How to Triage Dying Patients? CHARLES L. SPRUNG, M.D. Department of Anesthesiology and Critical Care Medicine Hadassah Medical Center

WHAT IS DYING?  Free online dictionary - About to die - Drawing to an end; declining

HOW DO WE DEFINE THE DYING PATIENT? We are all dying, every moment that passes of every day. That is the inescapable truth of this existence. It is a truth that can paralyze us with fear, or one that can energize us with impatience, with the desire to explore and experience, with the hope- nay, the iron-will!- to find a memory in every action. To be alive, under sunshine, or starlight, in weather fair or stormy. To dance with every step, be they through gardens of flowers or through deep snows. RA Salvatore

THE SPECTRUM OF TRIAGE TRIAGE CHAIN ELEMENTS FLOW LIMITATIONS HOME/INSTITUTION/ OTHER HOSPITAL ER/ DEPARTMENT ICU DEPARTMENT HOME SELF TRIAGE PRE- ICU TRIAGE POST-ICU TRIAGE INFLOW RESOURCE AVAILABILITY RESOURCE UTILISATION OUTFLOW LEVIN PD, SPRUNG CL. INTENSIVE CARE MED 2001;27:1441

ICU TRIAGE   Indications for ICU admission and discharge are poorly defined   Identification of patients who benefit is difficult

ICU FINAL SELECTION CRITERIA   Priority to patients more likely to benefit from ICU SCCM Ethics Committee. JAMA 1994;271:1200   Exclude patients that are “too well” or “too sick” ACCCM Task Force. Crit Care Med 1999; 27:

ICU TRIAGE   Patients & families are willing to go to ICU for one month survival DANIS M. JAMA 1988;260:797   ICU doctors admit patients with no hope of surviving more than a few weeks SCCM ETHICS COMM. CRIT CARE MED 1994;22:358 VINCENT JL. CRIT CARE MED 1999;27:1626

FOREGOING LIFE-SUSTAINING TREATMENTS INEQUITABLE USE OF CPR FOR DISEASES WITH SIMILAR PROGNOSIS AIDS52% CANCER47% CIRRHOSIS 16% CHF 5% WACHTER E. ANN INTERN MED 1989; 111:525

ICU TRIAGE   In the US, one third of all patients with terminal metastatic malignancy are admitted to the ICU and 60% of all hospital deaths occur after such an admission.   Admission to an ICU may serve only to transform death into a prolonged, painful, and undignified process.   In patients with a terminal illness, the focus should be on measures that ensure comfort and admission to an ICU should generally be avoided. Marik PE. Am J Hosp Palliat Care.2007;23:479-82

ICU TRIAGE   Haematological malignancy patients admission is controversial with a perception of poor prognosis despite intervention.   In the 1980s – - In-hospital mortality of 78% (Lloyd-Thomas et al, 1988) - ICU mortality of 90% for patients requiring ventilation and renal replacement (Brunet et al, 1990)   Survival rates are improving   Similar patients with an overall ICU mortality of 44%, although ventilated patients still had a mortality of 74% (Kroschinsky et al, 2002) Jones C. Br J Hosp Med. 2009:70:544

ICU TRIAGE   All patients admitted to the ICU for organ failures due to newly diagnosed, untreated cancer and to receive immediate cancer chemotherapy   Overall survival was 60% after 30 days  Variables independently associated with 30-day mortality: need for vasopressor therapy, mechanical ventilation and hepatic failure Darmon M. Crit Care Med 2005:33:

ICU TRIAGE  Mortality was mostly dependent on the nature and number of organ failures, not on the nature or stage of the malignancy  In this selected group of patients, advanced disease at cancer diagnosis should not lead to refusal of ICU admission  Routine ICU admission of patients with newly diagnosed cancer, specific organ failure, and the need for administration of chemotherapy in the ICU deserves evaluation Darmon M. Crit Care Med 2005:33:

ICU TRIAGE   Prospective, one-year hospital-wide study of all cancer and hematology patients for ICU admission.  Of 206 patients considered, 105 (51%) were admitted.  Of 101 patients not admitted, 54 patients (26%) were considered too sick to benefit from the ICU and 47 (23%) were considered to be too well to benefit.  Of the 47 ‘too well’ patients, 13 were admitted later.  In admitted patients, 30-day and 6-month survival rates were 54% and 32%, respectively. Thiery G. J Clin Oncol 2005:23:

ICU TRIAGE   Of the patients considered too sick to benefit, 26% were alive on day 30 and 17% on day 180.   Among patients considered too well to benefit, the 30-day survival rate was a worrisome 79%.   Both the excess mortality in too-well patients later admitted to the ICU and the relatively good survival in too-sick patients suggest the need for a broader admission policy. Thiery G. J Clin Oncol 2005:23:

ICU TRIAGE   Simulation depicting a 78-yr-old man with metastatic gastric cancer, life-threatening hypoxia attributable to cancer progression and stable preferences to avoid ICU admission and intubation  studied  27 hospital-based attending physicians studied  8 (30%) admitted the patient to the ICU; 3 initiated palliation, 2 documented the patient's code status and 1 intubated the patient Barnato AE. Crit Care Med 2008:36:

ICU TRIAGE  19 did not admit the patient to the ICU; 13 initiated palliation and 5 documented code status  Intensivists and ER physicians (p < 0.05) were more likely to admit the patient to the ICU  Hospital-based physicians from the same institution varied significantly in their treatment decisions Barnato AE. Crit Care Med 2008:36:

ICU TRIAGE Triage decisions correlated with admission diagnosis, number of beds available, severity of disease, ageand operative statusTriage decisions correlated with admission diagnosis, number of beds available, severity of disease, age and operative status Sprung CL. CCM 1999;27: Sprung CL. CCM 1999;27: Refusals associated with older age, diagnostic group and higher MPM II 0Refusals associated with older age, diagnostic group and higher MPM II 0 Joynt G et al. Int Care Med 2001;27: Refusals associated with ability of triaging physician to examine patient, ICU physician seniority, patient age, underlying diseases, self sufficiency and number of beds availableRefusals associated with ability of triaging physician to examine patient, ICU physician seniority, patient age, underlying diseases, self sufficiency and number of beds available Garrouste-Orgeas M. Intensive Care Med 2003;29:

ICU TRIAGE LIMITED MEDICAL SUITABILITY May exclude whether beds available or not  Irreversible brain damage or multi-organ failure  Unresponsive metastatic carcinoma Should exclude whether beds available or not  Persistent,vegetative or permanently unconscious state  Brain dead, non-organ donor  Patients refusing intensive care SCCM Ethics Committee. JAMA 1994;271:1200

THE SPECTRUM OF TRIAGE TRIAGE CHAIN ELEMENTS FLOW LIMITATIONS HOME/INSTITUTION/ OTHER HOSPITAL ER/ DEPARTMENT ICU DEPARTMENT HOME SELF TRIAGE PRE- ICU TRIAGE POST-ICU TRIAGE INFLOW RESOURCE AVAILABILITY RESOURCE UTILISATION OUTFLOW LEVIN PD, SPRUNG CL. INTENSIVE CARE MED 2001;27:1441

POST- ICU TRIAGE   All patients with hematologic malignancies/solid tumors for ICU admission were triaged.   Bedridden patients and those in whom palliative care was the only treatment option were not admitted.   Patients at earliest phase of the malignancy (diagnosis < 30 days) were admitted without any restriction.   All other patients were prospectively included in The ICU Trial, consisting of a full-code ICU admission followed by reappraisal of the level of care on day 5 Lecuyer L. Crit Care Med 2007:35:808

POST- ICU TRIAGE   Among the 188 patients, 103 survived the first 4 ICU days and 85 died from the acute illness.   Hospital survival was 22% overall.   Among the 103 survivors on day 5, none of the characteristics of the malignancy were significantly different between the 62 patients who died and the 41 who survived.  Organ failure scores were more accurate on day 6 than at admission or on day 3 for predicting survival. Lecuyer L. Crit Care Med 2007:35:808

POST- ICU TRIAGE   All patients requiring initiation of mechanical ventilation, vasopressors, or dialysis after 3 days died.   Survival was 40% in mechanically ventilated cancer patients who survived to day 5 and 22% overall.   If these results are confirmed in future interventional studies, we recommend ICU admission with full-code management followed by reappraisal on day 6 in all nonbedridden cancer patients for whom lifespan- extending cancer treatment is available. Lecuyer L. Crit Care Med 2007:35:808

ORCHESTRATION OF DEATH  Although life-support technologies are traditionally deployed to treat morbidity and delay mortality in ICU patients, they are also used to orchestrate dying  Advanced life support can be withheld or withdrawn to help determine prognosis  The tempo of withdrawal influences the method and timing of death Cook DJ. CMAJ 1999:161:

REASON Unresponsive to therapy Neurologic Chronic disease MSOF Poor quality of life Sepsis/shock Patient/family request Age Other TOTAL PRIMARY REASON FOR WD / WH / SDP Sprung CL. Ethicus. Intensive Care Med 2008;34:271 NUMBER (%) 1425 (46) 615 (20) 379 (12) 295 (10) 126 (4) 104 (3) 65 (2) 46 (2) 31 (1) 3086 (100)

POST- ICU TRIAGE   Although most intensivists prefer to have their patients die in their ICU, this is sometimes not possible   Patients may continue alive in ICU for several days despite witholding/ withdrawing   Some intensivists may not withdraw therapies   Some hospitals do not allow ventilated patients outside of ICUs even if they have DNR status   Difficult to discharge a dying patient to the ward

ICU WITHDRAWAL DECISIONS   Examined the relationship between ICU healthcare workers' confidence and their decision to withdraw life support using clinical scenarios.   Respondents were very confident about their decisions 34% of the time.   Intensivists (40%) were more confident than nurses (29%), who were more confident than housestaff (23%).   More confident when they chose extreme levels of care than when they chose intermediate levels of care. Walter SD. Crit Care Med 1998:26:44-49

ICU WITHDRAWAL DECISIONS   Considerable variability in responses even when only responses made with the highest level of confidence were considered.   While confidence in decisions about withdrawal of life support increases with seniority and authority, consistency of decisions may not.   When given standard information, healthcare workers can make contradictory decisions yet still be very confident about the level of care they would administer. Walter SD. Crit Care Med 1998:26:44-49

How to Triage Dying Patients? CHARLES L. SPRUNG, M.D. Department of Anesthesiology and Critical Care Medicine Hadassah Medical Center