Negotiating Transitions: Involvement of Critical Care Outreach Teams in End-of-Life Decision Making.
BACKGROUND
Little research has examined the involvement of critical care outreach teams in end-of-life decision making.


OBJECTIVE
To establish how much time critical care outreach teams spend with patients who are subsequently subject to limitation of medical treatment and end-of-life decisions and how much influence the teams have on those decisions.


METHODS
A single-center retrospective review, with qualitative analysis, in a large cancer center. Data from all patients referred emergently for critical care outreach from October 2010 to October 2011 who later had limitation of medical treatment or end-of-life care were retrieved. Findings were analyzed by using SPSS 19 and qualitative free-text analysis.


RESULTS
Of 890 patients referred for critical care outreach from October 2010 to October 2011, 377 were referred as an emergency; 108 of those had limitation of medical treatment and were included in the review. Thirty-five patients (32.4%) died while hospitalized. As a result of outreach intervention and a decision to limit medical treatment, 56 (51.9%) of the 108 patients received a formal end-of-life care plan (including care pathways, referral to palliative care team, hospice). About a fifth (21.5%) of clinical contact time is being spent on patients who subsequently are subject to limitation of medical treatment. Qualitative document analysis showed 5 emerging themes: difficulty of discussions about not attempting cardiopulmonary resuscitation, complexities in coordinating multiple teams, delays in referral and decision making, decision reversals and opaque decision making, and technical versus ethical imperatives.


CONCLUSIONS
A considerable amount of time is being spent on these emergency referrals, and decisions to limit medical treatment are common. The appropriateness of escalation of levels of care is often not questioned until patients become critically or acutely unwell, and outreach teams subsequently intervene.
Natalie Pattison is a senior clinical nursing research fellow, Geraldine O'Gara is a nurse researcher, and Timothy Wigmore is divisional medical director and consultant in critical care and anesthesia, The Royal Marsden NHS Foundation Trust, London, England. Natalie.Pattison@rmh.nhs.uk.
Natalie
N
Pattison
Natalie Pattison is a senior clinical nursing research fellow, Geraldine O'Gara is a nurse researcher, and Timothy Wigmore is divisional medical director and consultant in critical care and anesthesia, The Royal Marsden NHS Foundation Trust, London, England.
Geraldine
G
O'Gara
Natalie Pattison is a senior clinical nursing research fellow, Geraldine O'Gara is a nurse researcher, and Timothy Wigmore is divisional medical director and consultant in critical care and anesthesia, The Royal Marsden NHS Foundation Trust, London, England.
Timothy
T
Wigmore
D003422:Critical Care / Q000379:methods* / Q000706:statistics & numerical data*; D003657:Decision Making; D006801:Humans; D053208:Kaplan-Meier Estimate; D010166:Palliative Care / Q000706:statistics & numerical data; D010348:Patient Care Team / Q000706:statistics & numerical data*; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D013727:Terminal Care / Q000379:methods* / Q000706:statistics & numerical data*