Prevalence, goals of care and long-term outcomes of patients with life-limiting illness referred to a tertiary ICU

OBJECTIVE: To describe the prevalence, characteristics, long-term outcomes and goals-of-care discussions of patients with objective indicators of life-limiting illnesses (LLIs) referred to the intensive care unit. DESIGN, SETTING AND PATIENTS: A prospective, observational, cohort study of all adult inpatients referred to the ICU by the medical emergency team or by direct referral, during the period 30 August 2012 to 1 February 2013, at a tertiary teaching hospital in Australia. MAIN OUTCOME MEASURES: Mortality, LLIs, discharge destination and documentation on goals of care in medical record. RESULTS: A total of 649 of 1024 patients referred to the ICU had an LLI, and only 34.4% of these patients had goals of care documented. Overall, 49.2% were admitted to the ICU, 48.4% were discharged home, and the 1-year mortality was 35.1%. The most common LLI criteria were heart disease (52.2%), chronic obstructive pulmonary disease (24.8%) and frailty (23.7%). The highest 1-year mortality was associated with pre-hospital residence in a nursing home (64.9%), dementia (63.3%), cancer (60.8%) and frailty (50.6%). Analysis of patients by clinical trajectory showed that 1-year mortality was significantly higher for patients with cancer (59.6%), combined organ failure and frailty (47.3%), frailty (43.8%) and organ failure (23.6%), compared with patients with no LLI (P < 0.0001). CONCLUSIONS: A high proportion of patients referred to the ICU have an LLI, and this is associated with prolonged hospital length of stay and a high 1-year mortality, and only one-quarter have documented discussions on goals of care. Patients with cancer-related and frailty-related LLIs have the worst survival trajectories

Saving life or prolonging death?

Adelaide Festival of Ideas session, Chandelier Room West, Freemasons Hall, 11:30am, Sunday 20th October, 2013. Hosted by Chris Burrell.We choose how we live - but few of us choose how we die. Dr Charlie Corke has surveyed over 1000 people through his Personal Values Profile project and offers some surprising insights into how people see choices at the end of life, and how this might inform more effective planning in a system tailored towards prolonging life through technology.Charlie Corkehttp://adelaidefestivalofideas.com.au

The business of death

Adelaide Festival of Ideas session, Freemasons Chandelier Room, 1:30 pm, Saturday 19th October 2013. Chaired by Ian Gibbins.No one wants to talk about it, but we’re all going to have to do it sooner or later. Death, that is. Dr Charlie Corke and Lynette Wallworth, director of Tender discuss how to die well, or at least start the conversation.This session is proudly presented by the South Australian Government Department of Health. The Adelaide Festival of Ideas is recorded by Radio Adelaide through the support of The Barr Smith Library, University of Adelaide, University of South Australia Library and Flinders University Library.http://adelaidefestivalofideas.com.a

Predicting future intensive care demand in Australia

BACKGROUND: Predicting future demand for intensive care is vital to planning the allocation of resources. METHOD: Mathematical modelling using the autoregressive integrated moving average (ARIMA) was applied to intensive care data from the Australian and New Zealand Intensive Care Society (ANZICS) Core Database and population projections from the Australian Bureau of Statistics to forecast future demand in Australian intensive care. RESULTS: The model forecasts an increase in ICU demand of over 50% by 2020, with current total ICU bed-days (in 2007) of 471 358, predicted to increase to 643 160 by 2020. An increased rate of ICU use by patients older than 80 years was also noted, with the average bed-days per 10 000 population for this group increasing from 396 in 2006 to 741 in 2007. CONCLUSION: An increase in demand of the forecast magnitude could not be accommodated within current ICU capacity. Significant action will be required.<br /

The influence of medical enduring power of attorney and advance directives on decision making by Australian intensive care doctors

OBJECTIVE: Despite government encouragement for patients to make advance plans for medical treatment, and the increasing numbers of patients who have done this, there is little research that examines how doctors regard these plans. DESIGN: We surveyed Australian intensive care doctors, using a hypothetical clinical scenario, to evaluate how potential end-of-life treatment decisions might be influenced by advance planning - the appointment of a medical enduring power of attorney (MEPA) or an advance care plan (ACP). Using open-ended questions we sought to explore the reasoning behind the doctors\u27 decisions. RESULTS: 275 surveys were returned (18.3% response rate). We found that opinions expressed by an MEPA and ACP have some influence on treatment decisions, but that intensive care doctors had major reservations. Most did not follow the request for palliation made by the MEPA in the hypothetical scenario. CONCLUSIONS: Many intensive care doctors believe end-of-life decisions remain medical decisions, and MEPAs and ACPs need only be respected when they accord with the doctor\u27s treatment decision. This study suggests a need for further education of doctors, particularly those working in intensive care, who are responsible for initiating and maintaining life support treatment.<br /

Teaching general practitioners and doctors-in-training to discuss advance care planning : evaluation of a brief multimodality education programme

To develop and evaluate an interactive advance care planning (ACP) educational programme for general practitioners and doctors-in-training

High-stakes assessment of the non-technical skills of critical care trainees using simulation: feasibility, acceptability and reliability

To evaluate the use of high-fidelity simulation for summative high-stakes assessment of intensive care trainees, focusing on non-technical skills (NTS), testing feasibility and acceptability of simulation assessment, and the reliability of two NTS rating scales.Prospective observational study of senior intensive care trainees in a simulated specialist examination.Participants undertook a simulated patient management scenario and were assessed using two rating scales: the Anaesthesia Non-technical Skills (ANTS) scale and the Ottawa Global Rating Scale (GRS). Assessors were trained, currently active, high-stakes examiners. Participants also completed a survey on simulation-based summative assessment.The inter-rater reliability of two rating scales for NTS assessment. We evaluated the feasibility of simulation-based assessment, and used survey results to assess acceptability to participants.Simulation assessment was feasible. Participants considered simulation-based high-stakes assessment to be acceptable and felt their scenario performance was reflective of real-world performance. Participants identified a need for debriefing following scenario-based assessment. Inter-rater reliability was fair for the ANTS and Ottawa GRS scores (intra-class correlation coefficient, 0.39 and 0.42, respectively). There was only fair agreement between raters for an NTS pass or fail (weighted kappa, 0.32) and for a technical skills pass or fail (weighted kappa, 0.36).Summative high-stakes assessment using a single simulated scenario was feasible and acceptable to senior intensive care trainees. The low inter-rater reliability for the ANTS and Ottawa GRS rating scales and for pass or fail discrimination may limit its incorporation into an existing examination format