During busy periods in the ICU, decision-making regarding withdrawal of life-sustaining therapy is made more quickly, found a recent study.1 Researchers analyzed the effect of ICU capacity strain on 9,891 patients dying in the hospital.

“Prior work had looked at standard outcomes like mortality. We were interested in looking at end-of-life care because it is a time-consuming process,” says study author May Hua, MD, assistant professor of anesthesiology at Columbia University Medical Center in New York City.

Some of the researchers thought the process would take longer because of the need to discuss the situation with the family. Hua was in this group. “Getting people to the point of realizing that therapy isn’t working is time-consuming,” she notes.

The rest of the researchers expected the process to be shorter, and ended up being correct. “They hypothesized that if providers know someone isn’t going to do well, they will expedite decision-making in order to free up a needed bed for another patient,” says Hua.

If the study had found longer time frames, Hua would have used it as an argument to increase palliative care consultation to facilitate end-of-life discussions. “But the data suggest that we can perform more efficiently at end-of-life care if we are feeling pressured to do so,” says Hua. “This suggests that maybe this is a movable target in some way.”

Time frames to initiate do-not-resuscitate orders and time to death were shorter during high-capacity times. Some previous research echoes these findings. In Canada, when calling a rapid response team on the floor, the likelihood of having a goals-of-care discussion goes up when there are no available beds on the floor.2

“Ethically, you’d think that the process wouldn’t be affected by non-patient-centered variables, but they are,” says Hua. “We potentially can be more efficient.”

Slippery Slope

If the patient is ultimately not going to survive, delaying the dying process in any way is potentially engendering more suffering. “At the same time, you don’t want to hasten the dying process,” says Hua. “There is a delicate interplay where you need to be sensitive to all of those factors.”

In Hua’s experience, it’s not uncommon for the dying process to be prolonged. One often-cited reason is that families haven’t come to terms with things. “That’s where we are as a society, and some prolonged suffering exists because of that. At the same time, you see the slippery slope,” says Hua. If providers move too far in the other direction, they may be hastening death, or even facilitating death in some patients who would otherwise survive.

The study didn’t look at family outcomes. “We know that caregivers of ICU patients go on to suffer psychologically,” says Hua. Whether the quality of communication from an ethicist or palliative care specialist would be better than the hospitalist’s is unknown. Also unknown is how the quality of communication affects the grieving process. “So while we may be able to do it faster, it’s only one metric to look at,” says Hua.

REFERENCES

  1. Hua M, Halpern SD, Gabler NB, et al. Effect of ICU strain on timing of limitations in life-sustaining therapy and on death. Intensive Care Med 2016; 42(6): 987-994.
  2. Stelfox HT, Hemmelgarn BR, Bagshaw SM, et al. Intensive care unit bed availability and outcomes for hospitalized patients with sudden clinical deterioration. Arch Intern Med 2012; 172(6):467-474.

SOURCE

  • May Hua, MD. Assistant Professor of Anesthesiology, Columbia University Medical Center, New York City. Phone: (212) 305-6494. Email: mh2633@cumc.columbia.edu.