U.K. Intensivists' Preferences for Patient Admission to ICU: Evidence From a Choice Experiment

Factors influencing decision-making processes for intensive care therapy goals: A systematic integrative review

BACKGROUND

Delivering intensive care therapies concordant with patients' values and preferences is considered gold standard care. To achieve this, healthcare professionals must better understand decision-making processes and factors influencing them.

AIM

The aim of this study was to explore factors influencing decision-making processes about implementing and limiting intensive care therapies.

DESIGN

Systematic integrative review, synthesising quantitative, qualitative, and mixed-methods studies.

METHODS

Five databases were searched (Medline, The Cochrane central register of controlled trials, Embase, PsycINFO, and CINAHL plus) for peer-reviewed, primary research published in English from 2010 to Oct 2022. Quantitative, qualitative, or mixed-methods studies focussing on intensive care decision-making were included for appraisal. Full-text review and quality screening included the Critical Appraisal Skills Program tool for qualitative and mixed methods and the Medical Education Research Quality Instrument for quantitative studies. Papers were reviewed by two authors independently, and a third author resolved disagreements. The primary author developed a thematic coding framework and performed coding and pattern identification using NVivo, with regular group discussions.

RESULTS

Of the 83 studies, 44 were qualitative, 32 quantitative, and seven mixed-methods studies. Seven key themes were identified: what the decision is about; who is making the decision; characteristics of the decision-maker; factors influencing medical prognostication; clinician-patient/surrogate communication; factors affecting decisional concordance; and how interactions affect decisional concordance. Substantial thematic overlaps existed. The most reported decision was whether to withhold therapies, and the most common decision-maker was the clinician. Whether a treatment recommendation was concordant was influenced by multiple factors including institutional cultures and clinician continuity.

CONCLUSION

Decision-making relating to intensive care unit therapy goals is complicated. The current review identifies that breadth of decision-makers, and the complexity of intersecting factors has not previously been incorporated into interventions or considered within a single review. Its findings provide a basis for future research and training to improve decisional concordance between clinicians and patients/surrogates with regards to intensive care unit therapies.

Prognosticating the outcome of intensive care in older patients-a narrative review

Prognosis determines major decisions regarding treatment for critically ill patients. Statistical models have been developed to predict the probability of survival and other outcomes of intensive care. Although they were trained on the characteristics of large patient cohorts, they often do not represent very old patients (age ≥ 80 years) appropriately. Moreover, the heterogeneity within this particular group impairs the utility of statistical predictions for informing decision-making in very old individuals. In addition to these methodological problems, the diversity of cultural attitudes, available resources as well as variations of legal and professional norms limit the generalisability of prediction models, especially in patients with complex multi-morbidity and pre-existing functional impairments. Thus, current approaches to prognosticating outcomes in very old patients are imperfect and can generate substantial uncertainty about optimal trajectories of critical care in the individual. This article presents the state of the art and new approaches to predicting outcomes of intensive care for these patients. Special emphasis has been given to the integration of predictions into the decision-making for individual patients. This requires quantification of prognostic uncertainty and a careful alignment of decisions with the preferences of patients, who might prioritise functional outcomes over survival. Since the performance of outcome predictions for the individual patient may improve over time, time-limited trials in intensive care may be an appropriate way to increase the confidence in decisions about life-sustaining treatment.

Factors that influence paramedic decision-making about resuscitation for treatment of out of hospital cardiac arrest: Results of a discrete choice experiment in National Health Service ambulance trusts in England and Wales

Background

During out of hospital cardiac arrest (OHCA) paramedics must make decisions to commence, continue, terminate or withhold resuscitation. These decisions are known to be complex, subject to variability and often dependent on provider preference. This study aimed to understand paramedic decision-making regarding the commencement of resuscitation using a discrete choice experiment.

Methods

A discrete choice experiment between October-December 2022 surveying paramedics from ten National Health Service ambulance trusts in England and Wales. Respondents were presented with fourteen vignettes, each comprising thirteen attributes, and asked to decide if they would provide resuscitation or not.

Results

Eight hundred and sixty-four paramedics completed the survey (61.8% male, median age 36 years (IQR 17.1)) and half had < 5 years clinical experience (n = 443 (51.2%). Respondents expressed a general preference to offer resuscitation (p = <0.01). All attributes except patient gender were statistically significant and important regarding an offer of resuscitation. Cut-offs where an offer of resuscitation was less likely were patient age of 73 years (p=>0.05), mild dementia (p = >0.05) and moderate frailty (p = <0.01). Paramedic characteristics of female gender, longest (>10 years) and shortest (<5 years) period qualified, lower academic qualification, lower skill level and attending fewer OHCA's were more likely to result in an offer of resuscitation.

Conclusion

During OHCA paramedics use objective and non-objective factors to make pragmatic decisions regarding an offer of resuscitation. Future research should focus on how best to support paramedics to make decisions during OHCA, how variability in decision-making impacts patient outcomes and how this relates to patient and public expectations.

Limiting life-sustaining treatment for very old ICU patients: cultural challenges and diverse practices

BACKGROUND

Decisions about life-sustaining therapy (LST) in the intensive care unit (ICU) depend on predictions of survival as well as the expected functional capacity and self-perceived quality of life after discharge, especially in very old patients. However, prognostication for individual patients in this cohort is hampered by substantial uncertainty which can lead to a large variability of opinions and, eventually, decisions about LST. Moreover, decision-making processes are often embedded in a framework of ethical and legal recommendations which may vary between countries resulting in divergent management strategies.

METHODS

Based on a vignette scenario of a multi-morbid 87-year-old patient, this article illustrates the spectrum of opinions about LST among intensivsts with a special interest in very old patients, from ten countries/regions, representing diverse cultures and healthcare systems.

RESULTS

This survey of expert opinions and national recommendations demonstrates shared principles in the management of very old ICU patients. Some guidelines also acknowledge cultural differences between population groups. Although consensus with families should be sought, shared decision-making is not formally required or practised in all countries.

CONCLUSIONS

This article shows similarities and differences in the decision-making for LST in very old ICU patients and recommends strategies to deal with prognostic uncertainty. Conflicts should be anticipated in situations where stakeholders have different cultural beliefs. There is a need for more collaborative research and training in this field.

Triage of Critically Ill Patients: Characteristics and Outcomes of Patients Refused as Too Well for Intensive Care

BACKGROUND

The appropriate selection of patients for the intensive care unit (ICU) is a concern in acute care settings. However, the description of patients deemed too well for the ICU has been rarely reported.

METHODS

We conducted a single-centre retrospective observational study of all patients either deemed "too well" for or admitted to the ICU during one year. Refused patients were screened for unexpected events within 7 days, defined as either ICU admission without another indication, or death without treatment limitations. Patients' characteristics and organisational factors were analysed according to refusal status, outcome and delay in ICU admission.

RESULTS

Among 2219 enrolled patients, the refusal rate was 10.4%. Refusal was associated with diagnostic groups, treatment limitations, patients' location on a ward, night time and ICU occupancy. Unexpected events occurred in 16 (6.9%) refused patients. A worse outcome was associated with time spent in hospital before refusal, patients' location on a ward, SOFA score and physician's expertise. Delayed ICU admissions were associated with ICU and hospital length of stay.

CONCLUSIONS

ICU triage selected safely most patients who would have probably not benefited from the ICU. We identified individual and organisational factors associated with ICU refusal, subsequent ICU admission or death.

Use of Mechanical Ventilation Across 3 Countries

Importance

The ability to provide invasive mechanical ventilation (IMV) is a mainstay of modern intensive care; however, whether rates of IMV vary among countries is unclear.

Objective

To estimate the per capita rates of IMV in adults across 3 high-income countries with large variation in per capita intensive care unit (ICU) bed availability.

Design, Setting, and Participants

This cohort study examined 2018 data of patients aged 20 years or older who received IMV in England, Canada, and the US.

Exposure

The country in which IMV was received.

Main Outcomes and Measures

The main outcome was the age-standardized rate of IMV and ICU admissions in each country. Rates were stratified by age, specific diagnoses (acute myocardial infarction, pulmonary embolus, upper gastrointestinal bleed), and comorbidities (dementia, dialysis dependence). Data analyses were conducted between January 1, 2021, and December 1, 2022.

Results

The study included 59 873 hospital admissions with IMV in England (median [IQR] patient age, 61 [47-72] years; 59% men, 41% women), 70 250 in Canada (median [IQR] patient age, 65 [54-74] years; 64% men, 36% women), and 1 614 768 in the US (median [IQR] patient age, 65 [54-74] years; 57% men, 43% women). The age-standardized rate per 100 000 population of IMV was the lowest in England (131; 95% CI, 130-132) compared with Canada (290; 95% CI, 288-292) and the US (614; 95% CI, 614-615). Stratified by age, per capita rates of IMV were more similar across countries among younger patients and diverged markedly in older patients. Among patients aged 80 years or older, the crude rate of IMV per 100 000 population was highest in the US (1788; 95% CI, 1781-1796) compared with Canada (694; 95% CI, 679-709) and England (209; 95% CI, 203-214). Concerning measured comorbidities, 6.3% of admitted patients who received IMV in the US had a diagnosis of dementia (vs 1.4% in England and 1.3% in Canada). Similarly, 5.6% of admitted patients in the US were dependent on dialysis prior to receiving IMV (vs 1.3% in England and 0.3% in Canada).

Conclusions and Relevance

This cohort study found that patients in the US received IMV at a rate 4 times higher than in England and twice that in Canada in 2018. The greatest divergence was in the use of IMV among older adults, and patient characteristics among those who received IMV varied markedly. The differences in overall use of IMV among these countries highlight the need to better understand patient-, clinician-, and systems-level choices associated with the varied use of a limited and expensive resource.

Contribution of information about acute and geriatric characteristics to decisions about life-sustaining treatment for old patients in intensive care

BACKGROUND

Life-sustaining treatment (LST) in the intensive care unit (ICU) is withheld or withdrawn when there is no reasonable expectation of beneficial outcome. This is especially relevant in old patients where further functional decline might be detrimental for the self-perceived quality of life. However, there still is substantial uncertainty involved in decisions about LST. We used the framework of information theory to assess that uncertainty by measuring information processed during decision-making.

METHODS

Datasets from two multicentre studies (VIP1, VIP2) with a total of 7488 ICU patients aged 80 years or older were analysed concerning the contribution of information about the acute illness, age, gender, frailty and other geriatric characteristics to decisions about LST. The role of these characteristics in the decision-making process was quantified by the entropy of likelihood distributions and the Kullback-Leibler divergence with regard to withholding or withdrawing decisions.

RESULTS

Decisions to withhold or withdraw LST were made in 2186 and 1110 patients, respectively. Both in VIP1 and VIP2, information about the acute illness had the lowest entropy and largest Kullback-Leibler divergence with respect to decisions about withdrawing LST. Age, gender and geriatric characteristics contributed to that decision only to a smaller degree.

CONCLUSIONS

Information about the severity of the acute illness and, thereby, short-term prognosis dominated decisions about LST in old ICU patients. The smaller contribution of geriatric features suggests persistent uncertainty about the importance of functional outcome. There still remains a gap to fully explain decision-making about LST and further research involving contextual information is required.

TRIAL REGISTRATION

VIP1 study: NCT03134807 (1 May 2017), VIP2 study: NCT03370692 (12 December 2017).

Comparison of the Outcomes of Patients Starting Mechanical Ventilation in the General Ward Versus the Intensive Care Unit

OBJECTIVE

Mechanical ventilation is sometimes initiated in the general ward (GW) due to the shortage of intensive care unit (ICU) beds. We investigated whether invasive mechanical ventilation (MV) started in the GW affects the patient's prognosis compared with its initiation in the ICU.

METHODS

From January 2016 to December 2018, medical records of patients who started MV in the GW or ICU were collected. The 28-day mortality, ICU mortality, ventilator-free days, and complications related to the ventilator and the ventilator-free days were analyzed as outcomes.

RESULTS

A total of 673 patients were enrolled. Among these, 268 patients (39.8%) started MV in the GW and 405 patients (60.2%) started MV within 24 hours after admittance to the ICU. There was no difference in 28-day mortality between the 2 groups (27.2% versus 27.2%, P = 0.997). In addition, there was no difference between ventilator-related complication rates, ventilator-free days, or the length of hospital stay. A high Acute Physiology and Chronic Health Evaluation II score, the presence of solid tumor, the absence of chronic kidney diseases, and low platelet count were associated with higher 28-day mortality. However, the initiation of MV in the GW was not associated with an increase in 28-day mortality compared with the initiation in the ICU.

CONCLUSIONS

Starting MV in the GW was not a risk factor for 28-day mortality. Therefore, prompt application of a ventilator if medically indicated, regardless of the patient's location, is desirable if a skilled airway team and appropriate monitoring are available.

Who gets the ventilator? A multicentre survey of intensivists' opinions of triage during the first wave of the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic has caused a shortage of intensive care resources. Intensivists' opinion of triage and ventilator allocation during the COVID-19 pandemic is not well described.

METHODS

This was a survey concerning patient numbers, bed capacity, triage guidelines, and three virtual cases involving ventilator allocations. Physicians from 400 ICUs in a research network were invited to participate. Preferences were assessed with a five-point Likert scale. Additionally, age, gender, work experience, geography, and religion were recorded.

RESULTS

Of 437 responders 31% were female. The mean age was 44.4 (SD 11.1) with a mean ICU experience of 13.7 (SD 10.5) years. Respondents were mostly European (88%). Sixty-six percent had triage guidelines available. Younger patients and caretakers of children were favoured for ventilator allocation although this was less clear if this involved withdrawal of the ventilator from another patient. Decisions did not differ with ICU experience, gender, religion, or guideline availability. Consultation of colleagues or an ethical committee decreased with age and male gender.

CONCLUSION

Intensivists appeared to prioritise younger patients for ventilator allocation. The tendency to consult colleagues about triage decreased with age and male gender. Many found such tasks to be not purely medical and that authorities should assume responsibility for triage during resource scarcity.

A real-time integrated framework to support clinical decision making for covid-19 patients

BACKGROUND

The COVID-19 pandemic affected healthcare systems worldwide. Predictive models developed by Artificial Intelligence (AI) and based on timely, centralized and standardized real world patient data could improve management of COVID-19 to achieve better clinical outcomes. The objectives of this manuscript are to describe the structure and technologies used to construct a COVID-19 Data Mart architecture and to present how a large hospital has tackled the challenge of supporting daily management of COVID-19 pandemic emergency, by creating a strong retrospective knowledge base, a real time environment and integrated information dashboard for daily practice and early identification of critical condition at patient level. This framework is also used as an informative, continuously enriched data lake, which is a base for several on-going predictive studies.

METHODS

The information technology framework for clinical practice and research was described. It was developed using SAS Institute software analytics tool and SAS® Vyia® environment and Open-Source environment R ® and Python ® for fast prototyping and modeling. The included variables and the source extraction procedures were presented.

RESULTS

The Data Mart covers a retrospective cohort of 5528 patients with SARS-CoV-2 infection. People who died were older, had more comorbidities, reported more frequently dyspnea at onset, had higher d-dimer, C-reactive protein and urea nitrogen. The dashboard was developed to support the management of COVID-19 patients at three levels: hospital, single ward and individual care level.

INTERPRETATION

The COVID-19 Data Mart based on integration of a large collection of clinical data and an AI-based integrated framework has been developed, based on a set of automated procedures for data mining and retrieval, transformation and integration, and has been embedded in the clinical practice to help managing daily care. Benefits from the availability of a Data Mart include the opportunity to build predictive models with a machine learning approach to identify undescribed clinical phenotypes and to foster hospital networks. A real-time updated dashboard built from the Data Mart may represent a valid tool for a better knowledge of epidemiological and clinical features of COVID-19, especially when multiple waves are observed, as well as for epidemic and pandemic events of the same nature (e. g. with critical clinical conditions leading to severe pulmonary inflammation). Therefore, we believe the approach presented in this paper may find several applications in comparable situations even at region or state levels. Finally, models predicting the course of future waves or new pandemics could largely benefit from network of DataMarts.

Frailty Triage: Is Rationing Intensive Medical Treatment on the Grounds of Frailty Ethical?

In early 2020, a number of countries developed and published intensive care triage guidelines for the pandemic. Several of those guidelines, especially in the UK, encouraged the explicit assessment of clinical frailty as part of triage. Frailty is relevant to resource allocation in at least three separate ways, through its impact on probability of survival, longevity and quality of life (though not a fourth-length of intensive care stay). I review and reject claims that frailty-based triage would represent unjust discrimination on the grounds of age or disability. I outline three important steps to improve the ethical incorporation of frailty into triage. Triage criteria (ie frailty) should be assessed consistently in all patients referred to the intensive care unit. Guidelines must make explicit the ethical basis for the triage decision. This can then be applied, using the concept of triage equivalence, to other (non-frail) patients referred to intensive care.

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.

Physicians' Acceptance of Triage Guidelines in the Context of the COVID-19 Pandemic: A Qualitative Study

Aims: One of the major ethical challenges posed by the Covid-19 pandemic comes in the form of fair triage decisions for critically ill patients in situations where life-saving resources are limited. In Spring 2020, the Swiss Academy of Medical Sciences (SAMS) issued specific guidelines on triage for intensive-care treatment in the context of the Covid-19 pandemic. While evidence has shown that the capacities of intensive care medicine throughout Switzerland were sufficient to take care of all critically ill patients during the first wave of the outbreak, no evidence is available regarding the acceptance of these guidelines by ICU staff. The aim of this qualitative study was to explore the acceptance and perceived implementation of the SAMS guidelines among a sample of senior physicians involved in the care of Covid-19 patients in the Canton of Ticino. Specific objectives included capturing and describing physicians' attitudes toward the guidelines, any challenges experienced in their application, and any perceived factors that facilitated or would facilitate their application.

Methods: We conducted face-to-face and telephone interviews with a purposive sample of nine senior physicians employed as either head of unity, deputy-head of unit, or medical director in either one of the two Covid-19 hospitals in the Canton of Ticino during the peak of the outbreak. Interviews were transcribed verbatim and thematically analyzed using an inductive approach.

Results: We found that participants held different views regarding the nature of the guidelines, saw decisions on admission as a matter of collective responsibility, argued that decisions should be based on a medical futility principle rather than an age criterion, and found that difficulties to address end-of-life issues led to a comeback of paternalism.

Conclusions: Results highlight the importance of clarifying the nature of the guidelines, establishing authority, and responsibility during triaging decisions, recognizing and addressing sources of interference with patients' autonomy, and the need of a cultural shift in timely and efficiently addressing end-of-life issues.

Physicians' Views and Agreement about Patient- and Context-Related Factors Influencing ICU Admission Decisions: A Prospective Study

Background: Single patient- and context-related factors have been associated with admission decisions to intensive care. How physicians weigh various factors and integrate them into the decision-making process is not well known. Objectives: First, to determine which patient- and context-related factors influence admission decisions according to physicians, and their agreement about these determinants; and second, to examine whether there are differences for patients with and without advanced disease. Method: This study was conducted in one tertiary hospital. Consecutive ICU consultations for medical inpatients were prospectively included. Involved physicians, i.e., internists and intensivists, rated the importance of 13 factors for each decision on a Likert scale (1 = negligible to 5 = predominant). We cross-tabulated these factors by presence or absence of advanced disease and examined the degree of agreement between internists and intensivists using the kappa statistic. Results: Of 201 evaluated patients, 105 (52.2%) had an advanced disease, and 140 (69.7%) were admitted to intensive care. The mean number of important factors per decision was 3.5 (SD 2.4) for intensivists and 4.4 (SD 2.1) for internists. Patient’s comorbidities, quality of life, preferences, and code status were most often mentioned. Inter-rater agreement was low for the whole population and after stratifying for patients with and without advanced disease. Kappa values ranged from 0.02 to 0.34 for all the patients, from −0.05 to 0.42 for patients with advanced disease, and from −0.08 to 0.32 for patients without advanced disease. The best agreement was found for family preferences. Conclusion: Poor agreement between physicians about patient- and context-related determinants of ICU admission suggests a lack of explicitness during the decision-making process. The potential consequences are increased variability and inequity regarding which patients are admitted. Timely advance care planning involving families could help physicians make the decision most concordant with patient preferences.

Physicians' perspective on potentially non-beneficial treatment when assessing patients with advanced disease for ICU admission: a qualitative study

OBJECTIVE

The use of intensive care at the end of life can be high, leading to inappropriate healthcare utilisation, and prolonged suffering for patients and families. The objective of the study was to determine which factors influence physicians' admission decisions in situations of potentially non-beneficial intensive care.

DESIGN

This is a secondary analysis of a qualitative study exploring the triage process. In-depth interviews were analysed using an inductive approach to thematic content analysis.

SETTING

Data were collected in a Swiss tertiary care centre between March and June 2013.

PARTICIPANTS

12 intensive care unit (ICU) physicians and 12 internists routinely involved in ICU admission decisions.

RESULTS

Physicians struggled to understand the request for intensive care for patients with advanced disease and full code status. Physicians considered patients' long-term vital and functional prognosis, but they also resorted to shortcuts, that is, a priori consensus about reasons for admitting a patient. Family pressure and unexpected critical events were determinants of admission to the ICU. Patient preferences, ICU physician's expertise and collaborative decision making facilitated refusal. Physicians were willing to admit a patient with advanced disease for a limited amount of time to fulfil a personal need.

CONCLUSIONS

In situations of potentially non-beneficial intensive care, the influence of shortcuts or context-related factors suggests that practice variations and inappropriate admission decisions are likely to occur. Institutional guidelines and timely goals of care discussions with patients with advanced disease and their families could contribute to ensuring appropriate levels of care.

Level of Medical Intervention in Geriatric Settings: Decision Factors and Correlation With Mortality

OBJECTIVES

Level of medical intervention (LMI) has to be adapted to each patient in geriatric care. LMI scales intend to help nonintensive care (NIC) decisions, giving priority to patient choice and collegial discussion. In the present study, we aimed to assess the parameters associated with the NIC decision and whether these parameters differ from those associated with in-hospital mortality.

DESIGN

Prospective observational study.

SETTING AND PARTICIPANTS

All consecutive patients from a French 62-bed acute geriatric unit over 1 year.

METHODS

Factors from the geriatric assessment associated with the decision of NIC were compared with those associated with in-hospital and 1-year mortality, in univariate and multivariate analyses.

RESULTS

In total, 1654 consecutive patients (median age 87 years) were included. Collegial reflection led to NIC decision for 532 patients (32%). In-hospital and 1-year mortality were 22% and 54% in the NIC group vs 2% and 27% in the rest of the cohort (P < .001 for both). In multivariable analysis, high Charlson Comorbidity Index [odds ratio (OR) 1.15, 95% confidence interval (CI) 1.06-1.23, per point], severe neurocognitive disorders (OR 2.78, 95% CI 1.67-4.55), dependence (OR 1.92, 95% CI 1.45-2.59), and nursing home residence (OR 2.38, 95% CI 1.85-3.13) were highly associated with NIC decision but not with in-hospital mortality. Conversely, acute diseases had little impact on LMI despite their high short-term prognostic burden.

CONCLUSIONS AND IMPLICATIONS

Neurocognitive disorders and dependence were strongly associated with NIC decision, even though they were not significantly associated with in-hospital mortality. The decision-making process of LMI therefore seems to go beyond the notion of short-term survival.

Long-term trends in critical care admissions in Wales

As national populations age, demands on critical care services are expected to increase. In many healthcare settings, longitudinal trends indicate rising numbers and proportions of patients admitted to ICU who are older; elsewhere, including some parts of the UK, a decrease has raised concerns with regard to rationing according to age. Our aim was to investigate admission trends in Wales, where critical care capacity has not risen in the last decade. We used the Secure Anonymised Information Linkage Databank to identify and characterise critical care admissions in patients aged ≥ 18 years from 1 January 2008 to 31 December 2017. We categorised 85,629 ICU admissions as youngest (18-64 years), older (65-79 years) and oldest (≥ 80 years). The oldest group accounted for 15% of admissions, the older age group 39% and the youngest group 46%. Relative to the national population, the incidence of admission rates per 10,000 population in the oldest group decreased significantly over the study period from 91.5/10,000 in 2008 to 77.5/10,000 (a relative decrease of 15%), and among the older group from 89.2/10,000 in 2008 to 75.3/10,000 in 2017 (a relative decrease of 16%). We observed significant decreases in admissions with high comorbidity (modified Charlson comorbidity index); increases in the proportion of older patients admitted who were considered 'fit' rather than frail (electronic frailty index); and decreases in admissions with a medical diagnosis. In contrast to other healthcare settings, capacity constraints and surgical imperatives appear to have contributed to a relative exclusion of older patients presenting with acute medical illness.

UK consultants' experiences of the decision-making process around referral to intensive care: an interview study

OBJECTIVE

The decision whether to initiate intensive care for the critically ill patient involves ethical questions regarding what is good and right for the patient. It is not clear how referring doctors negotiate these issues in practice. The aim of this study was to describe and understand consultants' experiences of the decision-making process around referral to intensive care.

DESIGN

Qualitative interviews were analysed according to a phenomenological hermeneutical method.

SETTING AND PARTICIPANTS

Consultant doctors (n=27) from departments regularly referring patients to intensive care in six UK hospitals.

RESULTS

In the precarious and uncertain situation of critical illness, trust in the decision-making process is needed and can be enhanced through the way in which the process unfolds. When there are no obvious right or wrong answers as to what ought to be done, how the decision is made and how the process unfolds is morally important. Through acknowledging the burdensome doubts in the process, contributing to an emerging, joint understanding of the patient's situation, and responding to mutual moral duties of the doctors involved, trust in the decision-making process can be enhanced and a shared moral responsibility between the stake holding doctors can be assumed.

CONCLUSION

The findings highlight the importance of trust in the decision-making process and how the relationships between the stakeholding doctors are crucial to support their moral responsibility for the patient. Poor interpersonal relationships can damage trust and negatively impact decisions made on behalf of a critically ill patient. For this reason, active attempts must be made to foster good relationships between doctors. This is not only important to create a positive working environment, but a mechanism to improve patient outcomes.

Impact of frailty on protocol-based weaning from mechanical ventilation in patients with sepsis: a retrospective cohort study

Aim

Frailty has been shown to be associated with prolonged mechanical ventilation (MV). However, due to limited physiological data, it has been unclear how frailty affects weaning from MV in septic patients subjected to a specific weaning protocol.

Methods

This was a single‐center retrospective cohort study. The study included patients with sepsis on MV who underwent protocol‐based weaning between August 2015 and December 2018. Frailty was defined as a Clinical Frailty Scale score 4 or more. The association between frailty and weaning was evaluated.

Results

Ninety‐nine eligible patients were identified and categorized as frail (n = 67) or not frail (n = 32). The duration of MV was significantly longer in the frail group (8 days versus 5 days, P < 0.01). In multivariate analysis, frailty was independently associated with duration of MV (regression coefficient 17.97, 95% confidence interval 1.77–34.17) and successful weaning (hazard ratio 0.60, 95% confidence interval 0.36–1.00). There was no significant between‐group difference in duration until the first separation attempt or reintubation rate. Respiratory failure was significantly more common in the frail group as a cause of weaning failure, whereas airway failure was common in both groups.

Conclusion

Frailty was independently associated with a longer duration of MV in patients with sepsis who underwent protocol‐based weaning. Frail patients were more likely to fail spontaneous breathing trials than nonfrail patients during the weaning process, although the risk after extubation was similar.

Decision-making around admission to intensive care in the UK pre-COVID-19: a multicentre ethnographic study

Predicting who will benefit from admission to an intensive care unit is not straightforward and admission processes vary. Our aim was to understand how decisions to admit or not are made. We observed 55 decision-making events in six NHS hospitals. We interviewed 30 referring and 43 intensive care doctors about these events. We describe the nature and context of the decision-making and analysed how doctors make intensive care admission decisions. Such decisions are complex with intrinsic uncertainty, often urgent and made with incomplete information. While doctors aspire to make patient-centred decisions, key challenges include: being overworked with lack of time; limited support from senior staff; and a lack of adequate staffing in other parts of the hospital that may be compromising patient safety. To reduce decision complexity, heuristic rules based on experience are often used to help think through the problem; for example, the patient's functional status or clinical gestalt. The intensive care doctors actively managed relationships with referring doctors; acted as the hospital generalist for acutely ill patients; and brought calm to crisis situations. However, they frequently failed to elicit values and preferences from patients or family members. They were rarely explicit in balancing burdens and benefits of intensive care for patients, so consistency and equity cannot be judged. The use of a framework for intensive care admission decisions that reminds doctors to seek patient or family views and encourages explicit balancing of burdens and benefits could improve decision-making. However, a supportive, adequately resourced context is also needed.

Long-term mortality in very old patients with cancer admitted to intensive care unit: A retrospective cohort study

BACKGROUND

Long-term outcomes of older patients referred to intensive care unit (ICU) are of paramount importance for care planning and counseling of patients and relatives.

METHODS

We performed a retrospective study with patients aged ≥80 years admitted to ICU from 2011 to 2017 in a cancer center. We performed two Cox proportional hazard regressions. In the first, we tested whether type of cancer (solid locoregional, solid metastatic or hematologic), Eastern Cooperative Oncology Group Performance Status (ECOG PS), and comorbidities [Charlson Comorbidity Index - CCI]) were associated with one-year mortality in all patients. In the second, we assessed whether delirium, use of vasopressors, mechanical ventilation, renal replacement therapy, and forgoing life-sustaining therapies were associated with one-year mortality in survivors to hospital discharge.

RESULTS

Of 763 patients included, 482 (62.3%) patients died at one year. Metastatic cancer was significantly associated with one-year mortality (HR = 1.97; CI 95%, 1.16-3.36), but hematologic cancer, CCI and ECOG PS were not. Among patients who survived to hospital discharge, delirium, use of vasopressors, mechanical ventilation, renal replacement therapy and decisions to forgo life-sustaining therapies in ICU were not associated with one-year mortality.

CONCLUSIONS

Metastatic disease at ICU admission was associated with one-year mortality in patients aged ≥80 years. Delirium, use of vasopressors, mechanical ventilation and renal replacement therapy and decisions to forgo life-sustaining therapies in ICU were not associated with one-year mortality among the patients discharged from hospital.

Developing an intervention around referral and admissions to intensive care: a mixed-methods study

Background

Intensive care treatment can be life-saving, but it is invasive and distressing for patients receiving it and it is not always successful. Deciding whether or not a patient will benefit from intensive care is a difficult clinical and ethical challenge.

Objectives

To explore the decision-making process for referral and admission to the intensive care unit and to develop and test an intervention to improve it.

Methods

A mixed-methods study comprising (1) two systematic reviews investigating the factors associated with decisions to admit patients to the intensive care unit and the experiences of clinicians, patients and families; (2) observation of decisions and interviews with intensive care unit doctors, referring doctors, and patients and families in six NHS trusts in the Midlands, UK; (3) a choice experiment survey distributed to UK intensive care unit consultants and critical care outreach nurses, eliciting their preferences for factors used in decision-making for intensive care unit admission; (4) development of a decision-support intervention informed by the previous work streams, including an ethical framework for decision-making and supporting referral and decision-support forms and patient and family information leaflets. Implementation feasibility was tested in three NHS trusts; (5) development and testing of a tool to evaluate the ethical quality of decision-making related to intensive care unit admission, based on the assessment of patient records. The tool was tested for inter-rater and intersite reliability in 120 patient records.

Results

Influences on decision-making identified in the systematic review and ethnographic study included age, presence of chronic illness, functional status, presence of a do not attempt cardiopulmonary resuscitation order, referring specialty, referrer seniority and intensive care unit bed availability. Intensive care unit doctors used a gestalt assessment of the patient when making decisions. The choice experiment showed that age was the most important factor in consultants’ and critical care outreach nurses’ preferences for admission. The ethnographic study illuminated the complexity of the decision-making process, and the importance of interprofessional relationships and good communication between teams and with patients and families. Doctors found it difficult to articulate and balance the benefits and burdens of intensive care unit treatment for a patient. There was low uptake of the decision-support intervention, although doctors who used it noted that it improved articulation of reasons for decisions and communication with patients.

Limitations

Limitations existed in each of the component studies; for example, we had difficulty recruiting patients and families in our qualitative work. However, the project benefited from a mixed-method approach that mitigated the potential limitations of the component studies.

Conclusions

Decision-making surrounding referral and admission to the intensive care unit is complex. This study has provided evidence and resources to help clinicians and organisations aiming to improve the decision-making for and, ultimately, the care of critically ill patients.

Future work

Further research is needed into decision-making practices, particularly in how best to engage with patients and families during the decision process. The development and evaluation of training for clinicians involved in these decisions should be a priority for future work.

Study registration

The systematic reviews of this study are registered as PROSPERO CRD42016039054, CRD42015019711 and CRD42015019714.

Funding

The National Institute for Health Research Health Services and Delivery Research programme. The University of Aberdeen and the Chief Scientist Office of the Scottish Government Health and Social Care Directorates fund the Health Economics Research Unit.