SOPRA System of patient related activities

SIGLEAvailable from British Library Document Supply Centre-DSC:fm02/1439 / BLDSC - British Library Document Supply CentreGBUnited Kingdo

Talking to multi-morbid patients about critical illness: an evolving conversation.

Conversations around critical illness outcomes and benefits from intensive care unit (ICU) treatment have begun to shift away from binary discussions on living versus dying. Increasingly, the reality of survival with functional impairment versus survival with a late death is being recognised as relevant to patients. Most ICU admissions are associated with new functional and cognitive disabilities that are significant and long lasting. When discussing outcomes, clinicians rightly focus on patients' wishes and the quality of life (QoL) that they would find acceptable. However, patients' views may encompass differing views on acceptable QoL post-critical illness, not necessarily reflected in standard conversations. Maintaining independence is a greater priority to patients than simple survival. QoL post-critical illness determines judgments on the benefits of ICU support but translating this into clinical practice risks potential conflation of health outcomes and QoL. This article discusses the concept of response shift and the implication for trade-offs between number/length of invasive treatments and change in physical function or death. Conversations need to delineate how health outcomes (e.g. tracheostomy, muscle wasting, etc.) may affect individual outcomes most relevant to the patient and hence impact overall QoL. The research strategy taken to explore decision-making for critically ill patients might benefit from gathering qualitative data, as a complement to quantitative data. Patients, families and doctors are motivated by far wider considerations, and a consultation process should relate to more than the simple likelihood of mortality in a shared decision-making context

The craft of intensive care medicine

The practice of medicine is often represented as a dualism: is medicine a ?science? or an ?art?? This dualism has been long-lasting, with evident appeal for the medical profession. It also appears to have been rhetorically powerful, for example in enabling clinicians to resist the encroachment of ?scientific? evidence-based medicine into core areas of medical work such as individual clinical judgement. In this article I want to make the case for a more valid conceptualisation of medical practice: that it is a ?craft? activity. The case I make is founded on a theoretical synthesis of the concept of craft, combined with an analysis of ethnographic observations of routine medical practice in intensive care. For this context the craft aspects of medical work can be seen in how biomedical and other types of knowledge are used in practice, the embodied skills and practical judgement of practitioners and the technological and material environment. These aspects are brought together in two conceptual dimensions for ?craft?: first, the application of knowledge; second, interaction with the material world. Some practical and political implications of a ?craft? metaphor for medical practice are noted