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Rajiv Singhal wrote 08-13-2010 04:43:36 pm
I think, I would go in a little more detail about his effort tolerance, if he is able to maintain his own basic ADL's, without much trouble, and he also feels comfortable about the current quality of life, we can consider a short trial of intubation and ventilation and try to reverse whatever is reversible(?infection)

Todd Fraser wrote 08-14-2010 04:15:01 pm
I think this raises a philosophical question that I struggle with all the time - we sit in guardianship of a very expensive resource. In terms of bang-for-buck, ICU is an incredibly inefficient specialty. The same investment applied to primary care would doubtlessly have far more impact.

So is every patient "entitled" to ICU? If yes, how on earth can we afford it? If no, who makes the decisions and what are the criteria for doing so?

Christopher Dugan wrote 08-14-2010 06:13:15 pm
I'd leave the Peripheral Vascular Disease aside for the moment; yes it's an irreversible co-morbidity with an additive effect, but that's just the patient you're faced with.

From a respiratory point of view, it's probably worthwhile asking him (if able) or his family (if present) whether they've ever thought about this eventuality. With a documented fall in FEV1 to 0.51 then he probably presents regularly to HDU/ICU or is well-known to the hospital OPD. Accordingly, someone should've discussed this before, but Murphy had a law...

Try & figure out how's he tolerating NIV + if possible what he wants out of all of this- is it a new set of lungs (probably unreasonable), or is it to see his new grand-daughter born? Might give you an idea of how realistic the patient + his family are if it comes to an NFR or no-intubation order.

Try + figure out how where the Respiratory Physician's coming from. Older, more conservative types may be less inclined to limit treatment, if they've had time to form a bond with their patients over many years. Conversely, younger ones may also be uncomfortable with the idea of pulling out as well.

I'd agree with Rajiv, taking him into ICU for a short trial of intubation + mechanical ventilation may be the easiest way to go, especially in the middle of the night, but with clear limits set in place (e.g. improve within 24-48hrs, no CPR/dialysis/inotropes/vasopressors).

Subsequently, a family conference in daylight hrs led by the Intensivist +/- Res

andrew stapleton wrote 08-16-2010 10:24:14 am
Interesting comments, thank you. One could make the argument of giving a "short trial" with limits to almost all patients and I ed this which gives us the power to withdraw having "tried everything" but doesn't this just amount to moral cowardice on our part? In the public system don't we have a responsibilty to limit this expensive resource? The vast amount of money spent in the last year of life is going to be more, not less of a problem in the future. Politicians and , increasingly, our colleague are not up to treatment limiting decisions - is it up to us and if not have we thought through the consequences?

Benjamin Moran wrote 08-02-2011 03:22:33 pm
Recently, it seems that there is an increased request for our services. Like most things critical care related, it's multifactorial. The narcissist in me wants to believe that we are better general physicians (and with the recent outbreak of single-organ doctors, we may well be), but a more disturbing possibility exists- that doctors are nothing more than technicians. A previous consultant of mine would lament that doctors no longer want to make the difficult decisions, when it is when our patients need us the most. Most of the time, the treatment possibilities are simple- give an antibiotic, anti-hypertensive or laxative. The issue arises when the question of, "Should we give those antibiotics, etc?". Just because we can, doesn't mean we should. Our decisions obviously have quite dire outcomes, but an admission to ICU just to say, "We tried everything" can cause significant pain and suffering on the patient and their families. I find it frustrating that some non-ICU doctors don't appreciate this.

Todd raised an interesting point about who are the guardians to this expensive resource. I'd like to think that we as intensivists have a duty to not only be the guardians, but also to educate our non-ICU colleagues about the decisions we make and the reasons behind them. The presented case seems to be the norm. We have a patient with an advanced physiological age, with an FEV1 of 0.51 (less than most of our own tidal volumes!), with a 'reversible' condition. (A

Todd Fraser wrote 11-27-2010 07:39:57 pm
Interesting article on this subject and the related topic of ethics in end-of-life decision making :

Lancet Volume 376, Issue 9749, 16 October 2010-22 October 2010, Pages 1347-1353

Todd Fraser wrote 08-20-2010 03:08:17 pm
You're right Andrew, increasingly we seem to be the group most likely to initiate, if not complete these sorts of discussions and decision-making processes. You can feel like the grim reaper some days!

And as you say, it is likely to get worse as the baby boomers get older. Rationing of this resource already happens, we just don't seem to call it that, nor have overt criteria.

Todd Fraser wrote 08-03-2011 06:44:29 pm
Thanks Ben,

Your frustration is palpable, and I suspect far from an isolated case.

My question remains though - who's resource is it? Do we, as intensivists, truly have the right to refuse someone care when they ask for it? While I believe the answer is yes, when I try to flesh out that position, I find it hard to justify.

Benjamin Moran wrote 08-03-2011 09:24:44 pm
I would like to think that care to a patient would never be refused. It'a all semantics, but it's all about appropriate care. The problem is usually lack of medical consensus. I can understand how difficult it must be for physicians, who have been treating these patients for years, to be faced with the mortality of their patient, either due to the bond that they share, or a feeling of failure of their medical treatment of the patient. Families rarely will agree to treatments that may harm their loved ones, when a more peaceful and dignified option exists. Problems with acceptance of treatment limitations are usually due to unresolved issues within the family dynamic, or their own inability to 'let go'. This is where a good social worker is worth their weight in gold- it helps the family to move through these issues and start dealing with the poor health of their loved one. Once again, it's a shame that this role has fallen onto intensivists, but it also gives us a chance to give dignified and humane health care in the final stages of a patients life.

Todd Fraser wrote 01-25-2011 02:11:54 pm
Another interesting article to consider : Ann Intern Med 2010; 153:167-175. In this review, over 65% of patients ventilated >21 days had an outcome at 1 year described as poor (death or fully dependent).

alexander browne wrote 08-14-2011 09:53:12 pm
Yes there's no right answer here. Limits of care are a half way house that are generally unsatisfying for all. You know this patient will come to your unit, buy the whole bundle (lines, monitoring, sedation issues blah blah) and if things go badly a guaranteed pre-tortured death. Every now and again though, you stick the tube down some no hoper and they just don't die, and they come back and visit the unit with chocolates later. We can't exactly tell who is and who's not going to do poorly, and as one of my colleagues said to me "You're a long time dead."