Critical care: the critically-ill patient, decision making and judgement

Summary

Objectives

1. Identify signs of impending critical illness

2. Understanding and managing critical illness early on ICU

3. Appreciate limitations of intensive care.

Advice on critically ill patients must be provided at a senior level. Trainees should never take it upon themselves to manage the sickest patients in the hospital without asking their consultant for support. Events proceed much more quickly in ICU than elsewhere.

Intensive Care is an expensive and limited resource, and should only be offered to those who need it and will benefit from it. It is often said that it is not reasonable to refuse admission to ICU simply on the grounds of advanced age, and that old people have been shown to respond to intensive care just as well as younger ones with similar disorders. While this is true, death cannot be postponed indefinitely, and the humane and reasonable use of Intensive Care over the age of 80 requires particular care in patient selection. Regardless of age, when the appropriateness of ICU admission is in question, an assessing intensivist needs the following information:

1. ▪ Current diagnosis

2. ▪ Its prognosis

3. ▪ Co-morbidities

4. ▪ Functional status.

The last of these is often the decisive factor, and the personal history, such as exercise tolerance, whether patients can get out of the home and how, whether they manage to shop and do their own housework, and so on.