H. A. Lyfoung1, C. T. Minshall1, M. Cripps2, S. Kartiko1 1Baystate Medical Center,Springfield, MA, USA 2University Of Texas Southwestern Medical Center,Dallas, TX, USA
Introduction:
Critical care has made tremendous advances in recent years that have improved outcomes in many disease processes. However, the ability to sustain a patient’s life often requires invasive procedures, which frequently detract from patient comfort. Understanding our patient’s expectations and goals may allow us to make better decisions regarding their care. We retrospectively reviewed changes in the code status, determination of health care proxy and disposition for patients in our surgical intensive care unit (SICU) to characterize our patient population in an attempt to identify how we can better align patient goals with medical care.
Methods:
A retrospective chart study was performed on all patients admitted to the SICU in a tertiary level medical center from February to June 2018. We obtained information on advanced directives, Physician Order for Life-Sustaining Treatment (POLST), Health Care Proxy (HCP), gender, age, emergent/elective nature of surgery, documentations from providers, care managers, social workers, and family meetings. All patients that did not have an advanced directive at admission were assumed to be full code, until further clarification was available.
Results:
104 patients were admitted to the SICU during the study period: 40% trauma, 30% general surgery, and 30% were from other surgical subspecialties. 29% of patients had advance directives, 13% had POLST and 41% had a documented HCP. Twelve patients (12%) were determined to be DNR/DNI. This was temporarily suspended for surgical intervention in 11 (92%) prior to admission to the ICU. All but one patient had their DNR/DNI reinstated. Most patients (80%) admitted to the SICU had undergone a surgical intervention: 46% were emergent, 15.4% were urgent, and 19% were elective. 40% of patients without an advanced directive had an “on site” goal of care discussion, which resulted in a change from full code to DNR/DNI in 48% of the patients. 40% of patients, who did not have a HCP at SICU admission, had one at the time of SICU discharge. In the SICU, 20% of patients died including the 6% who expired after transitioning to comfort measures; while 4% were discharged to rehab or home. Most (76%) patients were transferred to a lower level of care in the hospital.
Conclusion:
This study characterizes our SICU patients and begins to highlight the difficult task of aligning patient goals and providing appropriate critical care. Most patients who are admitted to the SICU do not have an advance directive or a health care proxy. However, even when they do have an advance directive, the acuity of their surgical disease cause the patient or their HCP to hold the DNR/DNI status. While a lot of goal of care conversation is conducted in the SICU, there remain a large number of patients who was discharged from the SICU and still do not have a HCP or POLST form completed. A greater focus on what patients want versus what they need is needed to provide better care.