Admissions to intensive care of people highly likely to die

An accepted principle in intensive care medicine is that is intensive care should be provided for those with the greatest chance of benefit from the care. The demand for intensive care exceeds availability even in high income countries. So intensive should not ideally be provided those for whom death seems unavoidable, although palliative care in the intensive care unit (which sounds like an oxymoron) is growing. (1) Ironically many deaths in intensive care may be “better” than deaths on acute wards simply because the staff are so familiar with death and the ratio of staff to patients is much higher.

Decisions on whom to admit to intensive care are inevitably complex, although the chance that the patient can benefit is a prime criterion. The The Intensive Care National Audit and Research Centre (ICNARC) has been collecting data and conducting research in intensive care in England, Wales, and Northern Ireland for 25 years and has seen an increase in the number of intensive care beds and a drop in mortality.(2) The centre has developed a score that predicts accurately the chance of a patient dying in intensive care and produced for the Commission data on patients who had 80% or greater chance of dying (or 20% or less chance of surviving) in intensive care.

Overall in 2018-19 there were 163 340 total admissions to adult intensive care with 30 195 deaths (18.5%). Over the decade 2009-19, 93 870 patients with a greater than 80% chance of dying were admitted, accounting for 6.4% of all admissions; 57.5% of the admissions were for men, and the average age of those admitted was 68.6 years. The proportion of admissions varied across critical care units from 0 to 14.5% (median 6.5%, interquartile range 5.1 to 7.9%). After excluding readmissions of the same patient within the same acute hospital stay, overall acute hospital mortality for these patients was 89.5% (80,593/90,047), reflecting the accuracy of the predictive score. Over the decade the proportion of these admissions declined slightly but the absolute number increased slightly as the number of intensive care beds increased.

Nobody can say whether these rates are right or wrong, but they are interesting in providing data on the degree to which treatment continues when the risk of death is high. The variation that is seen among units is seen in almost all parts of health care, and it is reassuring that there has been no increase in the proportion of high risk patients admitted, showing that there is no increasing tendency to treat those likely to die.

We thank ICNARC for suppling these data, and their full paper is attached.

Four future scenarios of death and dying

The future is unpredictable. The unexpected happens often and can have a major impact. Nevertheless, some thought of how the future might look is important in preparing for it. Scenarios are one way of doing this and were developed after the wholly unforeseen oil shock of 1974. Scenarios are not predictions of the future but rather sketches of plausible futures with the limits of plausibility set wide. They are not what people would like to happen but rather what might happen. They have been used to think about the future of South Africa after Apartheid, the NHS, and scientific publishing. They are in many ways devices for thinking about the present, recognising things that will be important whatever the future brings.

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Warme Zorg

Laura Green

Whilst reading through a student’s dissertation recently I was reminded of the little-used notion of the term ‘warm care’. In the Netherlands the term warme zorg refers to an approach to care based on Bowlby’s attachment theory and the creation of feelings of security and safety. It attends to creating a sense of homeliness (even if someone is not at home), incorporating proximity (including touch), family and freedom. Emerging from home today into the chilly, dank darkness of the Luddenden Valley, I wrapped my coat tightly around myself and on my journey I considered the meaning of warmth.

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Why do doctors abandon the dying? A surgeon’s answer

Richard Smith

In his best-selling book “How We Die” the surgeon Sherwin B Nuland reflects at the end of the book on why it is that doctors abandon the dying. I remember attending a lecture in Edinburgh in 1974 by Cicely Saunders, the founder of hospices, who said (and I paraphrase): “I’ve had this brilliant idea. Instead of abandoning the dying and shoving them in a corner we should pay attention to their needs, their pain, breathlessness, incontinence, thirst, angst, and spiritual hunger.” The doctors in the Royal College of physicians leapt to their feet and applauded such an innovative idea. A humble (make that naive) medical student I thought: “How did it ever happen that we didn’t do what she recommends. Isn’t that what doctoring is about?”

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From medicalisation to humanisation of birth and death

Professor Lesley Page & Professor Celia Kitzinger

Birth, like death, has been over-medicalised.  Birth, like death, has moved from home to hospital – out of ordinary family life and social experience.  Many adults have never witnessed either birth or death.  Both the transition into life and the transition out of it can evoke fear in cultures in which they are unfamiliar, decontextualized, shorn of their historical and spiritual reference points.

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Dying in Intensive Care in low-income countries

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.

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Can hospices tame the fear of death?

Melanie Hodson, Tracey Bleakley

Over the course of the last century we have lost our familiarity with domestic dying and death. Ariès (1974) referred to ‘this great silence that… settled on the subject of death in the 20th century’[1] as medical, social and political developments encouraged better opportunities for good health so that our society was re-shaped as one in which ‘dying was largely deferred to old age’, giving rise to a public sense that death has been vanquished.[2] This despite the constancy of its portrayal across media, cinema and news feeds today.

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Notes on The Will to Live

Dr Ros Taylor MBE Nov 2019

The will to live, ‘wille zum leben’, is a powerful force first given a name by Schopenhauer – and it’s hard to know what is biological, cultural, conscious and unconscious about this drive to survive. We undoubtedly have a biological drive to reproduce, for the species to survive….but globally we are far outliving our reproductive years (though science is starting to tinker even with that!). So there is a desire to live well for longer – but this isn’t happening. We are living sicker for longer, the longed-for compression of morbidity[1] is not yet playing out.

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Designing systems of care for a modern death

Ivor Williams, Helix Centre, Institute of Global Health Innovation, Imperial College London

Dying in the 21st century is complex, and as we enter the third decade we continue to experience massive shifts in our way of life, not only in politics and economics but in health. The health challenges of the 21st century range from climate and ecological breakdown and its inevitable effects on our individual and collective health; the intensification of a global mental health crisis; the rise of antimicrobial resistance and ageing populations declining over longer periods with neuro-degenerative diseases such as Alzheimer’s. All of this is placing unprecedented strain on our existing models of care. Is the problem, as Madeleine Albright once put it, the fact that “we are taking 21st century challenges, evaluating them with 20th century ideas and responding with 19th century tools?

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Global attempts to avoid talking directly about death and dying

Nataly Kelly, Richard Smith

This blog was posted originally on the BMJ site, and many people added other examples in many languages of words and phrases used to avoid talking directly about death and dying. You can read them at (scroll to the end of the blog): https://blogs.bmj.com/bmj/2012/08/16/richard-smith-and-nataly-kelly-global-attempts-to-avoid-talking-directly-about-death-and-dying/

English speakers have been very inventive in finding words and phrases that allow them to avoid the words death and dying, and so we have discovered are people who speak other languages. This seems to be a global phenomenon. We are the kind of people who when we hear somebody say “X has passed away” want to shout “No X didn’t, X died.” But that’s intolerant, and we want here to praise the global talent for avoiding the dreaded words.

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