To the Editor: Recognising when someone is approaching the end of their life allows clinicians to develop treatment plans congruent with the patient's goals and values. Objective indicators of a life-limiting illness, such as the United Kingdom Gold Standards Framework1 and the Supportive and Palliative Care Indicators Tool,2 can help practitioners identify patients with a high likelihood of death in the following year.3 An intensive care unit (ICU) typically provides treatments to patients with high acuity of reversible disease and may be asked (or sometimes expected) to treat patients with a pre-existing life-limiting illness. While the prevalence and outcomes of patients admitted to the ICU with chronic disease is described,4 it is not known how often patients with a pre-existing life-limiting illness are admitted to an ICU in Australia and New Zealand.
We undertook a prospective, observational, cross-sectional study conducted under the auspices of the Australia and New Zealand Intensive Care Society Clinical Trials Group Point Prevalence Program.5 All patients (aged ≥ 16 years) in participating ICUs on one of two designated days in 2015 were included. Life-limiting illness indicators were adapted from those described previously1,2 and classified into subgroups of advanced cancer, chronic organ failure, and frailty/dementia (Online Appendix). Other data points collected were patient age, gender, severity of illness score (Acute Physiology and Chronic Health Evaluation [APACHE] II), documented advanced care directive or treatment limitation on admission to the ICU, lengths of stay, and mortality (in ICU and hospital). ICU research nurse coordinators in each institution collected data and submitted them to the coordinating centre. Research ethics approval was obtained from each contributing centre and coordinated by the George Institute for Global Health.
There were 49 ICUs that contributed data on 682 patients, of which 178 (26%) had a pre-existing life-limiting illness (Table 1). Patients with a life-limiting illness were older, had higher severity of illness scores, and a higher proportion died in hospital (17% v 9%). Mortality was similar for the cancer, frailty, and organ failure subgroups. An advanced care directive or treatment limitation was present for 29 patients with a life-limiting illness (16%): 8% (3/36) of those with cancer, 17% (17/62) of patients with frailty, and 11% (9/80) of patients with advanced chronic organ failure criteria.
Table 1.
Point prevalence of patients in the intensive care unit (ICU) with a pre-existing life-limiting illness in Australia and New Zealand (2015)
| Characteristic | All patients in ICU point prevalence study | Pre-existing life-limiting illness |
P | Life-limiting illness subgroups |
P | |||
|---|---|---|---|---|---|---|---|---|
| No | Yes | Cancer | Frailty | Organ failure | ||||
| Number of patients | 682 | 504 | 178 | 36 | 62 | 80 | ||
| Age (years), median (IQR) | 62 (47-72) | 59 (44-71) | 68 (59-76) | < 0.001 | 64 (56-72) | 75 (64-80) | 67 (58-72) | 0.012 |
| Male | 393 (58%) | 387 (57%) | 107 (60%) | 0.435 | 22 (61%) | 41 (66%) | 44 (55%) | 0.402 |
| APACHE II score, median (IQR) | 17 (12-22) | 16 (11-21) | 20 (15-25) | < 0.001 | 17 (12-21) | 20 (15-25) | 21 (15-26) | 0.012 |
| Advanced care plan present | 48 (7%) | 19 (4%) | 29 (16%) | < 0.001 | 3 (8%) | 17 (27%) | 9 (11%) | 0.012 |
| Outcomes | ||||||||
| ICU LOS (days), median (IQR) | 5 (2-14) | 6 (2-16) | 5 (2-10) | 0.344 | 4 (2-8) | 4 (3-13) | 5 (3-9) | 0.433 |
| Hospital LOS (days), median (IQR) | 17 (9-32) | 17 (9-33) | 16 (8-29) | 0.156 | 18 (6-31) | 18 (9-29) | 17 (8-29) | 0.863 |
| Inpatient at day 28 | 145 (21%) | 117 (23%) | 28 (16%) | 0.036 | 7 (19%) | 13 (21%) | 8 (10%) | 0.162 |
| ICU mortality | 48 (7.0%) | 29 (5.8%) | 19 (11%) | 0.027 | 6 (17%) | 6 (10%) | 7 (9%) | 0.421 |
| Hospital mortality | 76 (11%) | 45 (8.9%) | 31 (17%) | 0.002 | 6 (17%) | 11 (18%) | 14 (18%) | 0.991 |
APACHE = Acute Physiology and Chronic Health Evaluation; IQR = interquartile range; LOS = length of stay
We noted that a substantial proportion of adult patients admitted to an ICU in Australia and New Zealand had a preexisting life-limiting illness of which they were likely to die within 12 months. Only 16% of these patients had evidence of advance care or treatment planning before ICU admission. While most patients (80%) with a life-limiting illness survived to leave hospital, their longer term outcomes are not known, nor if the treatment and care aligned with their goals and values. The health care costs of managing these patients in the ICU were not obtained. Further research is required to understand the utility of treating patients with a life-limiting illness in the ICU and the barriers to advanced care planning.
Acknowledgments
Acknowledgements
Tania Elderkin† died suddenly while leading this project. We remember her dedication to patient-centred care, clinical research and friendship.
Competing interests
None declared.
Supplementary Information
References
- 1.The Gold Standards Framework. The GSF prognostic indicator guidance — the National GSF Centre's guidance for clinicians to support earlier recognition of patients nearing the end of life. https://www.goldstandardsframework.org.uk/cd-contentuploads/files/General%20Files/Prognostic%20Indicator%20 Guidance%20October%202011.pdf (viewed Nov 2019).
- 2.Highet G., Crawford D., Murray S.A., Boyd K. Development and evaluation of the Supportive and Palliative Care Indicators Tool (SPICT): A mixed-methods study. BMJ Support Palliat Care. 2014;4:285–290. doi: 10.1136/bmjspcare-2013-000488. [DOI] [PubMed] [Google Scholar]
- 3.Milnes S., Orford N.R., Berkeley L., et al. A prospective observational study of prevalence and outcomes of patients with Gold Standard Framework criteria in a tertiary regional Australian Hospital. BMJ Supportive Palliat Care. 2019;9:92–99. doi: 10.1136/bmjspcare-2015-000864. [DOI] [PubMed] [Google Scholar]
- 4.Anstey M., Watts N., Orford N., et al. Does anyone ever expect to die? Anaesth Intensive Care. 2017;45:466–468. doi: 10.1177/0310057X1704500409. [DOI] [PubMed] [Google Scholar]
- 5.Thompson K., Hammond N., Eastwood G., et al. The Australian and New Zealand Intensive Care Society Clinical Trials Group point prevalence program, 2009-2016. Crit Care Resusc. 2017;19:88–93. [PubMed] [Google Scholar]
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