Tagge, Garth F.

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The Linacre QuarterlyVolume 42 | Number 2 Article 7May 1975Relationship of Therapy to Prognosis in CriticallyIll PatientsGarth F. TaggeFollow this and additional works at: http://epublications.marquette.edu/lnqRecommended CitationTagge, Garth F. (1975) "Relationship of Therapy to Prognosis in Critically Ill Patients," The Linacre Quarterly: Vol. 42: No. 2, Article 7.Available at: http://epublications.marquette.edu/lnq/vol42/iss2/7Relationship of Therapy to Prognosis in Critically III Patients Garth F. Tagge, M.D. For the reasons so clearly out-lined in the paper by Dr. Cassem, there was developed a patient care classification integrating the intensity of therapy to be ren-dered a critically ill patient with the prognosis for his survival as a whole person. Serious use of the classification requires the un-qualified endorsement of the in ~ stitution which utilizes it, for it is clear that the categorization sys-tem involves awesome decisions - decisions which should be shared by the primary physician, the Medical Director of the I CU, and appropriate consultants. It is also mandatory that the wishes of the patient and/ or his family be given the highest priority in the deliberations. The classification system must not be instituted in a casual manner but should be approved for use in the intensive care unit by the Board of Direc-tors of the hospital and the Ex-cutive Board of the Medical Staff Dr. Tagge is Assistant Clinical Professor of Medicine at the Uni-versity of California l ruine-Col-lege of M edicine, and former Medical Director of the Acute Care Center, Anaheim Memorial Hospital. Dr. Tagge is a FPlhw of the American. College of Cardi-ology . May, 1975 and the ICU Committee. It must also enjoy the support of the Medical Staff members who use the ICU. Given this support there is every expectation that the classi-fication can serve the following functions: (a) to force the con-scious decision as to use or omis-sion of heroic measures (including cardiopulmonary resuscitation); (b) to promote dialogue between the primary physician, I CU staff and the family with respect to the treatment goals and likelihood of success; (c) to prevent confusion in those charged with the overall care of the ICU; (d) to encourage the development of a treatment plan based on a frequent reassess-ment of the patient which does not ask the ICU staff to render extraordinary care to a patient who has no reasonable hope for survival as a whole person; (e) to minimize the medico-legal risks; (f) to dignify the entire ICU op-eration for the patient, his fami-ly, and the staff; and most importantly, (g) to guarantee continual reassessment of each individual case with respect to the goals of treatment and the de-termination of that point in time when treatment should be stopped - when the goals are no longer attainable. The Intensive Care Unit activi-99 ties for which this classification has been structured bear much medico-legal implication. How-ever, the official position of the American Medical Association on the pertinent matters, coupled with the fact that the classifica-tion system has been employed at Mount Sinai Hospital and Massa-chusetts General Hospital, would seem to . constitute sufficient precedent for its use in an institu-tion which deals with critically ill patients on a large scale - as long as it is implemented in the formal manner suggested, and as long as it receives the institu-tion's endorsements recommend-ed above. Patient Care Classification Category I Maximal therapeutic e f for t without reservation. Category II Maximal therapeutic e f for t without reservation, but the patient is to be re-evaluated at a specific future time, e.g., 24 hours. Category III No new therapy (such as trans-fusions, antibiotics, etc.) is to be initiated. Conservative, pas-sive m e d i c a I care replaces heroic measures. Particular at-tention is given to comfort, including the use of oxygen and diuretics for s h 0 r t n e s s of breath, fluids for symptoms of dehydration, analgesics for re-lief of pain, etc. Relief of suf-fering is the primary goal. Those mechanical therapeutic measures including volume ven-tilators, cardiac pacemakers, 100 etc., already initiated, may be continued, but are not initiated anew. Category rv All therapy will be stopped, and life support assistance will be discontinued. Assignment and Use of the Classifications On admission to the rcu pa-tients will be assigned to a treat-ment classification, ordinarily Category 1. Assignment of treat-ment classification is the respon-sibility of the primary physician. Each day on unit rounds the classification is to be assessed. Whenever a question is raised whether the treatment of a pa-tient with an irreversible illness is improper or inhumane, it should be di s c u sse d at unit rounds. The question may arise from the patient himself, the family, the primary physician, the rcu staff or Unit Director, or consultants called by the primary physician. If there is consensus about treatment, no change in classification occurs. If the pa-tient or the family or someone not at rounds has raised the ques-tion, the primary physician or anyone he or t he Unit Director designates s h 0 u I d explain the treatment rationale to the person who raised the question. If treat-ment rationale remains unclear at unit rounds, the patient may be assigned to Category II by the primary physician. Category II is for that patient whose chances for survival are slim, but in whom the attending physician and other responsihle Linacre Quarterly members of the ICU team are un-willing to abandon the pursuit of life and health. This designation indicates that the primary physi-cian and other responsible parties may expect continuation of maxi-mal therapeutic effort for a defi-nite but limited period of time (24 hours), despite the fact that there is littie likelihood for sur-vivaL This arrangement elimi-nates the problem of placing un-realistic demands upon the ICU staff for an unlimited period of time when, in fact, chances for survival are slim. Patients in this category are te-evaluated by the ptimary physician in conjunction with responsible members of the ICU team and are either reclassi-fied or continued in Category II for an additional 24 hours by mu-tual agreement and understand-ing. Other purposes for assignment to Category II are (a) to provide opportuni ty for the p rim a r y physician to obtain further con-sultation and support in the man-agement of a difficult case, and (b) to insure dialogue between the primary physician and Unit Director and staff. If the ICU staff (nurses and physicians) do not understand the reasons for a specific treatment of a patient, or fail to see how it can reverse the patient's illness, they are encour-aged to request clarification of this at unit rounds from the pri-mary physician and/ or Unit Di-rector. If the primary physician is not present they are encouraged to make their request known to the Unit Director so that he may May, 1975 relay the request to t he primary physician. Since the majority of staff conflicts have arisen from communication failures , use of unit rounds to clarify specific treatment con sid era t ion is strongly recommended. Category III is for the patient who may have been in either Category I or Category II, but whose clinical course has de-teriorated to the point that there is every expectation that he will not survive des pit e maximal therapeutic efforts. In these pa-tients, conservative and passive medical care replaces heroic meas-ures. The Category III patient is not an ICU candidate at this point, but social and ethical con-siderations may dictate his con-tinued presence in the ICU until the propitious time for his trans-fer to the general medical or sur-gical floor. To designate a patient as Category III requires the con-currence of the primary physi -cian , his consultants, the inten-sive care doctors, and representa-tives of the senior nursing staff. In every instance the wishes of the patient's family are consid-ered, but in no instance is the onus for failure to pursue aggres-sively therapeutic goals placed upon members of the family. The decision to designate a patient as Category III implies that he has no chance of survival as a whole person. Moreover, a Category III designation implies an agreement or consensus in the medical and nursing management of the pa-tient and the family to avoid meaningless, expensive and time-101 consuming therapy. Such deci-sions allow for more attention to be appropriately redeployed to the other patients, with greater benefit. While it may not occur too frequently that the Category III patient cannot be promptly removed from the ICU setting in the university hospital, this is not the case in the community hos-pital where factors other than the medical condition of the patient are at w 0 r k to influence the census. When the primary physician designates a patient for treat-ment Category III , it is essential that he obtain the support of the Unit Director, ICU physicians, nursing staff, and his own con-sultants. This is prohably most conveniently given through dis-cussion at unit rounds, although the prior discussion may indicate that such supportive consensus is already clear. If the primary physician is uncertain whether his clinical reasoning has heen prop-erly understood by the ICU staff, he is encouraged to check with the Unit Director. At the transition from Cate-gory II to Category III the pri-mary physician, on whom this difficult decision f a II s, should avail himself of any consultation he wishes. Designation of Cate-gory III is an issue entirely inde-pendent of the question whether the patient should remain in the ICU. Because of the high cost of ICU beds, there is considerable pressure to make economic con-siderations primary in deciding where a particular patient should 102 reside. It is recommended that economic considerations a Ion e never be made the sole criterion for disposition and treatment of patients. Category IV includes those pa-tients in whom human life tech-nically exists but a human person no longer exists - e.g., patients with brain death. The conscious decision is made to relinquish a life which no longer has meaning. Such a decision requires a spe-cific definitive statement made after proper consultation with ap-propriate specialists, as well as laboratory analyses such as EEG or cerebral angiography in which the patient is judged to have ab-solutely no hope for survival. As in Category III , the decision to designate a patient as Category IV requires the concurrence of the primary physician, his con-sultants, the intensive care doc-tors, representatives of the seniol' nursing staff, and the family. The de fin i t i v e act of commission, namely turning off mechanical ventilators or other life support systems, is entertained; the final act is subject to local policy, cus-tom and legal opinion. Designation of a patient for Category IV is to follow the same recommendations as those given for III. The definitive act of com-mission, such as turning off a mechanical ventilator, is to be performed only hy an appropriate physician, after consultation with and concurrence of the family, where indicated. Placing the pa-tient in Category III or IV ob-viates the occasional prohlem Linacre Quarterly where the primary physician may want the ICU personnel to con-tinue maximal therapy for ap-pearance sake long after he and his consultants have abandoned hope for the patient's survival. In this system, unanimous de-cisions are desirable, but in the event of a difference of opinion in categorization, the Medical Di-rector of the ICU should be pre-pared to assume responsibility as the final authority. Whenever a patient is classified in Categories II to IV, his classification must be reviewed and reassigned daily. If it becomes proper that patients in treatment Category III should be returned to Category I, prompt notification of the ICU staff is essential. It is recommended that a sub-committee of the Critical Care Committee be established to serve in an advisory capacity in situa-tions where controversy exists as to the appropriateness of con-tinued intensive therapy in criti-cally ill patients. Such contro-versy would ordinarily arise when pat i en t s are transferred from Categories II to III or III to IV. Although the Unit Director may suggest a review by the com-mittee, the u I tim ate request should come from the primary physician. In the case of non-private patients, such a review must have the approval of the responsible attending physician. When requested by the primary physician, the subcommittee will act as expeditiously as possible to review all available information regarding the patient, calling on May, 1975 whatever resources it deems nec-essary. The subcommittee will then recommend to the primary physician what it considers to be a proper course of action. It should be emphasized that the committee's role is advisory, and the primary physician may accept or reject the decision of the sub-committee. Discussion The changing clinical status of several desperately ill patients, lying side by side in an intensive care unit, can generate confusion among the ICU staff unless pe-riodic reassessments of treatment goals and prognoses are made. The more formal such reassess-ments by responsible members be-come, the more salutory will be the benefits to the intensive care activities. The malpractice insurance car-riers are concerned with the in-creasing emphasis on intensive care. Some anticipate possible in-creases in malpractice suits when heroic measures are carried out wit h increasing frequency on critically ill patients. Aggressive interventions com-monly inflicted upon patients on the verge of circulatory or respir-atory collapse generate psycho-logical pressures among the family members ; often these are trans-ferred to the physician in the form of hostility when hostility is undeserved. These may ultimate-ly have litigation implications. Psychodynamic defenses devel-oped by the patient and family often involve hostility reactions toward the physicians and the 103 lCU staff. Commonpla ce re-sponses of family members of critically ill pat i e n t s include: technological paranoia, accusa-tions of brutalization, insistence on treatment at any cost, insist-ence on heroic treatment of an unsalvageable patient, and de-mands to hasten death. The for-mal, structured reassessments of patients by the responsible mem-bers of the l CU staff are a useful means to reduce medico-legal risks. Coming to grips with the treat-ment in relation to the prognosis discourages avoidance on the part of the primary physician of the responsibility for deciding about the use or omission of heroic measures. This may obviate the frequent situation where a con-fused house officer or nurse is faced with the responsibility for these decisions on an emergency basis. For example, when orders for therapy are: (a) do every-thing you can, but if the patient Are You Moving? arrests, do not resuscitate; (b) if the patient bleeds, transfuse him; (c) give antibiotics and steroids but not parenteral nutrition. These are unrealistic in the lCU setting. Frequently they merely prolong the process of dying or' are insufficient for survival. Half treatment of a critically ill pa-tient is illogical arid must be avoided. It is important that the cate-gorization of a patient be based upon ethical , religious, tech-nological, economic, legal, and psychosocial grounds as well as upon medical grounds. Decisions which consider only a few of these aspects may be incomplete or incorrect. The more formal the classification process, and the more participation from responsi-ble members of the lCU staff, the more likely the decision will en-compass the appropriate aspects, and the more likely the decision will be the correct one. If the next issue of this journal should be delivered to a differ-ent address, please advise AT ONCE. The return postage and cost of remailing this publication is becoming more and more costly . Your cooperation in keeping us up-to-date with your address will be most helpful. 104 Linacre Quarterly 

Relationship of Therapy to Prognosis in Critically Ill Patients

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Relationship of Therapy to Prognosis in Critically Ill Patients

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