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For the purposes of trying to clarify something emotive, from a medical point of view, what happens when it comes to a decision or not whether to offer intensive care? How do scores work? What factors in? And are there any dealbreakers?
Firstly the answer is it depends! It depends both on the person and their condition. This isn't a thread on rationing because I haven't personally seen it, or seen guidance, or heard of definite evidence in the UK, and outside my knowledge.
usually when someone is very unwell, either in the emergency department, or on the ward, a referral is made to intensive care. This is usually quite an experienced and senior member of the team. By this point, patient has already received treatment but it might not be helping
the registrar or consultant then attends the patient as soon as humanly possible. Care is split into two strands a) what can we do NOW to help the patient this second b) what treatments are available in ICU to modify the disease
ICU has plenty of skills and knowledge to lend that doesn't necessarily involve life support, but choice of drugs, choice of investigation, a wealth of wisdom behind sick people and their physiology
sometimes people are so urgently unwell (e.g. bleeding out or blue!) that they need immediate treatment but other times there is some time to gather lots of information to make a plan going forwards
This is best because not all our treatments are pleasant (actually they're all unpleasant), or very effective. It's also because the more information we have, the better we can treat the cause - some diseases look very similar but need different things.
Lots and lots of items enter this discussion and it involves lots of people - the medics/surgeons if a surgical patient/the emergency department doctors/the patient themselves if conscious, and very importantly, the patient's own relatives
These might be with the patient or sometimes we might have to ring them. It's very useful for establishing how someone is usually - do they go out and about much? Do they have allergies? Have they ever expressed what they would want to happen if they were dying?
It helps build a picture of the person and their wishes. On the clinical side we need to know how organs are functioning - what are the hearts/lungs/kidneys like? Their immune system? Are they diabetic? immunosuppressed? Anything else?
Something that is really important in critical illness is what we term someone's 'reserve' - do they have 'oil in the tank' to get through what is a marathon
in very basic terms, critical illness is running a marathon. You lose muscle. Need far more oxygen. Your heart often needs to beat harder and faster, your lungs need to exchange oxygen faster
The energy requirements of the whole body are very high. And this might persist for days and weeks. People lose a lot of weight and muscle. They get weaker whilst on life support - for example on the ventilator breathing muscles waste away
and if they were weak to begin with they will not recover, even if the disease or infection does. So when we consider 'reserve' another term we use is frailty. There are scoring systems (maybe we should use official scores but can't say have ever done it at this point!)
But to try and establish how fit someone is, we try and ask how much they can do in terms of metabolic equivilents [METS]. resting is 1. Stairs is 4. jogging is 7. I don't know how many METS ITU is but it is a lot!
If people are already bedbound, or very limited to maybe a chair or room, they are very unlikely/just not going to, survive critical illness. The hearts and lungs just would not cope, even with us helping them.
This is why things like sepsis are so much more prevalent and deadly in the elderly or people with organ damage.
And it is perfectly valid to ask why we don't give people 'a chance'. Or even, as I used to wonder, we didn't just keep people in a coma until we could do lots of organ transplants.
But I suppose, sometimes you just know that someone is dying. you look at their history, their oxygen levels, their potassium, their lactate, what they were like beforehand, their blood pressure, which disease is driving it.
if you can't cure the underlying disease, for example, end stage dementia, or end stage heart failure, or catastrophic brain injury, then someone is dying. Whatever you try and do, they are dying.
And the problem with life support is that it is fairly intense. pipes into your big neck blood vessels to replace kidneys. A medical coma, to allow ventilation - on entry to this coma, people may never wake up - if they will die anyway - is it right to steal these last hours?
Infections are common. Because of all the lines bypassing skin and cough reflexes, bacteria get inside the body. So does fungus that lives on the skin. When we give antibiotics, fungal infections are quite common
people get hot, sweaty, uncomfortable. Even in a coma they still seem distressed. But we still give pain relief or try and cool people down. Their lines all have to be changed again incase they are causing infection. A lot of needles!
Many survivors of ICU have PTSD. From the procedures, and coughing on the ventilator, and the noises, and distress of relatives and confused patients. People get very bad hallucinations, that are quite scary, and often think we are attacking them
which I can understand, if you don't know where you are or what's happening and heavily sedated. people get blood clots, and get very swollen. Their nerves start to get very weak as well, and often can't move limbs very easily
then once survival is possible - and we literally use the time on life support to let the body heal itself, or find a reversible cause (like autoimmune disease, or a treatable infection) - you have to slowly build up people's strength again, both with nutrition
which is often through a feeding tube because people can't eat on a ventilator, or their guts aren't absorbing because they're so sick (and in fact when ill, the gut can leak, allowing the intestines to perforate and leak bugs into the blood), and also gentle weaning
as organs don't switch on overnight, they gradually come back. All this time, many setbacks and complications - it really is tough and unpleasant - which is why it feels wrong to do it to someone who is dying
like I wouldn't walk into a lovely peaceful hospice and start doing this to people with terminal cancer, it would be horrific! And that is how viscerally wrong it feels to do to some people in A and E sometimes, even though that's how they've arrived to me
Anyway, once we have established if someone likely to survive - and this is a dynamic conversation between patient if possible, family, ED, medics/specialists/other hospitals sometimes/several members of the ICU team
based on signs, symptoms, history, blood tests, (yes frailty but in context - if someone can't walk as broken their leg that doesn't count as no reserve, or if someone needs help as has trouble cognitively but goes walking everywhere, that doesn't make them frail!)
and this overall discussion happens in context such as - maybe we don't think we would get someone through to the other side of a nasty pneumona - but we would get them through a quick bladder infection
in terms of quality of life - I think it can be difficult both for medics and patients to know what to expect as IVU doesn't often see patients a year later - just til they go to a ward
but we know that certain things can happen - death obviously, from the disease or a complication of life support [common]. Some people have serious brain damage from lack of oxygen delivery, and stay in a coma, or heavily disabled
some people might have scarred lungs and always need home oxygen and be unable to leave home or hospital. Tracheostomies, feeding tubes. older people, once fit and well, might need 24/7 care.
None of these are that predictable, and it can take years to achieve any of them. What quality of life means, to all of us, is very variable. When younger, I wouldn't have tolerated a wheelchair. Now I'd struggle with being 'locked in'
so the quality of life we chose as acceptable is based on some absolutes (permanent coma being an obvious one!), death another, but the rest varies, and we really try and explore slowly what this means to an individual, via an advance directive, direct chat, or conversation w fam
OR independent advocate which can be court appointed. There are no hard and fast rules about what we will admit and what outcome we accept - really can't predict that - but sometimes it is so obvious that life support is futile, or would leave in state unacceptable to person
These conversations are usually written down, or take place with a witness and written down. Not really ever seen a form for it (they may exist I haven't seen one), because it's just so complicated and doesn't lend itself to boxes being ticked
all conversations with family are written down, as are MDT discussions (which take place weekly-fortnightly) for complex patients. We really explore specialist opinions for rare disease, look up literature, and get psych/palliative care to come and offer suggestions
so that is typical ICU. With respect to rationing in the Uk in the setting of covid19 I HAVE NOT seen it, or any guidance. My broad understanding of the idea is that if
it had to happen, we can all accept some people get it and some people don't, though people trying to work out how to share ventilators etc. In Lombardy they did this based on age and comorbidity (because certain conditions increase mortality - such as heart and lung disease)
and none of us want to contemplate that obviously. There is no formal UK guidance I am aware of, and we have not filled every available ventilated bed in the country. Unlike US, national service means a network of beds and patient can be moved between
other general suggestions - and none of this is at all confirmed - are that there would be ethics commitees akin to those already used for rationing organ transplants like hearts. These would include clinicians, lawyers, and members of the public for balance, and available 24/7
All of the above is in context of massively increasing critical care beds/ventilators/training/testing/building new hospitals etc etc. It may be late and it may not be enough, but the push is there as no one wants to ration
I have never known a team work as hard and as cohesively as they do at the moment. the hospitals are ghost towns, operations cancelled, forming huge super teams to try and ensure we are ready. We do not want to leave any 'man' behind!
I hope this is useful and not insensitive, we all need to be able to challenge and explore other people's fears...and in the context of covid19, doctors and nurses etc face their own mortality too. We would also face rationing! We do not want it.
a huge vat of guidelines for both clinicians and public available here and changes frequently https://icmanaesthesiacovid-19.org/national-guidance
