Craig Hore gives important advice at BCC4 on when it is appropriate to refuse ICU admissions and how we should do it.

1. How to
say…..
Craig Hore
Intensive Care Unit
Liverpool Hospital

2. The ICU in 2023?
Bring out
your
dead!
Remember our philosophy:
1. If you want everything done, we’re always open!
2. ECMO is always the answer, no matter the question

3. “Refusal”???
 Appropriateness?
- appropriate referrals
- appropriate admissions
- appropriate management in wards and ICU
- appropriate communications
A better prospect for 2023!

4. ICU triage
 When evaluating a patient with a severe
acute illness for ICU admission determine:
(i) the diagnosis, prognosis, and treatment;
(ii) patient characteristics and co-morbidities;
(iii)whether the patient, if competent, (or
surrogate) consents to ICU admission;
(iv)and if they do, whether or not ICU admission
is warranted.

5. ICU triage
 The number of beds
available in ICU!

6. Do some patients
deserve an automatic
?

7. What ICU referrals commonly
make you go hmmmm…
 Which ones make you instinctively think “NO”?
ICU consultant considers another referral….

9. Patients with cancer in the
ICU
 “These patients never do well….”
 “The ‘cures’ are worse than the disease..”
VS
 21st Century!!!
 Advances in management in ICU as well as
oncology and haematology

10. Patients with cancer in the
ICU
 So what exactly are the outcomes?

11. Cancer and mechanical
ventilation – the past
Authors
Journal
Patients
Malignancy ICU
(N)
Hospital
Mortality
Mortality
Snow
JAMA 1979
180
Solid tumors
74
87
Ewer
JAMA 1986
46
Lung cancer
85
87
Peters
Chest 1988
119
Hematologic
/
82
Dees
NJM 1990
49
Both
67
76
Lee
JAMA 1995
115
Both
77
97
Tremblay
CIM 1995
32
AML
99
99
Epner
J I M 1996
157
Hematologic
/
83

12. Cancer patients needing ICU
in 2013
 Improved survival rates reported in cancer
patients requiring mechanical ventilation, CRRT
and vasopressors
 But limitations – heterogeneity; single centres;
retrospective; short-term outcomes (rarely 3 or 6
month survival)

13. Cancer patients needing ICU
in 2013
 Some sub-groups continue to have a high and
unchanged mortality:
- bedridden patients
- allogeneic BMT recipients with severe GVHD not
responsive to chemotherapy
- multiple organ failure (“delayed ICU admission”?)
- specific vignettes (eg pulmonary carcinomatosis
lymphangitis; carcinomatous meningitis with coma)
- not on “life-span expanding therapy”
(Azoulay et al Annals Intensive Care 2011)

14. Cancer patients in the ICU
“Only cancer patients with a chance of being
cured, who agree to undergo supportive
therapy, and those with best chances of
benefiting from intensive care should be
admitted by priority”.
Sculier Curr Opin Oncol 1991;3:656-662
As true now as in 1991!

15. Cancer patients in ICU –
admit or not?
 “Full active management” newly diagnosed
malignancies and malignancies in “complete
remission”
 3 day ICU trial as an alternative to ICU refusal in
other cancer patients?
 The nature and extent of organ dysfunctions at ICU
admission, and especially after day 3, are good
predictors of mortality
 Those in sub-groups mentioned earlier – comfort
cares
(Azoulay et al Annals Intensive Care 2011)

17. Elderly patients in the ICU
 “ICU care provided to younger patients is more
effective and more likely to be successful….they’re
more resilient and able to recover”
 “If ICU care is successful and the patient recovers, a
young person gains more years of life to live….whole life
ahead of them rather than behind them”
 “Where I worked before we would never admit anyone
over (insert random number here) years of age…”

18. Elderly patients in the ICU
 “But he’s a good 81 year old……”
The oldest man to
climb Mt Everest is
Yuichiro Miura (Japan,
b. 12 October 1932),
who reached the
summit on 23 May
2013 at the age of 80
years 223 days. This
is the third time that he
has held this record:
he previously reached
the highest point on
Earth as the world's
oldest summiteer in
2003 and again at
2008.

19. Elderly patients in the ICU
 ANZICS CORE (2000 – 2005): 15,640 patients aged ≥ 80yrs
(13.0%)
Bagshaw, Webb et al. Crit Care, 2009.
 Age ≥ 80 years:
- higher ICU and hospital death compared with younger
cohorts
- more likely to be discharged to rehabilitation / long-term
care
 Factors associated with lower survival included: admission
from a chronic care facility, co-morbid illness, nonsurgical
admission, greater illness severity, mechanical ventilation,
and longer stay in the ICU.

20. Elderly patients in the ICU
 Netherlands
 129 people 80+ years old vs 620 people <80 years
 Admitted to ICU for >48 hours
 Elderly patients: mean age 83; median APACHE II of
18; median ventilator days 3
 Primary outcome was health-related quality of life
HRQOL before and after ICU admission.
Hofhuis, Spronk et al: CHEST 2008

21. Elderly patients in the ICU
 Main conclusion: HRQOL recovered to pre-ICU
baseline by 6 months, and in fact were close to
age-matched controls.
 “Denying admission to the ICU should not just rely
on old age.”
 VERY TRUE!
 But…….
- 49 of 129 octogenarians survived to be analysed at
6 months (62% mortality rate)
- the younger (~67 year old) cohort did better at six
months, although still poorly (43% mortality rate)

22. Elderly patients in the ICU
 Elderly cohort relatively healthy pre-ICU - likely bias
toward admitting healthier elderly patients to the
ICU
 Isn’t this the real point?

23. Elderly patients in the ICU
 “Age…represents an additive factor when
coupled with frailty, physiologic reserve,
burden of co-morbid illness, primary diagnosis,
and illness severity……”
 “……important bearing not only on short- term
survival but also on long-term survival,
neurocognitive performance, functional
autonomy, and quality of life.”
Bagshaw, Webb et al. Crit Care, 2009.

24. Similar conclusions
 Patients with cancer are a heterogeneous group
 The elderly are a heterogenous group
 Similar conclusions for any patient group!
 Appropriate patient selection not routine denial!

25. ICU triage
 When evaluating a patient with a severe
acute illness for ICU admission determine:
(i) the diagnosis, prognosis, and treatment;
(ii) whether the patient, if competent, (or
surrogate) consents to ICU admission;
(iii) and if they do, whether or not ICU admission
is warranted.

26. Some common reasons
raised to stop you
saying

28. “….but this is REVERSIBLE!”
 Reversible ≠ must treat
 Context!

29. “….but the family want
EVERYTHING done!”
 Was the right question asked?

30. “… but this is IATROGENIC…”
 Iatrogenic ≠ must treat
 Context!

31. A reminder on medical futility
 Medical Board of Australia 2012:
- “you do not have a duty of care to prolong life at
all cost. However, you have a duty to know when
not to inititiate and when to cease attempts at
prolonging life.”
- as Intensivists, this is part of our specialist expertise –
embrace it!

32. So the time has
come……how do I say

34. General principles
 Knowledge!
 Consider risks and benefits of different modalities of
treatment
 Consider risks and benefits of ICU admission
 Involve the patient (where able)!
 Involve the surrogate decision-maker
 Involve the family
 Involve the admitting team

35. Suggestions if conflict
 Clarify goals of treatment – cure; prolong survival;
symptom relief
- consider interests of patient first (but don’t ignore
interests of the family)
- consider biases that may be influencing your
decision (fear of litigation; fear of conflict; bullying;
lack of knowledge)
- seek expert advice (senior colleague or other
expert) when needed
Adapted from Koczwara: MJA, 2013

36. Suggestions if conflict
 Communicate with patient and significant others
and clarify any areas of disagreement
 Use clear, consistent communication. Consultant
level.
 Involve a third party if necessary
 Support the patient, his or her family and the staff
 Offer alternatives (“not for ICU but this is what we
can do…”)
Adapted from Koczwara: MJA, 2013

37. Suggestions if conflict

38. The ICU in 2023?
Remember our philosophy: