This is a slightly sensational headline to an otherwise balanced article. We must be careful of unvalidated scoring systems, especially specific cut-offs. But the components of this tool are based on good evidence and clinical experience - a thread explaining why👇
The factors that predict outcome from critical illness (by ‘outcome’ we mean death, rehospitalisation and persistent reduction in functioning) are frailty, pre-existing conditions and severity of organ failure. Age is just a number, but it’s also correlated with these factors
ICU is a pretty horrid experience- delirium occurs in 80% of our patients, post-ICU trauma is common, our therapies carry risks of harm (2ndry pneumonia, blood clots, bleeding, pressure ulcers*). Subjecting someone to this without realistic prospect of recovery is unethical
(* we do what we can to prevent these complications, but even the best care cannot stop them all)
It’s not about judging whether someone’s life is ‘worth living’- no one can judge that but the patient themselves. But it is about asking ‘Will this person survive ICU and get back to a level of functioning they find acceptable’?
Critical illness as a result of Covid19 is severe, even by the standards of ICU. Many patients will be in ICU on a ventilator for two weeks or more. Patients who may benefit from short periods of ICU-based support may not benefit from such a prolonged admission.
How do intensive care doctors decide who to bring to ICU? We look at these factors-
1st patient wishes, if they competently refuse ICU that is the final say.
1st patient wishes, if they competently refuse ICU that is the final say.
2nd by looking at frailty, pre-existing illnesses, severity of illness, reversibility and known disease trajectory we make a judgement about the chances of survival- and return to level of function acceptable to the patient.
This is not a precise science, the individual doctor has to integrate their knowledge of the situation with the understanding from large populations and apply it to patient in front of them. When it is not straight-forward we will often seek a 2nd (or 3rd) opinion from colleagues
So, the factors in this clinical decision tool are all sensible and all ones we consider- but the key caveat is that it remains a clinical decision, the tool must be applied by an appropriately skilled and experienced doctor with access to other doctors to help
Anyone using the score alone, or using it as the final say on matters, would be miss-using it.
My biggest concern is the advocation of prophylactic antibiotics- no one has ever shown this be be of benefit in viral pneumonitis. It risks selecting resistant organisms for secondary infections. Abx should, IMHO, be de-escalated as soon as bacterial infection is ruled out.
Important to note, this is not about rationing resources- triage during a major disaster where resources are limited and we cannot great everyone who might benefit is a different situation and one we are not currently in. This tool is about identifying those who might benefit.
