Unsuitable for ICU: what happens next?

Introduction

This observational prospective study examined the outcomes and symptoms in those patients who are unsuitable for ICU admission.

Methods

All patients referred to ICU for admission but deemed unsuitable were recorded by the team. These patients were reviewed by palliative care researchers. Demographic information (age, sex, diagnosis) and data on patient's symptoms of progress and outcome were collected at four time points (24, 48, 72 hours and 1 week).

Results

Fifty patients were identified between January and April 2009. There was an age range of 24 to 86 (mean = 62). The commonest cause for referral was respiratory failure (40%). Overwhelming sepsis requiring inotropic and ICU support was also common (28%). Patients were most frequently deemed unsuitable for admission as they were too well at the time of referral (48%). The second most common reason for unsuitability was co-morbidities (32%) with nine (18%) identified as suffering probable fatal insults. One patient was referred for assessment for ICU support post emergency surgery which was not required. A number of patients remained in hospital at 1 week post referral, with ongoing illness (32%) or rehabilitation (8%). Twenty-six per cent (13/50) of patients were discharged home and 34% (17/50) died. Of those that died, 59% were within 24 hours of ICU referral. All other deaths occurred within 1 week of referral. Nine of these 17 had been identified as having nonsurvivable insults at ICU referral, seven as having excess co-morbidities making ICU inappropriate, and just one identified as being too well.

Conclusions

This study suggests that our ICU team is both sensitive and specific at identifying those patients who are either too well for admission or those patients for whom ICU is unlikely to be of benefit as their insult is presumed fatal. We suggest those patients whom the ICU identifies as unlikely to survive should be assessed and referred to the palliative care team, where appropriate. This should facilitate appropriate communication of this by clinical staff and allow the relevant social, psychological and spiritual preparations for death that are the hallmarks of good care of the dying.