Dying in Intensive Care in low-income countries

Tim Baker*1,2,3, Carl Otto Schell3,4,5, Eve Namisango6,7, Raphael Kazidule Kayambankadzanja1,8, Laura Hawryluck9, Maya Jane Bates1,10

Institutional Affiliations

  1. College of Medicine, University of Malawi, Blantyre, Malawi
  2. Ifakara Health Institute, Dar es Salaam, Tanzania
  3. Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
  4. Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
  5. Department of Internal Medicine, Nyköping Hospital, Sörmland, Sweden
  6. African Palliative Care Association, Uganda
  7. Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation , King’s College London
  8. Department of Anaesthesia and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi
  9. Department of Critical Care Medicine, University of Toronto, Toronto, Canada
  10. Liverpool School of Tropical Medicine, Liverpool, UK

Word count:  888

* Tim Baker tim.baker@ki.se Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden

Introduction

An increasing number of people in low-income countries (LICs) are dying in Intensive Care Units (ICUs). There is little written about the quality of these deaths. This article aims to highlight this neglected issue and provide a roadmap for the way forward.

Intensive Care in LICs

ICUs provide resource-intensive care with a focus on reversing physiological abnormalities and curing patients’ critical illness. There are an increasing number of ICU beds in LICs. Ten years ago, Muhimbili National Hospital in Tanzania had one 6-bedded ICU. The same hospital now has 45 ICU beds. Despite the increase in ICU beds, there are still far fewer than there are critically ill patients in LICs. While high-income countries have 33-240 ICU beds per million population, LICs may have only 1 per million.1,2 The greatest burden of diseases that cause critical illness is outside of high-income countries.2,3 In hospitals in Malawi, 7% of adult in-patients were found to have sepsis – as defined as a life-threatening infection4 – implying that a 500-bed hospital should have 35 beds for managing this subgroup of critically ill patients, ten times more than is currently the case. Compounding this, critically ill patients in LICs often present late to hospital and to ICU due to delays in recognition or referral leading to initially treatable conditions becoming complicated or even irreversible.

The limited intensive care capacity together with the large number of critically ill patients poses a huge challenge of selecting the patients best suited for ICU care. An accepted principle is that intensive care should be provided for those with the greatest chance of benefit from the care. However, clinical, ethical, legal, financial, political and authority dimensions all interplay in decisions, and hospitals often develop patient selection procedures that are implicit and convoluted.5 It may be that the hospital’s sickest patients are selected, rather than those with a potential for recovery. These sickest patients are, in many cases, dying.

The scarce data available indicates that a large proportion of patients admitted to ICUs in LICs die before discharge. Of 360 patients admitted to a university hospital’s ICU in Tanzania, 46% died in the unit.6 In a similar ICU in Malawi, 110 patients died in one year – a mortality rate of 36% (unpublished data). These figures are substantially higher than the 8-18% mortality rates seen in ICUs in high-income countries.2

Patients who die in ICU in LICs are typically young and very sick: the median age of those who died in the Malawian ICU cohort was 34 (IQR 25-42), 85% had at least one severely deranged vital sign at arrival to ICU and 45% had a cardiac arrest requiring cardio-pulmonary resuscitation either before or on admission to ICU. The patients stayed in ICU for a median of 2 days before dying (IQR 0.6-4 days) and 8% of them remained in ICU for more than one week. They were treated aggressively at admission with 77% receiving mechanical ventilation and 43% receiving a vasopressor.

Implications of the current situation

These data, together with our clinical experience, suggest that a substantial number of patients admitted to ICU in LICs have irreversible disease with death as the inevitable outcome. ICUs may not provide the most appropriate or cost-effective care for dying patients. Intensive Care’s curative paradigm presumes that a patient’s condition is reversible and staff, families and physical space are often poorly prepared for managing death, despite its daily occurrence. Unrealistic hopes of cure may lead to attempts at increasingly aggressive interventions, and referral to a palliative care team may be delayed or omitted, resulting in suffering for families and staff and a repeated sense of failure and additional cost burdens.7,8

Roadmap for improving dying in ICUs

Death is an inevitable part of life and increased discussion around the value of death as promoted in this commission form the bedrock of improved deaths from critical illness. A greater understanding about the quality of deaths for those with critical illness is required.9,10 Social, cultural and religious perspectives about critical illness, care in ICUs and death need to be understood through engagement with individuals, stakeholders and communities. This will inform decision making and reduce fear, enabling communication about the dying process and the appropriate withholding and withdrawal of life-prolonging therapies.11 Healthcare practices should be encouraged to shift from a curative aim when the chances of survival are small to facilitating palliation and a good death. Responsive national ethical and legal frameworks are needed to reflect both the increasing technological possibilities of ICU care and priorities for resource allocation.12 Improving triage through the development and implementation of context-appropriate prediction models and transparent admission criteria would ensure that those with the greatest possible benefit are selected for ICU. Promoting good quality end-of-life care in other units would avoid prolonging suffering and the transition from life to death for dying patients, increase space available to those for whom ICU care can be life-saving and improve perceptions around care of critical illness, health worker morale and the cost-effectiveness of care.  

Conclusion

High death rates in ICUs in LICs are common. Most of us would prefer not to die in an ICU, but this is happening to an increasing number of people in low-income countries. Enhanced community engagement, improved patient selection for ICU care and an increased focus on dignified dying could lead to substantial gains including improving deaths for many.

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2.            Adhikari NK, Fowler RA, Bhagwanjee S, Rubenfeld GD. Critical care and the global burden of critical illness in adults. Lancet 2010; 376(9749): 1339-46.

3.            Razzak J, Usmani MF, Bhutta ZA. Global, regional and national burden of emergency medical diseases using specific emergency disease indicators: analysis of the 2015 Global Burden of Disease Study. BMJ Glob Health 2019; 4(2): e000733.

4.            Kayambankadzanja R, Schell C, Namboya F, et al. The prevalence and outcomes of sepsis in adult patients in two hospitals in Malawi. American Journal of Tropical Medicine & Hygiene 2019: 1-6 doi:10.4269/ajtmh.19-0320.

5.            Engdahl Mtango S, Lugazia E, Baker U, Johansson Y, Baker T. Referral and admission to intensive care: A qualitative study of doctors’ practices in a Tanzanian university hospital. PloS one 2019; 14(10): e0224355.

6.            Baker T, Blixt J, Lugazia E. Single deranged physiologic parameters are associated with mortality in a low-income country. Critical care medicine 2015; 43.

7.            Chuang C-H, Tseng P-C, Lin C-Y, Lin K-H, Chen Y-Y. Burnout in the intensive care unit professionals: A systematic review. Medicine (Baltimore) 2016; 95(50): e5629-e.

8.            Sibanda S, Mambende B, Maunganidze L. Examining the psychological and social predictors of burnout among nurses employed by the government: A study of nurses at Gweru Provincial Hospital. International Journal of Law, Humanities & Social Science 2017; 1(4): 41-54.

9.            Wachterman MW, Pilver C, Smith D, Ersek M, Lipsitz SR, Keating NL. Quality of End-of-Life Care Provided to Patients With Different Serious Illnesses. JAMA Intern Med 2016; 176(8): 1095-102.

10.          Mah K, Powell RA, Malfitano C, et al. Evaluation of the Quality of Dying and Death Questionnaire in Kenya. J Glob Oncol 2019; 5: 1-16.

11.          Morgan J. Celebrating life in a Death Cafe. The Lancet Neurology 2017; 16(9): 690.

12.          Manda-Taylor L, Mndolo S, Baker T. Critical care in Malawi: The ethics of beneficence and justice. Malawi medical journal : the journal of Medical Association of Malawi 2017; 29(3): 268-71.

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