Outline your principles for conveying bad news to family members.
There are many published studies (including multiple reviews) addressing this area. Most information relates to non-critical care areas, and the majority are written from a medical perspective, and relate to conveying new to a conscious patient. Few studies address actual outcomes of the process. The welfare of the deliverer of the news should also be considered (eg. preparedness, training). The general principles espoused include: the importance of knowledge (content) of the medical details; delivery in a comfortable location offering privacy and relative quiet; setting aside sufficient time; identifying support network for the family members and having them present; delivery by or with a staff member who knows the family; sitting close to family members without physical barriers in between; non-verbal messages consistent with the verbal message; consider warning of bad news before news actually broken; awareness of what family know/have been told; present information in a way that conveys respect and empathy, use of touch may be appropriate in some circumstances; deliver at a pace appropriate to the family, allowing time for discussion; use clear & simple language to avoid confusion, though specific medical terminology may be referred to; convey some hope, even if in terms of minimising discomfort; provide for follow up meetings; document information regarding meeting in medical record. (Ptacek JT. Breaking bad news. JAMA 1996 26(6):496-502; Fallowfield L. Communicating sad, bad, and difficult news in medicine. Lancet 2004 363:312-9)
As far as resources go, one cannot go past the excellent Education Module for Critical Care Communication from the UCLA. The college answer also quotes two articles : Ptacec et al (1996) and Fallowfield et al (2004). These resources have been recompiled to form the answer offered below:
Basic premise
Location and setting
Personnel present
Essentials of the verbal communication
Non-verbal communication
Importance of content: the medical details
Follow-up
Documentation
Welfare of the deliverer
Ptacek, J. T., and Tara L. Eberhardt. "Breaking bad news: a review of the literature." Jama 276.6 (1996): 496-502.
Fallowfield, Lesley, and Valerie Jenkins. "Communicating sad, bad, and difficult news in medicine." The Lancet 363.9405 (2004): 312-319.
Outline your approach to palliative care in the dying intensive care patient.
This is a common scenario in the care of the critically ill. The usual ethical principles need to be considered:
• Autonomy (patient’s right to choose or refuse therapies),
• Beneficence (obligation to further the patient’s interests),
• Nonmaleficence (not inflict evil or harm, including refraining from interventions which are more likely to be of harm than benefit), and
• Justice (social justice, including fair allocation of societal resources).
The key premise is one of full disclosure regarding medical condition, understanding of patient’s wishes (direct or via appropriate surrogate), and a collaborative plan of management which clearly outlines priorities (eg. relief of pain and suffering versus prolongation of life at all costs) and plans regarding interventions (eg. analgesic medications, removal of ETT, not for futile procedures or therapies [eg. CPR]).
One proposed tool is the PEACE tool, which considers:
• Physical symptoms (including pain, nausea, other side effects)
• Emotive and cognitive symptoms (including anxiety)
• Autonomy (sense of control and participation in decision making)
• Closure of life affairs (spend time with family, others to visit etc.)
• Economic (assistance, arrangements, insurance etc) and existential issues (eg. religious and spiritual)
Conflict resolution is essential, and is usually prevented by adequate communication with patient and families involving complete and open discussion, but on occasions may require external input (eg. external specialist, courts etc)
A 40 year old male, with no significant past medical history, has a severe head injury following a motor vehicle accident one week previously. It is deemed that he has a non survivable injury, although he is not brain dead. The wife has raised the possibility of organ donation post cardiac death (DCD). In your conversation with his wife about donation after cardiac death, outline the important discussion points about DCD.
DCD issues
Details of the process of treatment withdrawal, including the available locations, and ability for the
family to be present until shortly after the time of death.
That organ retrieval needs to begin without delay after death in order to minimise the effect of warm ischaemia. This allows family members very little time with their loved one after death has been declared.
That anxiolytics and analgesics will be given, as necessary, until the moment of death.
That predicting the time from treatment withdrawal to death is difficult. If this interval is greater than the maximum that allows organ retrieval for transplantation, organ donation will not be possible. Tissue donation may still occur if suitable and the family consents.
The organs that may be suitable for transplantation and the effect on this of the time from treatment withdrawal to death.
That if organ donation is not possible, care for the patient will be continued in the ICU or another suitable location. That consenting to donation will usually result in a significant delay in the time that treatment may be withdrawn, due to the complex logistics associated with arranging donation and transplantation. The family must be prepared for and consent to this.
That blood is taken for serology and tissue typing before treatment is withdrawn.
That the family’s permission will be sought for the administration of drugs (e.g. IV heparin)
and procedures (e.g. bronchoscopy) to facilitate organ donation.
That pre-operative assessment or organ removal surgery may reveal medical reasons why donation may not proceed.
That the circumstances of the death may need to be reported to the coroner and a coronial post- mortem examination may occur. This is independent of the donation process.
That families may change their minds and withdraw consent at any time.
Consent:
Inconveniences for the family, for their patience with which we are grateful:
Reassurance of high standards:
Pre-conditions for donation after circulatory death:
Ongoing treatment which is unhelpful to the patient, but which maintains organ viability:
Conditions during and after treatment withdrawal
Possible ineligibility
A junior trainee in distress has asked to speak to you regarding a medical error she has committed that has resulted in a life-threatening adverse outcome for the patient.
Outline the key points of the initial discussion with the trainee.
The key points that the candidate needs to cover are:
1. Facilitating the initial critical incident debrief of the Registrar and allowing him/her to vent and tell his/her version of events
2. Ensuring there is ongoing psychological and emotional support for the Registrar
a. Give him/her the option of standing down for the rest of the shift or providing support if he/she chooses to stay
b. Arranging a mentor within the department (eg SOT)
c. Ensuring there is back-up from friends/family at home d. Offering professional counselling
3. Providing advice on the medico-legal process that will ensue a. Open disclosure with family
b. Need for comprehensive and accurate documentation in records and factual account for registrar’s own records
c. Early contact with medical defence organisation and hospital medico-legal advisors
d. Reporting to coroner if/when the patient dies
e. The event will be the subject of a Root Cause Analysis by the hospital
4. Counselling with regards to future career and training
5. Arrange follow-up meeting with mentor and departmental head for next day
International Critical Incident Stress Foundation
CICM: GUIDELINES FOR ASSISTING TRAINEES WITH DIFFICULTIES (T-13), 2010
Mitchell, Jeffrey T. "Stress. The history, status and future of critical incident stress debriefings." JEMS: a journal of emergency medical services 13.11 (1988): 46-7.
Mitchell, Jeffrey T., and George S. Everly Jr. "Critical Incident Stress Debriefing (CISD) and the Prevention of Work-Related Traumatic Stress among High Risk occupational Groups." Psychotraumatology: Key papers and core concepts in post-traumatic stress (1994): 267.
Bledsoe, Bryan E. "C RITICAL I NCIDENT S TRESS M ANAGEMENT (CISM): B ENEFIT OR R ISK FOR E MERGENCY S ERVICES?."Prehospital Emergency Care 7.2 (2003): 272-279.
Harris, Morag B., Mustafa Baloğlu, and James R. Stacks. "Mental health of trauma-exposed firefighters and critical incident stress debriefing." Journal of Loss &Trauma 7.3 (2002): 223-238.
Laurent, Alexandra, et al. "Error in intensive care: psychological repercussions and defense mechanisms among health professionals." Critical care medicine 42.11 (2014): 2370-2378.
You arrive at work one morning to learn that, overnight, the on-call junior trainee committed a medical error that has resulted in a life-threatening adverse outcome for the patient. The trainee has been waiting for your arrival to talk to you.
Outline the key points of this discussion with the trainee.
Facilitation of an emotional debrief not an operational debrief
Allow the trainee to vent and tell his/her version of events
Remain neutral and avoid criticism/censorship of the trainee’s actions
Ensure there is on-going psychological and emotional support for the trainee
Give him/her the option of time off work or ensure support if he/she chooses to stay
Arrange an appropriate mentor within the department who is not otherwise involved in this incident (may be self or other senior colleague)
Ensure there is back-up from friends/family at home
Offer professional counselling
Advice on:
Open disclosure with patient’s next-of-kin
The medico-legal process that will ensue
Need for comprehensive and accurate documentation in records and factual account for
registrar’s own records
Early contact with medical defence organisation and hospital medico-legal advisors
Need for reporting to coroner if/when the patient dies
Root Cause Analysis of the event by the hospital
Counselling with regards to future career and training
Plan follow-up meeting with mentor and SOT/departmental head for next day
This question is identical to Question 18 from the second paper of 2010.
That answer is reproduced below:
International Critical Incident Stress Foundation
CICM: GUIDELINES FOR ASSISTING TRAINEES WITH DIFFICULTIES (T-13), 2010
Mitchell, Jeffrey T. "Stress. The history, status and future of critical incident stress debriefings." JEMS: a journal of emergency medical services 13.11 (1988): 46-7.
Mitchell, Jeffrey T., and George S. Everly Jr. "Critical Incident Stress Debriefing (CISD) and the Prevention of Work-Related Traumatic Stress among High Risk occupational Groups." Psychotraumatology: Key papers and core concepts in post-traumatic stress (1994): 267.
Bledsoe, Bryan E. "C RITICAL I NCIDENT S TRESS M ANAGEMENT (CISM): B ENEFIT OR R ISK FOR E MERGENCY S ERVICES?."Prehospital Emergency Care 7.2 (2003): 272-279.
Harris, Morag B., Mustafa Baloğlu, and James R. Stacks. "Mental health of trauma-exposed firefighters and critical incident stress debriefing." Journal of Loss &Trauma 7.3 (2002): 223-238.
Laurent, Alexandra, et al. "Error in intensive care: psychological repercussions and defense mechanisms among health professionals." Critical care medicine 42.11 (2014): 2370-2378.
a) Define “Open Disclosure” in the healthcare setting. (10% marks)
b) Outline the general steps involved in Open Disclosure? (50% marks)
c) Discuss the importance of Open Disclosure. (40% marks)
a)
Open Disclosure is the process of communicating with a patient and/or their support person(s) about a patient-related incident or harm caused during the process of healthcare.
b)
Acknowledge the incident and its impact Explain the known clinical facts
Apologise for what has occurred
Reassure and agree on a plan for ongoing care
Investigate the incident to learn what has happened. Feedback to patient and staff
Document by incident reporting tool and in the patient’s medical record
c)
Actively and openly managing such incidents, including through the exchange of timely and appropriate information, is important for:
The recovery process of patients and next-of-kin
Clinicians to manage their involvement in, and recovery from, adverse events Health service organisations to learn from errors.
Practising open disclosure can assist health service organisations develop a reporting culture as it supports clinicians managing unintended patient harm.
Effective and timely communication, transparency and establishing a rapport with the patient and/or family along with an apology when incidents occur might mitigate potential legal action.
Additional Examiners’ Comments:
Candidates who did not pass this question did not demonstrate an understanding of Open Disclosure with failure to offer an apology an important omission.
a) Definition of open disclosure:
b) Steps of open disclosure:
c) Importance of open disclosure: This again comes straight from the CEC Open Disclosure Handbook, specifically from page 18 ("Why does open disclosure matter?")
The CEC Open Disclosure Handbook (thank you, readers, for continuing to update me with new versions of this thing as they come out)
Australian Commission on Safety and Quality in Health Care (ACSQHC) Australian Open Disclosure Framework, Sydney, 2013
Disclosure Working Group. Canadian disclosure guidelines: being open with patients and families. Canadian Patient Safety Institute, 2011.
A 65-year-old male with a severe hypoxic brain injury following an out of hospital cardiac arrest has been in your ICU for eight days. The only evidence of neurological activity is that he takes an occasionalbreath whilst on the ventilator. The decision has been made to withdraw treatment on the grounds of futility. You consider him to be a candidate for donation after cardiac death (DCD).
The family has indicated that they support a previously expressed desire by the patient to donate his organs should such a situation arise.
Outline the points that should be discussed with the family concerning the process of DCD.
NB: Different states have different legislation and practices.
• Treatment withdrawal in patient’s best interest
• Discuss the process of treatment withdrawal including the location where treatment
withdrawal will occur (ICU, OT or a room next to the OT etc.) as well as the family’s ability
to be present until shortly after death
• Organ retrieval will need to occur very shortly after death thus limiting the time that the
family can spend with their loved one after death has occurred
• Any medications including anxiolytics and analgesics can be administered at any time up
until death to ensure patient comfort
• Predicting the time of death is very difficult, and, if it does not occur in a time frame, it may
preclude organ donation but tissue donation is still a possibility
• The organs that can be donated will also be dependent on the time from withdrawal of
treatment to death
• If organ donation is not possible because death has not occurred within the time frame,
then the care of the patient will be continued either within the ICU or another suitable
location
• Family consent will need to be gained for bloods to be taken for tissue typing and serology
as well as for any procedures that need to be done to assess organ suitability, e.g.
bronchoscopy, femoral catheters
• Organ removal surgery may reveal medical reasons for organ donation not to proceed
• Depending on the circumstances surrounding the cardiac arrest, there may be a need to
refer the case to the Coroner who may decide on a post-mortem examination
• The family has the right to withdraw consent at any time
Consent:
Inconveniences for the family, for their patience with which we are grateful:
Reassurance of high standards:
Pre-conditions for donation after circulatory death:
Ongoing treatment which is unhelpful to the patient, but which maintains organ viability:
Conditions during and after treatment withdrawal
Possible ineligibility
a) Define “Open Disclosure” in the healthcare setting. (10% marks)
b) Outline the general steps involved in “Open Disclosure”. (50% marks)
c) Discuss the importance of “Open Disclosure”. (40% marks)
a)
Open Disclosure is the process of communicating with a patient and/or their support person(s) about a patient-related incident or harm caused during the process of healthcare.
b)
• Acknowledge the incident and its impact
• Explain the known clinical facts
• Apologise for what has occurred
• Provide support to staff patient and families including avenues of complaint/patients’ rights
• Reassure and agree on a plan for ongoing care • Investigate the incident to learn what has happened.
• Feedback to patient and staff and families
• Document by incident reporting tool and in the patient’s medical record
c)
Actively and openly managing such incidents, including through the exchange of timely and appropriate information, is important for:
• The recovery process of patients and next-of-kin
• Clinicians to manage their involvement in, and recovery from, adverse events
• Health service organisations to learn from errors.
Practising open disclosure can assist health service organisations develop a reporting culture as it supports clinicians managing unintended patient harm.
Effective and timely communication, transparency and establishing a rapport with the patient and/or family along with an apology when incidents occur might mitigate potential legal action.
This question is identical to Question 5 from the second paper of 2015, with the exception of the fact that some sub-editor removed the awkward question mark from the end of question b).
a) Definition of open disclosure:
b) Steps of open disclosure:
c) Importance of open disclosure: This again comes straight from the CEC Open Disclosure Handbook, specifically from page 18 ("Why does open disclosure matter?")
You are the appointed welfare advocate for your unit. Overnight, the on-call junior trainee committed a medical error that has resulted in a life-threatening adverse outcome for the patient. The trainee has been waiting for your arrival to talk to you.
Outline the key points of this discussion with the trainee.
Not available.
This is a question basically identical to Question 28 from the second paper of 2014 and the Question 18 from the second paper of 2010, except this time you're the "the appointed welfare advocate".
CICM: GUIDELINES FOR ASSISTING TRAINEES WITH DIFFICULTIES (T-13), 2010
Mitchell, Jeffrey T. "Stress. The history, status and future of critical incident stress debriefings." JEMS: a journal of emergency medical services 13.11 (1988): 46-7.
Mitchell, Jeffrey T., and George S. Everly Jr. "Critical Incident Stress Debriefing (CISD) and the Prevention of Work-Related Traumatic Stress among High Risk occupational Groups." Psychotraumatology: Key papers and core concepts in post-traumatic stress (1994): 267.
Bledsoe, Bryan E. "C RITICAL I NCIDENT S TRESS M ANAGEMENT (CISM): B ENEFIT OR R ISK FOR E MERGENCY S ERVICES?."Prehospital Emergency Care 7.2 (2003): 272-279.
Harris, Morag B., Mustafa Baloğlu, and James R. Stacks. "Mental health of trauma-exposed firefighters and critical incident stress debriefing." Journal of Loss &Trauma 7.3 (2002): 223-238.
Laurent, Alexandra, et al. "Error in intensive care: psychological repercussions and defense mechanisms among health professionals." Critical care medicine 42.11 (2014): 2370-2378.
Regarding the provision of palliative care to ICU patients, outline the advantages and disadvantages of using:
a) A traditional Intensive care consultant - based approach (integrative palliative care).
(50% marks)
b) Palliative care specialty involvement in the ICU by specific consultation (consultative palliative care). (50% marks)
Generally answered well by outlining the limitations of an ICM physician, especially time pressure, care of other critically ill patients and transition of care to the ward. There were multiple references to ICM physicians considering palliation as failure of ICU therapy or having "guilt" which impacts provision of palliative care. Virtually all candidates discussed specific clinical aspects, whereas other aspects such as resources, staffing, and model comparisons, were not addressed.
This answer would work better as a table. The use of the terms "integrative" and "consultative" is not unique but suggests that specific (largely North American) resources were used by the examiners to create this question.
| Advantages | Disadvantages |
| "Integrative" intensivist-led palliative care | |
|
|
| "Consultative" palliative medicine referral | |
|
|
Hill, Stephanie A., et al. "Palliative medicine in the intensive care unit: needs, delivery, quality." BMJ Supportive & Palliative Care 12.1 (2022): 38-41.
Einav, Sharon, Nathan I. Cherny, and J. Randall Curtis. "Palliative medicine in the intensive care unit." Oxford Textbook of Palliative Medicine (2021): 121.
Kościuczuk, Urszula, et al. "Aspects of palliative medicine in intensive care units: A narrative review." Palliative Medicine in Practice (2022).
Stamper, Tara Orgon, Renee Kerr, and Daniela Sporter. "The Evolution of Palliative Medicine in Intensive Care." Critical Care Nursing Quarterly 45.4 (2022): 332-338.
Tomko, Caitlin, et al. "The Practical Implementation of an Embedded Palliative Care Team in a Medical Intensive Care Unit (QI435)." Journal of Pain and Symptom Management 63.5 (2022): 904.
Bhan, Swati, et al. "Palliative Care in Intensive Care Unit." Onco-critical Care: An Evidence-based Approach. Singapore: Springer Nature Singapore, 2022. 515-524.
Ito, Kaori, et al. "Primary palliative care recommendations for critical care clinicians." Journal of Intensive Care 10.1 (2022): 20.
Effendy, Christantie, et al. "Barriers and facilitators in the provision of palliative care in adult intensive care units: a scoping review." Acute and Critical Care 37.4 (2022): 516-526.
Martins, Belmira DCPCC, Reinaldo A. Oliveira, and Antonio JM Cataneo. "Palliative care for terminally ill patients in the intensive care unit: Systematic review and metaanalysis." Palliative & Supportive Care 15.3 (2017): 376-383.
Carson, Shannon S., et al. "Effect of palliative care–led meetings for families of patients with chronic critical illness: a randomized clinical trial." Jama 316.1 (2016): 51-62.
Strand, Jacob J., and J. Andrew Billings. "Integrating palliative care in the intensive care unit." The journal of supportive oncology 10.5 (2012): 180-187.
Trankle, Steven A. "Is a good death possible in Australian critical and acute settings?: physician experiences with end-of-life care." BMC palliative care 13.1 (2014): 1-14.
You are the Intensivist working at a regional hospital. A 45-year-old patient has presented with a head injury following an assault. The GCS is 7/15 (E2 V2 M3) and a CT scan shows an acute subdural haematoma. The retrieval team will arrive in 4 hours to transport the patient to a neurosurgical centre.
a) Outline your management of the patient until the retrieval team arrives. (6 marks)
b) Outline the principles of a safe and effective clinical handover of this patient to the retrieval team. (4 marks)
Syllabus topic/section:
2.2.1 Communication and collaboration in ICU: Handover and referrals
Discussion:
Most candidates did reasonably on part a), but many were let down by part b). Some candidates did better in part b), but very few candidates performed well in both sections of this question. Candidates that scored less well in part a) simply listed targets without any detail or rationale for those chosen, or they over focused on a single aspect eg how to intubate. Good answers had structure (usually by system) and included specific management aspects and targets that related back to ICP control. Good answers also included an awareness of the regional location and the limitations this posed on ICP monitoring. Several candidates did not mention broader trauma issues like C spine management as part of their answer. Candidates that scored less well in part b) tended to limit the answer to repetition of the management outlined in part a) for the handover, but didn’t include the location, personnel or non-technical features required for a safe handover. Answers that scored higher marks in part b) included communication for safety (the accurate and careful exchange of information between clinicians) and used a formalised or non-formalised structure to aid this (for example ISBAR, MIST or AMPLE).
It is telling that the examiners had chosen to label this SAQ with the "handover and referrals" syllabus item. Consider: six marks are in brain injury, but this generic question on neuroprotective strategies cannot possibly be a good discriminator, as everyone should be able to answer it with enough content to achieve near-100% pass marks at this stage in their training.
a) Management of the patient is basically a reiteration of the BTF guidelines (mostly the prehospital sections), and consists of:
A - intubate the patient
- if impossible (i.e. nobody there knows how), introduce an airway device and await a skilled operator
B - maintain SpO2 > 90% and PaCO2
C - maintain normotension, but if there are features of raised ICP, aim for a higher MAP (80 or 90)
- Avoid cerebral venous hypertension; care not to tighten ETT tapes and ties
- loosen C-spine collar and sandbag the neck and head while awaiting a formal CT report for the neck
- Elevate head of bed 30-45o
D - sedation and analgesia to prevent ICP rises
- serial reexamination of pupils to detect herniation
- if ICP increase is suspected, give mannitol or hypertonic saline as rescue therapy
- detect and treat seizures
E - avoid causing hyponatremia or hyperglycaemia; rewarm the patient to normothermia
F - avoid albumin infusion
demand
b) Principles of a safe and effective clinical handover:
The best way to answer this would probably be to borrow from something like "Communicating for Safety". Note that the SAQ has specifically asked for the "principles", not "the specific information you think might be relevant to ask for". The principles of handover are:
Australian Medical Association. "Safe handover-safe patients: guidance on clinical handover for clinicians and managers: AMA 2006." 2016,
Bywaters, E., et al. "Safe handover: safe patients." (2004).
Bomba, David T., and Robert Prakash. "A description of handover processes in an Australian public hospital." Australian health review 29.1 (2005): 68-79.
Garling, Peter Richard. "Final report of the special commission of inquiry into acute care services in NSW public hospitals." (2009).
Gordon, Morris, et al. "Educational interventions to improve handover in health care: an updated systematic review." Academic Medicine 93.8 (2018): 1234-1244.
Sonntag, Oswald, et al. Effective communication in clinical handover: From research to practice. Vol. 15. Walter de Gruyter GmbH & Co KG, 2016.
Slade, Diana, et al. "Effective communication in clinical handover: challenges and risks." Effective communication in clinical handover: From research to practice (2016): 1-17.
Miller, C. "Ensuring continuing care: styles and efficiency of the handover process." The Australian journal of advanced nursing: a quarterly publication of the Royal Australian Nursing Federation 16.1 (1998): 23-27.
With regard to long term, conscious intensive care patients who have a tracheostomy:
a) Discuss the consequences of inadequate communication between staff and these patients (4 marks)
b) Outline techniques to improve communication in these patients (6 marks)
Syllabus topic/section: 2.2.1 Communication and collaboration in Intensive Care: Topic - Communication with patients as part of care in the ICU.
Discussion:
This is an essential topic. Good candidates could demonstrate the ability to have an in-depth discussion of consequences of long-term ICU care including relevant aspects of patient centred care, issues with decision making, dealing with negative emotions, sentinel events/adverse events and quality of life, as related to communication.
Specific strategies to improve marks could include a comprehensive outline of both nonverbal (e.g., writing, mouthing, gestures, switches and many more) and verbal methods of communication, with an emphasis on verbal techniques specific to patients with a tracheostomy (cuff inflated, ventilated; cuff deflated, not ventilated).
Morris, Linda L., et al. "Restoring speech to tracheostomy patients." Critical care nurse 35.6 (2015): 13-28.
Hess, Dean R. "Facilitating speech in the patient with a tracheostomy." Respiratory Care 50.4 (2005): 519-525.
Zaga, Charissa J., et al. "A multidisciplinary approach to verbal communication interventions for mechanically ventilated adults with a tracheostomy." Respiratory care 68.5 (2023): 680-691.
IJssennagger, C. E., et al. "Caregivers' perceptions towards communication with mechanically ventilated patients: the results of a multicenter survey." Journal of Critical Care 48 (2018): 263-268.
Fowler, Susan B. "Impaired verbal communication during short‐term oral intubation." International Journal of Nursing Terminologies and Classifications 8.3 (1997): 93-98.
Khalaila, Rabia, et al. "Communication difficulties and psychoemotional distress in patients receiving mechanical ventilation." American journal of critical care 20.6 (2011): 470-479.
a. Discuss the considerations involved in the decision to discharge patients directly home from the ICU (6 marks)
b. Outline the reasons why two different ICUs might have different rates of direct home discharge from ICU (4 marks)
Syllabus topic/section: 2.1.1 Structure and Process; 2.1.2 Decision Making; 2.2.1 Communication and collaboration in Intensive Care; 2.1.16 Populations requiring special considerations in Intensive Care
Candidates who scored better in this question exhibited a broad and high-level grasp of the more global issues and not simply the mechanics of moving the patient out of the ICU. For instance, answers that addressed issues such as identifying those groups of patients who may be suitable for discharge home tended to gain more marks.
Candidates are again reminded to take note of the Glossary terms, especially the subheadings of what a ‘discuss’ answer should include. Those candidates who incorporated this structure into their answer were rewarded for their attention to the glossary of terms instructions with higher scores.
A "discuss" answer should ideally include some pros, cons, controversies, etc. A definition or introductory statement is always helpful in such SAQs, as it tends to gently ease the examiners into a docile state of receptive grade generosity, where even vague and poorly handwritten answer statements are scored more highly because the candidate has given the appearance of understanding the problem. For example, for a), "Considerations involved in the decision to discharge patients directly home from the ICU":
A block of advantages and disadvantages should then follow, and of these, a massive number could potentially be brought up. Here's a list of just the ones the author could come up with:
| Advantages | Disadvantages |
|---|---|
| Shorter hospital stay: avoids a pointless ward admission for a patient who is already fit to leave hospital, which was one of the main findings in Stelfox et al (2018). | Premature discharge risk: bypassing the safety buffer of ward admission does not allow enough time for the team to identify patients who are unready for home discharge for reasons that are harder to observe in ICU (eg. mobility/falls risk) |
| Better patient flow: allows the ICU to free a bed and avoids using ICU capacity for patients waiting for low-acuity ward care | Institution-centred bias: a decision based on bed availability is contaminated by the nonclinical pressure, i.e. it has nothing to do with the patient's interests. |
| Fewer care transitions: avoids another handover to a ward team which may add little value for a patient needing only prescriptions, follow-up, and discharge information. | Less mature infrastructure: ICU teams may have zero idea of what a discharge is supposed to look like, and could omit vital prescriptions or appointments. |
| Avoids hospital complications: less ward time may reduce exposure to delirium-provoking environments, hospital-acquired infection, falls, VTE, sleep disruption, deconditioning, MROs, etc. | Misses hospital complications: a period of hospital stay could be needed to detect complications of critical illness (DVTs, psedoaneurysms etc) which may go unrecognised in the community. |
| Patient and family satisfaction: the patients and their families want to go home, so naturally they are satisfied by this outcome (eg. in Lam et al, 2020) | Physician disssatisfaction with the risk: in the same study, a large percentage of physicians were uncomfortable with the idea of direct home discharge. Hilariously, most were uncomfortable because they thought the families would complain. |
| Potentially faster functional recovery: home may be a better environment for sleep, mobility, nutrition, family help, and return to normal roles in a genuinely recovered low-acuity patient. | Potentially slower functional recovery: Sure, you will recover faster at home if you have housing, transport, health literacy, social supports, carers, phone access, money to see a physiotherapist. Or you have none of those things, and continue to deteriorate. |
| Resource stewardship: may reduce unnecessary hospital days, which have a nontrivial social and personal cost; to say nothing of the opportunity cost for patients who need the ICU bed. | Resource burden export: all of the ongoing care and surveillance work is transferred to the community health providers, who have a lot less resources than hospitals, but a lot more patients and certainly a lot less critical care experience to troubleshoot post-ICU problems. |
Controversies:
b)
An ICU may differ in their rate of direct-to-home discharge if it has:
Kennedy, Tessa K., and Andrew Numa. Factors associated with discharge delay and direct discharge home from paediatric intensive care. Journal of Paediatrics and Child Health 56.7 (2020): 1101-1107.
Chawla, Sujata, et al. Homeward bound: An analysis of patients discharged home from an oncologic intensive care unit. Journal of Critical Care 27.6 (2012): 681-687.
Lau, Vincent I., et al. Factors Associated With the Increasing Rates of Discharges Directly Home From Intensive Care Units-A Direct From ICU Sent Home Study. Journal of Intensive Care Medicine 33.2 (2018): 121-127.
Lam, Joyce N. H., et al. Patient, Family, and Physician Satisfaction With Planning for Direct Discharge to Home From Intensive Care Units: Direct From ICU Sent Home Study. Journal of Intensive Care Medicine 35.1 (2020): 82-90.