hand-and-pen-blog

By Barbara Phillips, Council Member

Doctor, could you define futility for me please? “This patient is not suitable for intensive care” is a statement in the notes we will all have seen or written.  But what is meant, and how was the conclusion reached? There are patients for whom intensive care would clearly be of little benefit, but I’m not worried about those, I worry about the grey area which exists between the decisions of clarity.

These patients tend to be medical patients with chronic co-morbidities, the very elderly or those with severe physical or learning disabilities.  Take this patient for an example; a woman her late 60s with a BMI of 40, severe heart failure, liver impairment secondary to NASH and chronic kidney disease.  She was admitted to hospital in fast AF.  As a consequence she was hypotensive and had developed an acute kidney injury. On the medical ward she had a respiratory arrest with neurological recovery and was referred to ICU team.  They decided she wouldn’t benefit from intensive care. Why? On what basis? I agree this was a patient with a poor prognosis, but why not take her to the intensive care unit and seek to rate control the AF and haemofilter her?  Her latest decompensation was acute and therefore potentially reversible.

We have to be wary of ‘fait accompli’ in our decisions. The patient with multiple co-morbidities who is acutely unwell, with minimal monitoring on a sparsely nursed ward may well die…were you proved right not to take her to intensive care….. or did he or she  die because of sub optimal management? There is very little evidence out there to help us decide and you have to be wary of basing your decisions on previous experience. Things change too! When I started ICM, all ventilated, neutropaenic haematological malignancy patients died; now not all of them do.

I don’t admit everyone I’m asked to consider for intensive care, it would be the wrong use of a scarce resource.  When I am asked about a patient who is very elderly or with significant co-morbidities, the question I ask myself is this.  Is there anything acute I can usefully and successfully reverse without a prolonged ICU admission (see resources below)? The answer may be yes for an elderly patient with urosepsis.  If the answer is no, then I have discussion with those concerned about what their expectations of an ICU admission are and more often than not an ICU admission is avoided.

Finally, try defining futility, and then try again from the point of view of the patient or their relative. I was asked to do this by our Professor of Medical Law and Ethics (and a forensic psychiatrist). It’s harder than you think. I no longer use the word in medical records.

One thought on “Who do we let through the door?

  1. I agree, the term futility is no longer acceptable medical jargon. If there is doubt, I believe most clinicians would admit and assess response, particularly as many interventions are significantly less burdensome (peripheral metaraminol and HFNO).

    I am not sure though, that your main example is a good one. Fast AF, ARF deteriorating to a respiratory arrest on the background of severe CCF, liver disease and CRF; I think many would struggle to see the benefit of ICU in this case, both short-term and long-term. Whereas urosepsis appears to respond well even in the high-risk patient – but it is dependent on it being recognised and escalated early!

    Like

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