Hilton et al. Critical Care 2013, 17:224 http://ccforum.com/content/17/2/224 REVIEW Clinical review: The role of the intensivist and the rapid response team in nosocomial end-of-life care Andrew K Hilton1, Daryl Jones1,2 and Rinaldo Bellomo*1,2 organ supports in patients who would otherwise rapidly Abstract die without them. Such technology may facilitate In-hospital end-of-life care outside the ICU is a new recovery, and is therefore of potential benefi t to the and increasing aspect of practice for intensive care individual. In a signifi cant proportion of cases, however, physicians in countries where rapid response teams artifi cial life support will not confer an enduring benefi t have been introduced. As more of these patients to the patient and will be associated with physical, die from withdrawal or withholding of artifi cial life emotional, spiritual and fi nancial burdens to patients, support, determining whether a patient is dying their families and society [2]. or not has become as important to intensivists as Owing to the uncertainty of predicting death at the the management of organ support therapy itself. onset of clinical deterioration, a proportion of ICU Intensivists have now moved to making such decisions admissions inevitably involve patients who receive in hospital wards outside the boundaries of their usual artifi cial life support, only to die despite provision of such closely monitored environment. This strategic change support, or, more often, only able to die when these are may cause concern to some intensivists; however, removed. In this environment, death may then become a as custodians of the highest technology area in the programmed or orchestrated event, where the custodians hospital, intensivists are by necessity involved in such of life-support technology may substantially infl uence processes. Now, more than ever before, intensive when and how death will happen [3,4]. Th e management care clinicians must consider the usefulness of key of dying and the provision of nasocomial end-of-life care concepts surrounding nosocomial death and dying (EOLC) have become ubiquitous and intrinsic to the and the importance and value of making a formal daily practice of intensivists. diagnosis of dying in the wards. In this article, we Furthermore, because the intensivist’s role has also assess the conceptual background, reference points, recently expanded to that of rapid response team (RRT) challenges and implications of these emerging aspects leader [5,6], EOLC decisions are frequently made out of of intensive care medicine. hours in a limited amount of time, in a non-ICU environment, in patients with whom the intensivist may not be familiar and with limited documentation of Introduction advanced care planning (Figure 1). In this article, we Life-support technology has profoundly changed medi cine review and discuss the characteristics, conceptual and and has contributed to improved life expectancy in ethical implications, and practical consequences of the resource-rich nations. However, the technology has also rapidly expanding developments of RRTs [5,7-17] in the substantially aff ected the circumstances, mode and practice of this aspect of intensive care medicine. timing of death in such societies. In this context, cessation of breathing or of the heartbeat no longer End-of-life care and intensivists necessarily signifi es the arrival of death [1] because Th ere are several reasons why intensivists are in a unique doctors can substitute these vital functions with artifi cial position to improve nosocomial EOLC. Intensive care physicians have a detailed understanding of key aspects of critical illness and limits of vital organ support. *Correspondence: [email protected] Independent of the patient’s admission diagnosis ICU 2Australian and New Zealand Intensive Care – Research Centre, School of Public Health and Preventive Medicine, Monash University, Alfred Hospital Campus, physicians also take into account the eff ect of specifi c Commercial Road, Prahran, Victoria 3181, Australia physiological derangements on the probability of sur- Full list of author information is available at the end of the article vival. Prognosis based on severity of organ dysfunction may diff er substantially from that attributed to the ad- © 2010 BioMed Central Ltd © 2013 BioMed Central Ltd mission diagnosis alone. Finally, intensive care physicians Hilton et al. Critical Care 2013, 17:224 Page 2 of 11 http://ccforum.com/content/17/2/224 Figure 1. Key aspects in the evolution of decision-making in relation to nosocomial end-of-life situations. Patients with chronic illness have reduced function and increasing frailty, which increase their risk of a crisis. This leads to hospital admission. As this happens, family observation of the patient’s physical changes has an eff ect on their attitudes and perceptions of what might be desirable in terms of medical intervention. While in hospital with an acute admission, discussions with the clinician may also shape decision-making. An acute deterioration then leads to intensivist involvement and, in the absence of a clear documented plan, a partly informed semi-urgent or urgent decision has to be made to either pursue aggressive treatment or comfort treatment alone. are in a position to explain to patients and families what Th e above diff erences between ICU and non-ICU the limits of the technology of life support might be in a physicians are made more relevant by recent develop ments specifi c clinical situation. Intensive care physicians can in healthcare. In particular, an increasing propor tion of thus guide colleagues, patients and their families to an deaths are happening in hospitals rather than at home. informed shared decision regarding the clinical utility Furthermore, within the hospital, an increas ing propor- and limits of artifi cial organ supports. tion of deaths occur in the ICU instead of on the general Similarly, there are several reasons why non-ICU wards [23-31], perhaps as a consequence of the greater physicians may be less favorably positioned to optimally use of technology-based interventions. Finally, the intro- deliver nosocomial EOLC in the critically ill. First, the duc tion of RRTs has resulted in an increased involvement ability of non-ICU physicians to prognosticate in cases of of ICU physicians in the care of dying ward patients [5,8,9]. advanced disease has been reported to be poor and Th e intensive care physician’s unique skills, experience typically overly optimistic [18-20]. Second, as the task of and knowledge of advanced organ support technology providing care to critically ill patients shifts to the ICU has increased their involvement in managing acutely team, primary physicians may only see such patients for a deteriorating ward patients. Consequently, they are now limited period of time during each day. Th is may impair making more frequent and often diffi cult decisions about their ability to make a fully informed judgment on their who should receive treatment escalation and who should patients’ condition and their appreciation of the degree of receive EOLC in the wards. Such concerns necessitate discomfort, loss of dignity and family distress being that all clinicians ought to refl ect more deeply on the experi enced while treatment is continued. Finally, non- concept of death and its management; the uncertainties ICU physicians are less frequently exposed to EOLC surrounding the concept of and the diff erential diagnosis decisions in a high-technology environment and typically of dying; the management of these issues within the fi nd conversations with families in this setting diffi cult context of RRT calls; and the future role of intensive care [21,22]. medicine in these processes. Hilton et al. Critical Care 2013, 17:224 Page 3 of 11 http://ccforum.com/content/17/2/224 Diagnosing and defi ning nosocomial death: Th e defi nition must both encompass and be coherent basic concepts with medical diagnostic and technical capability and Diagnosing death is the fi nal step in the provision of practice; and societal norms, values and expectations. EOLC. However, a universally applicable and acceptable Th is historical and cultural contingency in the defi nition of death remains elusive [32,33]. Scientifi c or defi nition of death is exemplifi ed in the evolution of the philosophic responses to this problem often propose a concept of brain death. Catastrophic brain injury remains functional defi nition: an organism is dead when its inte- technologically irreplaceable in itself, but for over gra tive and homeostatic functions are irreversibly lost 40 years it has been possible to provide and continue [32]. Although such a defi nition appears intuitive, it cardio-respiratory support almost indefi nitely. Logically, presents a number of problems. in such cases, the patient cannot be declared dead by First, it is not possible to generally defi ne a level of applying cardio-respiratory criteria even though inde- irreversible functional loss that constitutes death in all pen dent existence without cardio-respiratory support species. For example, what defi nes death in a jellyfi sh and would be impossible. Th e medical, social and legal in a human is profoundly diff erent. ramifi cations of this problem lead to the concept of brain Second, until recently humans have been deemed dead death. Irreversible loss of consciousness, brain stem solely on cardiorespiratory criteria – loss of the fl ow of refl exes and spon ta neous breathing have all become blood in the circulation or air in the lungs [1,32,33]. Un- accepted criteria for death in many countries [1,31,33]. responsive loss of consciousness was a recognized Th is advance also coincided with the development of associated sign, but cardiopulmonary criteria remained solid organ trans plantation – an endeavor with wide primary. Th e irreversible loss of all three of these key social, political and legal endorsement, and which is physiologic functions has been, and continues to be, used technically and ethically facilitated by using donors to defi ne the moment of death at an earlier time than the declared dead on neurologic criteria.