Triage of intensive care patients: identifying agreement and controversy

Abstract

Rationale Intensive care unit (ICU) resources are limited in many hospitals. Patients with little likelihood of surviving are often admitted to ICUs. Others who might benefit from ICU are not admitted. Objective To provide an updated consensus statement on the principles and recommendations for the triage of patients for ICU beds. Design The previous Society of Critical Care Medicine (SCCM) consensus statement was used to develop drafts of general and specific principles and recommendations. Investigators and consultants were sent the statements and responded with their agreement or disagreement. Setting The Eldicus project (triage decision making for the elderly in European intensive care units). Participants Eldicus investigators, consultants, and experts consisting of intensivists, users of ICU services, ethicists, administrators, and public policy officials. Interventions Consensus development was used to grade the statements and recommendations. Measurements and main results Consensus was defined as 80 % agreement or more. Consensus was obtained for 54 (87 %) of 62 statements including all (19) general principles, 31 (86 %) of the specific principles, and 10 (71 %) of the recommendations. Inconsistencies in responses were noted for ICU admission and discharge. Despite agreement for guidelines applying to individual patients and an objective triage score, there was no agreement for a survival cutoff for triage, not even for a chance of survival of 0.1 %. Conclusions Consensus was reached for most general and specific ICU triage principles and recommendations. Further debate and discussion should help resolve the remaining discrepancies.

“Are you sure it’s about ‘age’?”

“…Several studies have confirmed the very poor long-term prognosis of elderly patients admitted to the ICU [2][3][4][5][6][7][8][9] (Table 1). Importantly, factors such as an atypical presentation with delayed diagnosis and treatment, suboptimal management (because guidelines are not tailored for an elderly population), lower physiologic reserve, immuno-senescence coupled with an inadequate immune response, more frequent and earlier treatment limitations, and finally inadequate discharge policies (location, timing) may account for or at least contribute to excess mortality.…”

The Durban World Congress Ethics Round Table Conference Report: II. Withholding or withdrawing of treatment in elderly patients admitted to the intensive care unit

“…Similarly, when a panel of international experts in intensive care medicine issued a list of criteria that could assist the decision making processes regarding admission or refusal of admission of patients to ICU there was a strong consensus that age should not be considered as a sole decision making criterion [1]. Nevertheless, economic pressures, the need for rationing of ICU beds [2] and changing demographics -in particular the aging of most populationsmight jeopardize this idealized view of ICU access and treatment for elderly patients [3].…”

Year in review in Intensive Care Medicine 2013: II. Sedation, invasive and noninvasive ventilation, airways, ARDS, ECMO, family satisfaction, end-of-life care, organ donation, informed consent, safety, hematological issues in critically ill patients

“…Last, Sprung and the Eldicus investigators, consultants, and experts provided an updated consensus statement on the triage of patients for ICU beds. They reached a consensus for most general and specific ICU triage principles and recommendations [69].…”