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ANALYSIS: Ursula K Braun, Rebecca J Beyth, Marvella E Ford, and Laurence B McCullough Defining limits in care of terminally ill patients BMJ 2007; 334: 239-241 [Full text]

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If he were my Dad...

Gareth J Gibbon   (7 February 2007)

An integrated proactive approach is required

Simon IR Noble, Ian Williamson, Alsion Brewster, Helen Caddick   (9 February 2007)

If he were my Dad... 7 February 2007
Gareth J Gibbon, Specialist Registrar in Anaesthetics Bristol Royal Infirmary, BS1 3NU Send response to journal: Re: If he were my Dad...	Professor Braun’s example of an elderly gentleman with presumably incurable malignancy and significant cardiovascular and respiratory co- morbidity raised my eyebrows1. Offering ventilation to such a patient is clearly associated with significant burden and risk. The overall outcome following re-presentation and consideration for critical care may have justified a more palliative approach to managing this patient on his initial presentation. I would be surprised if he were managed so aggressively on an intensive care unit in the resource limited United Kingdom. Are my assumptions prejudiced? It seems medical practitioners hold different views about resuscitation to the general population2 and also that law would support patient autonomy over utilitarian ethics of resource preservation3 (and rightly so). But the issue of informed consent is challenging. If he were my Dad I would hope that his doctor at his initial presentation would explain the implications of prolonged intensive care for invasively ventilating a severe pneumonia and his predicted poor outcome. If consulted, I would decide quite correctly that my Father would not want to be put through this4. Intensivists vary significantly in their approaches to end-of-life decisions5 and experience is key in predicting outcome6 and in giving balanced appropriate information to relatives. In most intensive care units I suspect that it will be junior members of the team who will be liaising most closely with the patient and the patient’s surrogates on presentation when urgent decisions need to be made (as seemed to happen with the clinical scenario). If we wish to provide the information to allow our patient’s surrogates to consent with treatment plans formed to our patients’ best interests then we need better training. Trainees require guidance in predicting and discussing outcome and in assessing the benefit and burden of potential management pathways. The apprenticeship style of training in the acute specialities and intensive care is becoming more difficult in the face of accelerated training programmes, the imposition of shift systems to deliver service and reduced working hours7. All that we have currently is a tick-box competency based training booklet8 and the infrequent opportunity to sit in with our seniors when they talk with relatives. Thankfully the mentality of selling decisions made by senior clinicians, decisions they seldom found the time to explain to their juniors let alone their patients’ surrogates, is passing but I feel more needs to be done. This requires time, thought and funding – a luxury that today’s health service is reluctant to afford without clear positive statistical benefit. 1 Braun UK, Beyth RJ, Ford ME, McCullough LB. Defining limits in care of terminally ill patients. BMJ 2007;334:239-241 2 Kerridge IH, Pearson SA, Rolfe IE, Lowe M. Decision making in CPR: attitudes of hospital patients and healthcare professionals. Med J Aust 1998; 169(3): 128-31 3 Burke vs GMC (2005) EWCA Civ 1003; CI/2004/2086 4 Personal Communication Jeff Gibbon 6th Feb 2007 5 Wunsch H, Harrison DA, Harvey S, Rowan K. Variation of end-of-life decisions: a cohort study of the withdrawal of all active treatment in intensive care units in the United Kingdom. Intensive Care Med 2005; 31(6): 823-31 6 Fuchs RJ, Berenholtz SM, Dorman T. Do Intensivists in ICU improve outcome? Best Pract Res Clin Anaesthesiol 2005; 19(1): 125-35 7 Underwood SM, MacIndoe AK. Influence of changing work patterns on training in anaesthesia: an analysis of activity in a UK teaching hospital from 1996 to 2004. British Journal of Anaesthesia 2005; 95: 616-21 8 Competency-based Training in ICM: Parts 1-5. The Intercollegiate Board for Training in Intensive Care Medicine http://www.rcoa.ac.uk/ibticm/index.asp?InterPageID=6 Gareth Gibbon Specialist Registrar in Anaesthetics, Bristol Royal Infirmary, Bristol BS1 3NU gizgibbon@hotmail.com Competing interests: None declared
An integrated proactive approach is required 9 February 2007
Simon IR Noble, Senior Lecturer and Honorary Consultant Palliative Medicine Cardiff University and Royal Gwent Hospital, Newport Gwent, NP20 2UB, Ian Williamson, Alsion Brewster, Helen Caddick Send response to journal: Re: An integrated proactive approach is required	The need to integrate palliative care into medical practice is well illustrated in Professor Braun’s article and earlier involvement of palliative care alongside acute medicine may pre-empt difficult scenarios as described (1). With respect to the majority of lung cancer patients there is a case for palliative care services to be involved at diagnosis, since the majority will, at that point, be symptomatic and eighty percent will die within a year. We have developed a system of parallel clinics running concurrently between respiratory medicine, oncology and palliative care. This allows immediate access for lung cancer patients to palliative care input, without loss of contact with the key physician. The transition of care is made easier by the consistency in clinic staff and location and the appreciation that palliative care is another facet to the active multiprofessional team approach. Palliative care is still a relatively new specialty and we appreciate that services differ between countries. The palliative care service model we have developed is viewed as a proactive one, not only with respect to symptom control and advanced decision making but also in improving patient performance status to enable access to palliative chemo or radiotherapy when appropriate. To better serve the needs of our patients and the potentially complex bereavements of their loved ones, we need to integrate our service with the acute sector at an earlier stage of the patient journey and dispel misperceptions that palliative care is solely focussed on the management of the terminal phase of life. 1. Braun UK, Beyth RJ, Ford ME, McCullough LB. Defining limits in care of terminally ill patients. BMJ 2007;334:239-241 Competing interests: None declared