A/Prof Neil OrfordDivisional Director ICUUniversity Hospital Geelonghttp://barwonhealthicu.com

Dying for person-centred care

UHG ICU

Surviving critical illness

K-M Kaukonen, e tal , JAMA. 2014;311(13);1308-1316

Is there a problem

Social and Political

Moral and Personal

Scientific

The questions

1. Can we identify people at high risk of dying in the next year due to long-term disease?

2. Can we identify these same people in the critical care setting?

3. Do we practice SDM / PCC in Australian ICU?4. Can we train our doctors and nurses to deliver SDM? 5. Will SDM improve health care utilisation, person-centred

outcomes?6. Do we want SDM all the time in all situations?

1. Can we identify people at high risk of dying in the next year due to long-term disease?

2. Can we identify these same people in the critical care setting?

Frailty

Cancer

NoneOrgan failure

Orford N, Milnes S, Lambert N, et al CCR Sep 2016;(18)3:181-8

3. Do we practice SDM / PCC in Australian ICU?

No LLI Organ failure

Frailty Cancer

No. (1024) 419 305 196 104

Pre-hospital ACP 3% 9% 14% 13%

Hospital GoC form 3% 24% 55% 40%

Discharge to independent living

78% 61% 25% 45%

1-year mortality 8% 24% 46% 60%

Orford N, Milnes S, Lambert N, et al CCR Sep 2016;(18)3:181-8

4. Can we train our doctors and nurses to deliver SDM?

Who should we train?

All* ED Ward ICU

Total GoC 223 14 150 47

MO completing GoC

Intern 2% 0% 3% 0%

Resident 18% 14% 19% 19%

Registrar 67% 86% 73% 53%

Consultant 8% 0% 4% 28%

Orford N, Milnes S, Lambert N, et al CCR Sep 2016;(18)3:181-8

4. Can we train our doctors and nurses to deliver SDM?

Effect of communication skills training on outcomes in critically ill patients with life-limiting illness referred for intensive care management – A before-and-after study

Orford N, Milnes S, Simpson N, et al, BMJSPC accepted

4. Can we train our doctors and nurses to deliver SDM?

Before (n=119) After (n=103) P-value

Age 72.6 (+13.6) 73.9 (+12.4) 0.47

Pre-hospital living at home 81% 78% 0.62

LLI Criteria

Cancer 24% 22% 0.83

CCF 29% 12% 0.16

COPD 23% 21% 0.68

Renal failure 11% 6% 0.18

Frailty / dementia / stroke 45% 48% 0.74

Nursing home 13% 13% 1.00

Neurological disease 3 % 5% 0.35

4. Can we train our doctors and nurses to deliver SDM?

Before (n=119) After (n=103) P-value

Patent-centred discussion documented 50% 69% 0.004

Competence and surrogate 31% 48% 0.01

Values and goals discussed 17% 42% <0.0001

Medical advice provided 49% 61% 0.08

PCD in cohort deceased by day-90 43% 94% <0.0001

(Documented by 48 hrs post ICU referral)

5. Will SDM improve health care utilisation, person-centred outcomes?

5. Will SDM improve health care utilisation, person-centred outcomes?

Survival for cancer before and after

5. Will SDM improve health care utilisation, person-centred outcomes?

Survival for organ failure before and after

5. Will SDM improve health care utilisation, person-centred outcomes?

Frailty Before (n=48) After (n=43) P-value

ICU/HDU admission 15% 21% 0.4

MET incidence 94% 79% 0.04

Palliative care referral 13% 21% 0.3

90-day readmission 48% 19% 0.003

90-day mortality 35% 44% 0.4

The questions

1. Can we identify people at high risk of dying in the next year due to long-term disease?

2. Can we identify these same people in the critical care setting?

3. Do we practice SDM / PCC in Australian ICU?4. Can we train our doctors and nurses to deliver SDM? 5. Will SDM improve health care utilisation, person-centred

outcomes?6. Do we want SDM all the time in all situations?

Sep Oct Nov Dec Jan Feb Mar Apr0

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18

20

GoM for Patients with LLI in ICU

GoM in ICU No GoM

50%

70%

61% 58%

33%

UHG ICU 2017

New registrars

IvalCourse

IvalCourse

“90% of adults in the US have no or limited knowledge of palliative care, but after reading a definition, more than 90% would want it for them or their family” Amy Kelley, NEJM 2015

“Everyone dies. Death is not an inherent failure. Neglect, however, is.”(Atul Gawande, JAMA 2016)

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