possible in the vast majority of patients requiring ICU admission/higher levels of care/CPR to
