Rapid Response Systems and End of Life Care
While rapid response systems (RRSs) were initially designed to RECOGNISE seriously ill patients early and then to RESPOND to them in a manner that prevent further deterioration, experience has shown that up to one-third of all RRS calls are for patients with end-of-life issues, and in such cases, for patients that may not be appropriate recipients of aggressive care. Thus an extension of the original rapid response concept is to RECOGNISE patients near the end-of-life, and to rapidly steer them toward appropriate end of life care in a manner that prevents unnecessary distress. This content section will highlight recent and influential literature in this growing area. Important developments include interventions to manage pre-frailty, coordinating care transitions, and the identification of patients for whom initiating end-of-life discussions may be more important the use of traditional “rescue” function of the RRS.
PREDICTING ELDERLY PATIENTS NEAR THE END-OF-LIFE
- Cardona-Morrell M, Chapman A, Turner RM, Lewis E, Gallego-Luxan B, Parr M, et al. Pre-existing risk factors for in-hospital death among older patients could be used to initiate end-of-life discussions rather than Rapid Response System calls: A case-control study. Resuscitation. 2016;109:76-80. https://www.ncbi.nlm.nih.gov/pubmed/27769903
Decision aids can assist clinicians in steering the end-of-life conversations to suit individual patient needs
- Cardona-Morrell M, Benfatti-Olivato G, Jansen J, Turner RM, Fajardo-Pulido D, Hillman K. A systematic review of effectiveness of decision aids to assist older patients at the end of life. Patient Education and Counseling 2017; 100(3):425-435. http://www.sciencedirect.com/science/article/pii/S0738399116304578
- This article is a systematic review evaluating decision aids used to identify older patients near the end-of-life.
- The decision aids were aimed at helping patients to understand their prognosis and to formally state their choices with regard to further management.
- Patient preferences were the most common decision aids, but they overlooked their goals and values. Prognostic information and financial implications were not well covered.
Many patient, clinician and system factors hamper appropriate management of older patients near the end of life
- Hillman KM, Cardona-Morrell M. The ten barriers to appropriate management of patients at the end of their life. Intensive Care Medicine. 2015;41:1700-2. http://www.ncbi.nlm.nih.gov/pubmed/25749572
However, objective assessments of risk of death can help minimise prognostic uncertainty and trigger earlier engagement of palliative care consultants
- Cardona-Morrell, M, Hillman K. Development of a tool for defining and identifying the dying patients in hospital: Criteria for Screening and Triaging to Appropriate aLternative care (CriSTAL). BMJ Supportive and Palliative Care 2015;5:78-90. http://spcare.bmj.com/content/5/1/78
- Williams M, Cardona-Morrell M, Stevens P, Bey J, Smith Glasgow ME. Timing of palliative care team referrals for inpatients receiving rapid response services: A retrospective pilot study in a US hospital. International journal of nursing studies. 2017;75:147-53. https://www.ncbi.nlm.nih.gov/pubmed/28818571
Frailty is a relatively new concept for acute medicine. There are many dozens of different scores. These scores measure concepts such as gait speed and grip strength and some incorporate activities of daily living whereas others incorporate comorbidities. The scores correlate very well with outcomes such as mortality and length of stay in the elderly. It is important for those caring for the elderly seriously ill to familiarise themselves with the concept and at least some of the simpler scores as it will become more important when assessing the clinical state and prognosis of the elderly. Below is one of the more recent reviews.
- Muscedere J, Waters B, Varambally A, Bagshaw SM, Gordon Boyd J, Maslove D, Sibley S, Rockwood K. The impact of frailty on intensive care unit outcomes: a systematic review and meta-analysis. Intensive Care Medicine 2017;43(8):1105-1122. https://link.springer.com/article/10.1007/s00134-017-4867-0
- Cardona-Morrell M, Lewis E, Suman S, Haywood C, Williams M, Brousseau AA, et al. Recognising older frail patients near the end of life: What next? Eur J Intern Med. 2017;17:30376-X. https://www.ncbi.nlm.nih.gov/pubmed/28993099
- Frailty is becoming more important in accessing the elderly frail.
- Frailty is characterised by decreased mobility, weakness, reduced muscle mass, poor nutritional status and diminished cognitive function.
- Ageing and frailty are not synonymous.
- About 35% of people over the age of 65 have some degree of frailty; and over 50% of those over the age of 85.
- There are many scales for measuring frailty.
- This article is the most comprehensive review of evaluating the impact of frailty on patients in intensive care.
- The review found that frailty was associated with:
- A higher hospital mortality
- A higher post-hospital mortality
- Less likelihood of being discharged home fit