Illness trajectories are also valuable in critical care

Editor—I was uplifted by the simple wisdom of Murray et al and suggest that the concept of illness trajectories has value in critical as well as palliative care.¹ Intensivists are often referred patients with similar trajectories to those presented,¹ where a catastrophe so dominates the presentation that an immediate attempted rescue is undertaken before the opportunity is taken to appraise both the less evident underlying trajectory and the acute event. An example is the frail elderly patient with dementia and multiple comorbidities swho presents with a “potentially curable” fungating mandibular tumour.

Even previously well patients develop faster “trajectories of dying” after admission to intensive care units. I have noted a trend to attempt escalated rescue of increasingly daunting complications in dying patients. An example is the patient with severe pancreatitis who develops infected necrosum, then intraabdominal abscesses, and finally drain associated erosion of retroperitoneal vessels.

Since predicting survival of a critically ill individual is imprecise, all patients should receive good end of life care from the moment of admission to intensive care, even though most will survive their critical illness. Murray et al's figure 2 conveys this concept well.¹

Critical care seems stuck in the old paradigm—a moment before which there is only a “curative” objective and after which only a “comfort” objective.² This paradigm is clearly unsatisfactory when a patient takes an unfavourable illness trajectory, and it can deprive the patient and family of time to prepare for death while “curative” treatments are escalated and emotional and spiritual needs are neglected.