Facing the challenge of managing the deteriorating patients in an acute hospital

Dr Merlina Sulistio, Advanced physician trainee in palliative medicine, Monash Health 2011 and current palliative medicine physician, Cabrini Health, Australia, explains the background to the longer article selected as ‘Editor’s Choice’ in the April issue of Palliative Medicine.

Dr Merlina

Dr Merlina Sulistio

Like many young doctors, I began my specialist training in palliative care after years of doing general medicine and surgery in acute hospitals. During those years, I encountered many deteriorating patients who needed input from the hospital rapid response team (RRT). This team, commonly consisting of a combination of an intensive care unit doctor and nurse and general medicine junior doctors, is established in many hospitals worldwide to urgently respond to and improve outcomes in clinically deteriorating patients. These patients were challenging to a junior doctor: from obtaining venous access, to assessing and discussing the limitations of treatment.

It became apparent to me, during the initial months of training in palliative care, how timely discussions can prepare and empower patients to receive the type of care they desire. This was in striking contrast to the end-of-life care received by some patients I had cared for earlier in my career.

Recognising and responding to deteriorating hospitalised patients is an important issue globally in acute medicine. The RRT has been introduced to address this issue. However, it is clear that a significant proportion of patients that deteriorate in hospital do so because of their progressive life-limiting illness. Many of these patients receive more interventions than required, due to a medical culture that fights the inevitability of death. Systems and structures for delivering safe and high quality end-of-life care should work in synergy with those for recognising and responding to clinical deterioration.

With the help of my clinical supervisors, Dr Michael Franco and Dr Leeroy William, we conceptualised this retrospective cohort study, published in this month’s Palliative Medicine, to identify patients with poorer outcomes following RRT consultations. Given the known demographics of these patients, we felt that it was likely many of these patients had life-limiting illness. We used the Supportive and Palliative Care Indicators Tool (SPICT™)1 to identify these patients.

Our retrospective study confirmed that:

  • Nearly 40% of patients who required RRT consultations have a life-limiting illness
  • These patients have worse outcomes after RRT consultations compared to their counterparts (mortality rates of 41.7% vs 13.2%).

Given these findings, we recommend that:

  • Patients with life-limiting illness are identified using validated tools such as SPICT™
  • They should be offered the opportunity for clarification of goals of care within three days of hospital admission.

We hope this approach will provide clarity and direction to treating teams, reduce the burden of unnecessary interventions and promote patient-centred care agreed upon in advance of any deterioration.

1. Boyd K, Highet G, Crawford D, et al. Identifying patients with advanced illness for needs assessment and care planning: SPICT in practice. BMJ Support Palliat Care 2012; 2: A43.

PM April4.coverDownload a free copy of the full article…
This post relates to a longer article, Hospital rapid response team and patients with life-limiting illness: A multicentre retrospective cohort study’, by Merlina Sulistio, Michael Franco, Amanda Vo, et al, published in Palliat Med. 2015 29: 29: 302-309. Published online before print January 29, 2015, doi: 10.1177/0269216314560802. EAPC members and registered users of the EAPC website can download a free copy of this article and other ‘Editor’s choice’ papers from the EAPC website. 

(If you need to register or login to download this paper please follow the instructions in the top right-hand corner of EAPC home page and scroll down to the article). Click here to view other EAPC-originated papers.

EAPC congress 2015Are you coming to Copenhagen?
See you at the 14th World Congress of the European Association for Palliative Care – Copenhagen, Denmark, 8-10 May, 2015. Follow us on Twitter @EAPCOnlus – our official congress hashtag is #eapc2015 

Tienes pensado venir a Copenhague?
Te esperamos en el 14º Congreso Mundial de la Sociedad Europea de Cuidados Paliativos – Copenhague, Dinamarca, del 8 al 10 de Mayo 2015. Consulta toda la información aquí.  También puedes seguirnos en Twitter @EAPCOnlus – el hashtag oficial del congreso es #eapc2015 

This entry was posted in EAPC-LINKED JOURNALS, Palliative Medicine: Editor's Choice, RESEARCH and tagged . Bookmark the permalink.

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