GUEST EDITORIAL doi: 10.1111/nicc.12074
Making appropriate decisions about admission to critical care: the role of critical care outreach and medical emergency teams The numbers of patients admitted to critical care exceeds 130 000 a year in the UK, and one in six patients will die there (ICNARC, 2013). Critical illness episodes can often become transition points for patients, where intentions of medical treatment are questioned and can change from curative to palliative when patients are critically or acutely unwell. The impetus for making decisions regarding treatment in a patient’s illness trajectory is often prompted by the onset of critical illness. This is particularly so in the case of chronic health conditions where an acute exacerbation or event might require an admission to a critical care unit. Critical care outreach teams (CCOTs) have a prominent role in triaging these sick, at-risk or deteriorating patients for admission to critical care and care for these patients on the ward. For many patients, the first time a limitation of treatment (LOMT) decision is made, such as ‘not for admission to critical care’, will be when they become critically ill. In such situations, questions may need to be raised about the appropriateness of admission to critical care. A large study of 82 European intensive care units (ICUs) showed that many patients in critical care are perceived by ICU staff (and particularly nurses) to be receiving care inappropriately (Piers et al., 2011). There is much debate about admission criteria to critical care, but proposed new guidance in the UK has not yet materialized. Admitting patients for a ‘trial of critical care’ is popular; however, this 4
approach is not advocated by all, with some clinicians seeing an open admission policy as a burden on precious resources. These doctors may choose to have a qualified trial, where only those patients with an expectation of being able to survive are admitted. Admission decisions require some sort of assessment of predicted prognosis, particularly in this era of bed and fiscal pressures. Such pressures will contribute to decisions to admit patients, particularly in the UK, which has one of the lowest numbers across Europe of ICU beds (6·6/100 000) per population head (Rhodes et al., 2012). This figure is set against a recent media backlash in the UK of accusations of poor care associated with the use of a care of the dying pathway, the Liverpool Care Pathway (LCP). This has led to a recent governmental review (Department of Health, 2013), with criticisms of the LCP evidence base and misuse. The backlash may well increase the pressure on critical care beds because clinicians are likely to be even more reluctant to make timely decisions and diagnose dying for fear of being seen as using the LCP inappropriately, or using it at all. Patients with long-term complex conditions are known to be high users of critical care resources, often appropriately, but when a patient’s condition or illness is deteriorating and leading towards end-of-life (EOL) then it is right to initiate early discussions about the ongoing appropriateness of level 3 care.
So, what prompts clinicians to consider appropriateness of admission? Increasingly, these questions are raised by critical care outreach (CCO), rapid response or medical emergency teams (METs). As critical care experts and the first point of contact for many worried ward staff, it is left to CCO and similar teams to help triage patients for admission and to assess whether admission to critical care is appropriate (Pattison et al., 2010; Jones et al., 2012). Reasons for negotiation include situations where patients referred to CCOT might need a limitation of medical treatment (LMOT) initiating because of a poor prognostic outlook in the face of critical and concomitant illness. Or, they may have an LMOT already in situ, but require support for a reversible illness. CCO nurses have to act between the parent medical team and the critical care team to mediate and advocate for patients. Work has shown that some clinicians, such as haematologists and surgeons, find it hard to draw back from patients with whom they have established a ‘covenant of care’ (Cassell et al., 2003; McGrath, 2002). Review by critical care staff, such as the CCOT, can provide objective review of the situation, and provide expert input on what admission to critical care for that individual is likely to entail. EOL decision-making is a vastly underestimated aspect of the CCO nurses’ role. Referrals to CCOT that end in an LOMT, or end-of-life decision, comprise around a third of all emergency referrals to CCOTs (Jones et al., 2012),
© 2014 British Association of Critical Care Nurses • Vol 19 No 1
Guest Editorial
and constitute a significant amount of clinical contact. Moreover, dealing with these EOL decisions falls outside the scope and competencies outlined in many CCO and MET role descriptions although it has now been recognized in the National Outreach Forum standards and competencies (National Outreach Forum, 2012). Outreach nurses are required to carefully negotiate with both critical care and parent medical teams and present the critical care options to the patient or patient’s family, outlining the implications of these. For example, in a situation where a patient with an advanced chronic lung condition is admitted to the ward with a recurrent presentation of type 1 respiratory failure, this might mean a plan is instituted not to escalate the patients’ care to include ventilation, but it might mean a symptomatic trial of non-invasive ventilation or perhaps nasal high-flow oxygen. However, the implications of this in a situation where a patient is dying have to be considered if we are to try to achieve the patients wishes: namely to die in their preferred place of care (Department of Health, 2009). Interventions such as ward-based non-invasive ventilation, no matter how well meaning, might prolong a dying process or inhibit a transfer home to die, and there needs to be significant consideration given to how community services will manage these interventions, if at all. It must be remembered when deciding to admit, or not, that survival is not the only endpoint for critical care. Inflicting a critical care trial on a patient who is likely to die has several ethical implications, including providing treatment in the face of futility. I have frequently argued that good end-oflife care can be provided in critical care (Pattison et al., 2013); however, this should not detract from an honest debate as to whether it is appropriate to admit each individual patient. This is particularly the case when patients are too ill at the point of an admission decision to state their own © 2014 British Association of Critical Care Nurses
wishes. Families are relied on for assessment of patients’ wishes. While families nearly always have patients’ best interests in mind, they do get the presumption of wishes wrong for ongoing treatment (White et al., 2012). Predictive models, such as organ dysfunction and severity of illness scores such as SOFA, MODS and APACHE, acute physiology and chronic health evaluation can help in the estimation of likely outcomes for groups of critically ill patients. However, making a certain prognosis for an individual remains problematic. This uncertainty can be compounded when the parent medical team cannot give an accurate prognosis of the patient’s underlying chronic condition. Outreach nurses frequently end up being the catalysts that force parent medical teams to confront the situation of a deteriorating patient who will not benefit from critical care admission and finally diagnose dying. Communicating that a person is dying requires skill, but to do this when patients are critically ill, and losing capacity is complex and challenging. Immense sensitivity and frank honesty is required, not only from the parent medical teams but also from the CCO nurses, who are often involved in breaking bad news to patients and their families. These nurses are ideally placed to clarify a patient’s wishes, but this can only be done after they have established the patient has capacity to make an informed decision about whether they want to be admitted to the critical care unit. Indeed, some CCO teams in the UK are already leading the way with nurseled Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) policies, allowing nurses to initiate DNACPR decisions, and EOL decisions including admission to critical care, and therefore contribute more substantially and meaningfully to patients’ illness trajectories. CCO nurses need to be confident in their expertise and use of advanced communication skills, as well as be aware of the importance
of their contribution to the medical decision-making process, and strong leadership is a prerequisite. A collaborative approach involving shared decision-making should be what we strive for in order to make appropriate decisions at what can be the most difficult time for the patient and their significant others. N. Pattison and G. O’Gara Royal Marsden NHS Foundation Trust, London, UK
REFERENCES Cassell J, Buchman TG, Streat S, Stewart RM. (2003). Surgeons, intensivists, and the covenant of care: administrative models and values affecting care at the end of life – updated. Critical Care Medicine; 31: 1551–1559. Department of Health. (2009). National End of Life Care Programme. http://webarchive. nationalarchives.gov.uk/+/www.dh.gov. uk/en/Healthcare/IntegratedCare/Endof lifecare/DH_086083 (accessed 03/07/13). Department of Health. (2013). More Care, Less Pathway: Review of Liverpool Care Pathway for Dying Patients. http://www.england. nhs.uk/2013/07/15/lcp/ (accessed 18/07/13). ICNARC (Intensive Care National Audit and Research Centre). (2013). Summary Statistics and CMP Data 2011–2012. https:// www.icnarc.org/documents/Summary %20statistics%20-%202011-12.pdf (accessed 16/07/13). Jones DA, Bagshaw SM, Barrett J, Bellomo R, Bhatia G, Bucknall TK, Casamento AJ, Duke GJ, Gibney N, Hart GK, Hillman KM, J¨aderling G, Parmar A, Parr MJ. (2012). The role of the medical emergency team in end-of-life care: a multicenter, prospective, observational study. Critical Care Medicine; 40: 98–103. McGrath P. (2002). End-of-life care for hematological malignancies: the technological imperative and palliative care. Journal of Palliative Care; 18: 39–47. National Outreach Forum. (2012). National Outreach Forum Operational Standards and Competencies for Critical Care Outreach Services. http://www.norf.org.uk/ Resources/Documents/NOrF%20CCCO %20and%20standards/NOrF%20 Operational%20Standards%20and%20 Competencies%201%20August%202012. pdf (accessed 03/07/13). Pattison N, Ashley S, Farquhar-Smith P, Roskelly L, O’Gara G. (2010). Thirty-day
5
Guest Editorial
mortality in critical care outreach patients with cancer: an investigative study of predictive factors related to outreach referral episodes. Resuscitation; 81: 1670–1675. Pattison N, Carr SM, Turnock C, Dolan S. (2013). Viewing in slow motion’: patients’, families’, nurses’ and doctors’ perspectives on end-of-life care in critical care. Journal of Clinical Nursing; 22(9–10): 1442–1454. Piers RD, Azoulay E, Ricou B, Dekeyser Ganz F, Decruyenaere J, Max A, Michalsen A, Maia
6
PA, Owczuk R, Rubulotta F, Depuydt P, Meert AP, Reyners AK, Aquilina A, Bekaert M, Van den Noortgate NJ, Schrauwen WJ, Benoit DD. (2011). Perceptions of appropriateness of care among European and Israeli intensive care unit nurses and physicians. Journal of American Medical Association; 306: 2694–2703. Rhodes A, Ferdinande P, Flaatten H, Guidet B, Metnitz PG, Moreno RP. (2012). The
variability of critical care bed numbers in Europe. Intensive Care Medicine; 38: 1647–1653. White DB, Cua SM, Walk R, Pollice L, Weissfeld L, Hong S, Landefeld CS, Arnold RM. (2012). Nurse-led intervention to improve surrogate decision making for patients with advanced critical illness. American Journal of Critical Care; 21: 396–409.
© 2014 British Association of Critical Care Nurses
Making appropriate decisions about admission to critical care: the role of critical care outreach and medical emergency teams The numbers of patients admitted to critical care exceeds 130 000 a year in the UK, and one in six patients will die there (ICNARC, 2013). Critical illness episodes can often become transition points for patients, where intentions of medical treatment are questioned and can change from curative to palliative when patients are critically or acutely unwell. The impetus for making decisions regarding treatment in a patient’s illness trajectory is often prompted by the onset of critical illness. This is particularly so in the case of chronic health conditions where an acute exacerbation or event might require an admission to a critical care unit. Critical care outreach teams (CCOTs) have a prominent role in triaging these sick, at-risk or deteriorating patients for admission to critical care and care for these patients on the ward. For many patients, the first time a limitation of treatment (LOMT) decision is made, such as ‘not for admission to critical care’, will be when they become critically ill. In such situations, questions may need to be raised about the appropriateness of admission to critical care. A large study of 82 European intensive care units (ICUs) showed that many patients in critical care are perceived by ICU staff (and particularly nurses) to be receiving care inappropriately (Piers et al., 2011). There is much debate about admission criteria to critical care, but proposed new guidance in the UK has not yet materialized. Admitting patients for a ‘trial of critical care’ is popular; however, this 4
approach is not advocated by all, with some clinicians seeing an open admission policy as a burden on precious resources. These doctors may choose to have a qualified trial, where only those patients with an expectation of being able to survive are admitted. Admission decisions require some sort of assessment of predicted prognosis, particularly in this era of bed and fiscal pressures. Such pressures will contribute to decisions to admit patients, particularly in the UK, which has one of the lowest numbers across Europe of ICU beds (6·6/100 000) per population head (Rhodes et al., 2012). This figure is set against a recent media backlash in the UK of accusations of poor care associated with the use of a care of the dying pathway, the Liverpool Care Pathway (LCP). This has led to a recent governmental review (Department of Health, 2013), with criticisms of the LCP evidence base and misuse. The backlash may well increase the pressure on critical care beds because clinicians are likely to be even more reluctant to make timely decisions and diagnose dying for fear of being seen as using the LCP inappropriately, or using it at all. Patients with long-term complex conditions are known to be high users of critical care resources, often appropriately, but when a patient’s condition or illness is deteriorating and leading towards end-of-life (EOL) then it is right to initiate early discussions about the ongoing appropriateness of level 3 care.
So, what prompts clinicians to consider appropriateness of admission? Increasingly, these questions are raised by critical care outreach (CCO), rapid response or medical emergency teams (METs). As critical care experts and the first point of contact for many worried ward staff, it is left to CCO and similar teams to help triage patients for admission and to assess whether admission to critical care is appropriate (Pattison et al., 2010; Jones et al., 2012). Reasons for negotiation include situations where patients referred to CCOT might need a limitation of medical treatment (LMOT) initiating because of a poor prognostic outlook in the face of critical and concomitant illness. Or, they may have an LMOT already in situ, but require support for a reversible illness. CCO nurses have to act between the parent medical team and the critical care team to mediate and advocate for patients. Work has shown that some clinicians, such as haematologists and surgeons, find it hard to draw back from patients with whom they have established a ‘covenant of care’ (Cassell et al., 2003; McGrath, 2002). Review by critical care staff, such as the CCOT, can provide objective review of the situation, and provide expert input on what admission to critical care for that individual is likely to entail. EOL decision-making is a vastly underestimated aspect of the CCO nurses’ role. Referrals to CCOT that end in an LOMT, or end-of-life decision, comprise around a third of all emergency referrals to CCOTs (Jones et al., 2012),
© 2014 British Association of Critical Care Nurses • Vol 19 No 1
Guest Editorial
and constitute a significant amount of clinical contact. Moreover, dealing with these EOL decisions falls outside the scope and competencies outlined in many CCO and MET role descriptions although it has now been recognized in the National Outreach Forum standards and competencies (National Outreach Forum, 2012). Outreach nurses are required to carefully negotiate with both critical care and parent medical teams and present the critical care options to the patient or patient’s family, outlining the implications of these. For example, in a situation where a patient with an advanced chronic lung condition is admitted to the ward with a recurrent presentation of type 1 respiratory failure, this might mean a plan is instituted not to escalate the patients’ care to include ventilation, but it might mean a symptomatic trial of non-invasive ventilation or perhaps nasal high-flow oxygen. However, the implications of this in a situation where a patient is dying have to be considered if we are to try to achieve the patients wishes: namely to die in their preferred place of care (Department of Health, 2009). Interventions such as ward-based non-invasive ventilation, no matter how well meaning, might prolong a dying process or inhibit a transfer home to die, and there needs to be significant consideration given to how community services will manage these interventions, if at all. It must be remembered when deciding to admit, or not, that survival is not the only endpoint for critical care. Inflicting a critical care trial on a patient who is likely to die has several ethical implications, including providing treatment in the face of futility. I have frequently argued that good end-oflife care can be provided in critical care (Pattison et al., 2013); however, this should not detract from an honest debate as to whether it is appropriate to admit each individual patient. This is particularly the case when patients are too ill at the point of an admission decision to state their own © 2014 British Association of Critical Care Nurses
wishes. Families are relied on for assessment of patients’ wishes. While families nearly always have patients’ best interests in mind, they do get the presumption of wishes wrong for ongoing treatment (White et al., 2012). Predictive models, such as organ dysfunction and severity of illness scores such as SOFA, MODS and APACHE, acute physiology and chronic health evaluation can help in the estimation of likely outcomes for groups of critically ill patients. However, making a certain prognosis for an individual remains problematic. This uncertainty can be compounded when the parent medical team cannot give an accurate prognosis of the patient’s underlying chronic condition. Outreach nurses frequently end up being the catalysts that force parent medical teams to confront the situation of a deteriorating patient who will not benefit from critical care admission and finally diagnose dying. Communicating that a person is dying requires skill, but to do this when patients are critically ill, and losing capacity is complex and challenging. Immense sensitivity and frank honesty is required, not only from the parent medical teams but also from the CCO nurses, who are often involved in breaking bad news to patients and their families. These nurses are ideally placed to clarify a patient’s wishes, but this can only be done after they have established the patient has capacity to make an informed decision about whether they want to be admitted to the critical care unit. Indeed, some CCO teams in the UK are already leading the way with nurseled Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) policies, allowing nurses to initiate DNACPR decisions, and EOL decisions including admission to critical care, and therefore contribute more substantially and meaningfully to patients’ illness trajectories. CCO nurses need to be confident in their expertise and use of advanced communication skills, as well as be aware of the importance
of their contribution to the medical decision-making process, and strong leadership is a prerequisite. A collaborative approach involving shared decision-making should be what we strive for in order to make appropriate decisions at what can be the most difficult time for the patient and their significant others. N. Pattison and G. O’Gara Royal Marsden NHS Foundation Trust, London, UK
REFERENCES Cassell J, Buchman TG, Streat S, Stewart RM. (2003). Surgeons, intensivists, and the covenant of care: administrative models and values affecting care at the end of life – updated. Critical Care Medicine; 31: 1551–1559. Department of Health. (2009). National End of Life Care Programme. http://webarchive. nationalarchives.gov.uk/+/www.dh.gov. uk/en/Healthcare/IntegratedCare/Endof lifecare/DH_086083 (accessed 03/07/13). Department of Health. (2013). More Care, Less Pathway: Review of Liverpool Care Pathway for Dying Patients. http://www.england. nhs.uk/2013/07/15/lcp/ (accessed 18/07/13). ICNARC (Intensive Care National Audit and Research Centre). (2013). Summary Statistics and CMP Data 2011–2012. https:// www.icnarc.org/documents/Summary %20statistics%20-%202011-12.pdf (accessed 16/07/13). Jones DA, Bagshaw SM, Barrett J, Bellomo R, Bhatia G, Bucknall TK, Casamento AJ, Duke GJ, Gibney N, Hart GK, Hillman KM, J¨aderling G, Parmar A, Parr MJ. (2012). The role of the medical emergency team in end-of-life care: a multicenter, prospective, observational study. Critical Care Medicine; 40: 98–103. McGrath P. (2002). End-of-life care for hematological malignancies: the technological imperative and palliative care. Journal of Palliative Care; 18: 39–47. National Outreach Forum. (2012). National Outreach Forum Operational Standards and Competencies for Critical Care Outreach Services. http://www.norf.org.uk/ Resources/Documents/NOrF%20CCCO %20and%20standards/NOrF%20 Operational%20Standards%20and%20 Competencies%201%20August%202012. pdf (accessed 03/07/13). Pattison N, Ashley S, Farquhar-Smith P, Roskelly L, O’Gara G. (2010). Thirty-day
5
Guest Editorial
mortality in critical care outreach patients with cancer: an investigative study of predictive factors related to outreach referral episodes. Resuscitation; 81: 1670–1675. Pattison N, Carr SM, Turnock C, Dolan S. (2013). Viewing in slow motion’: patients’, families’, nurses’ and doctors’ perspectives on end-of-life care in critical care. Journal of Clinical Nursing; 22(9–10): 1442–1454. Piers RD, Azoulay E, Ricou B, Dekeyser Ganz F, Decruyenaere J, Max A, Michalsen A, Maia
6
PA, Owczuk R, Rubulotta F, Depuydt P, Meert AP, Reyners AK, Aquilina A, Bekaert M, Van den Noortgate NJ, Schrauwen WJ, Benoit DD. (2011). Perceptions of appropriateness of care among European and Israeli intensive care unit nurses and physicians. Journal of American Medical Association; 306: 2694–2703. Rhodes A, Ferdinande P, Flaatten H, Guidet B, Metnitz PG, Moreno RP. (2012). The
variability of critical care bed numbers in Europe. Intensive Care Medicine; 38: 1647–1653. White DB, Cua SM, Walk R, Pollice L, Weissfeld L, Hong S, Landefeld CS, Arnold RM. (2012). Nurse-led intervention to improve surrogate decision making for patients with advanced critical illness. American Journal of Critical Care; 21: 396–409.
© 2014 British Association of Critical Care Nurses
