Critical care outreach services and early warning scoring systems: a review of the literature.

AIM: The aim of this paper is to explore the literature relating to critical care outreach services and the use of early warning scoring systems to detect developing critical illness. BACKGROUND: Several studies have identified how suboptimal care may contribute to physiological deterioration of patients with major consequences on morbidity, mortality and requirement for intensive care. In a review of adult critical care services, the Department of Health (DOH) (England) recommended in 2000 that outreach services be established to avert admissions to Intensive Care, to enable discharges and to share critical care skills. METHODS: A literature search was carried out of the BIOMED and NESLI databases using the key words "outreach", "early warning signs/systems" and "suboptimal care". The literature review was limited to the past 10 years, and primary research articles of particular relevance were included in the review. The literature is examined within the context of recent findings relating to the provision of suboptimal care within general wards prior to cardiac arrest and/or admission to Intensive Care Units (ICU), and subsequent government initiatives. Discussion. The discussion explores the potential contribution of critical care outreach services and early warning scoring systems to the care of patients in acute general wards, including the role that education can have in developing the knowledge base and assessment skills of ward nurses. CONCLUSION: The paper concludes that further study is required to evaluate the effectiveness of critical care outreach services and early warning scoring systems, and that ward staff need to be educated to identify those patients at risk of developing critical illness. Finally, it is suggested that nurses' decision-making in relation to calling the outreach team requires further investigation.

Incorporating palliative care into critical care education: principles, challenges, and opportunities.

OBJECTIVE: To identify the goals and methods for medical education about end-of-life care in the intensive care unit (ICU). DATA SOURCES AND STUDY SELECTION: A status report on palliative care, a summary report of recent research on palliative care education, articles in the medical literature on end-of-life care and critical care, and expert opinion were considered. DATA EXTRACTION: A working group, including specialists in critical care, palliative care, medical ethics, consumer advocacy, and communications, was convened at the "Medical Education for Care Near the End of Life National Consensus Conference." A modified nominal group process was used to develop a consensus. DATA SYNTHESIS: In the ICU, life and death decisions are often made in a crisis mode or in the face of uncertainty, and may necessitate the withholding and withdrawal of life-supporting technologies. Because critical illness often diminishes the capacity of patients to make decisions, clinicians must often make decisions in conjunction with surrogates, rather than with patients. Discontinuity of care can threaten trusting relationships, and cultural diversity can have a particularly powerful impact on choices for care. In the face of these realities, it is possible and appropriate to give compassionate palliative care to dying patients and their families in the ICU. CONCLUSIONS: Teaching care of the dying in the ICU should emphasize the following: a) the goals of care should guide the use of technology; b) understanding of prognostication and treatment withholding and withdrawal is essential; c) effective communication and trusting relationships are crucial to good care; d) cultural differences should be acknowledged and respected; and e) the delivery of excellent palliative care is appropriate and necessary when patients die in the ICU.

A community-based clinical selective in end-of-life care.

There is a widespread recognition among medical educators and accreditation organizations that medical students and young physicians lack the competency necessary to care for persons near the end of life. This article describes the institutional and attitudinal barriers to innovation in curriculum design. It then presents and evaluates a 1-month selective for fourth year students that focuses on providing end-of-life care to immigrant populations in community-based home hospice. The selective joined biomedical training in pain management and palliative care, a clinical rotation in home hospice care with an analysis of the way that social and ethnic factors inform and influence end-of-life care.

Tube feeding and the permanently unconscious: the Supreme Court's decision in Cruzan.

In the recent case of Cruzan v. Director, Missouri Department of Health, a majority of the United States Supreme Court voted to affirm a Missouri decision rejecting the request of guardians for removal of tubes used to provide nutrition and hydration to a woman in a persistent vegetative state. This article analyzes the Court's decision, focusing specifically on the concurring and dissenting opinions in the case, and discusses the implications of this decision for the states.

Prehospital DNR orders.

KIE: This case study and commentaries concern a terminally ill patient dying at home who is resuscitated and transported to a hospital emergency department despite having signed a living will refusing resuscitative efforts. Only after her identity is confirmed, and her medical records located at another hospital and interpreted, is treatment halted and the woman allowed to die. Iserson, a physician in emergency medicine, outlines the responsibilities of paramedics and emergency room personnel when confronted with an unfamiliar patient in an acute condition. He believes that the prehospital DNR order is an idea whose time has come, despite problems with its implementation in emergency settings. Rouse, director of legal services for the Society for the Right to Die, sees this case as an inevitable death made worse by confusion and uncertainty, and calls for education preparing family and care givers for death at home.^ieng

Legal and ethical guidelines for physicians in geriatric terminal care.

In the American legal system, the right to refuse treatment--the right, in other words, to be "let alone"--is an important aspect of autonomy and individuality. In health care decision making, people rarely choose to have no treatment at all, but usually choose from among various forms of medical treatment. Even when aggressive technological options are rejected, patients will often elect to have intensive nursing and pain control. Sometimes they choose to forego treatment and risk hastening death. Particularly among the elderly, a series of small decisions may have to be made as health status worsens over time. No matter what the decision, in observing patients' wishes, physicians will find support in current ethical and legal concepts.