Multiple organ failure

Brenda E. Field, M.D.;([unkeyable]) Lynn E. Devich, R.N., M.S.N.; ([unkeyable]) and Richard W. Carlson, M.D., Ph.D., F.C.C.P.(Section)

We developed a supportive care team for hopelessly ill patients in an urban emergency/trauma hospital. The team includes a clinical nurse specialist and a faculty physician as well as a chaplain and social worker. The supportive care team provides an alternative to intensive care or conventional ward management of hopelessly ill patients and concentrates on the physical and psychosocial comfort needs of patients and their families. We describe our experience with 20 hopelessly ill patients with multiple organ failure vs a similar group treated before the development of the supportive care team. Although there was no difference in mortality (100 percent), the length of stay in the medical ICU for patients with multiple organ failure decreased by 12 days to 6 days. Additionally, there were 50 percent fewer therapeutic interventions provided by the supportive care team vs intensive care or conventional ward treatment of multiple organ failure patients. We describe the methods that the supportive care team uses in an attempt to meet the physical and psychosocial comfort needs of hopelessly ill multiple organ failure patients and their families. This multidisciplinary approach to the care of the hopelessly ill may have applications in other institutions facing the ethical, medical, and administrative challenges raised by these patients.

Advances in the diagnosis and treatment of the seriously ill and injured have enabled some patients with previously fatal conditions to be restored to health. Despite these advances, the outcome for some patients is less optimistic; their course may be characterized by severe impairment or death after sequential organ failure. These hopelessly ill patients present difficult ethical, logistical, medical, and nursing problems.

We previously reported on the development of a multidisciplinary Comprehensive Supportive Care Team (CSCT) to care for the hopelessly ill on a university hospital medical service.[1] Patients with severe neurologic dysfunction account for two thirds of patients referred to the CSCT. The next most frequent problem is multiple organ failure (MOF), which we have defined clinically as severe, irreversible dysfunction of at least two organ systems. The purpose of this study is to examine the impact of the CSCT on length of stay (LOS), and the intensity of diagnostic and therapeutic interventions for hopelessly ill patients with MOF. We also describe how we have addressed some of the unique challenges encountered in the management of these patients and the support of their families.

We believe that the care of the hopelessly ill will receive increasing attention from the health care community as the number of such patients increases. Innovative, multidisciplinary, and community-specific approaches must be created to provide humane and appropriate care while attempting to limit the psychological and financial burden imposed by these patients on all concerned.

METHODS

Rationale and Description of CSCT

Prior to the development of the CSCT, optimal care of hopelessly ill patients at Detroit Receiving Hospital was hampered by several factors, including lack of previous contact by the physician staff with the patient and the patient's family, discontinuity of treating physicians, and inexperience or inability of junior house officers to deal with the ethical issues raised by these patients. These factors contributed to prolonged hospital courses for hopelessly ill patients as well as the ongoing use of invasive and resuscitative therapy beyond any reasonable hope of benefit. Hopelessly ill patients remained in the Medical Intensive Care Unit (MICU) until death or were transferred to traditional medical ward teaching services, where they continued to receive aggressive care. The CSCT was established to address these issues. It consists of a clinical nurse specialist, staff physician, chaplain, social worker, respiratory therapist, and the patient's bedside nurse.

Since implementation of the CSCT, patients in the MICU who have failed to respond to treatment and are considered hopelessly ill are referred to the CSCT by the MICU intensivist. At the time of referral, most patients are receiving significant life support measures. The CSCT evaluates each patient. If there is agreement regarding a hopeless prognosis, the team develops a comprehensive care plan for the patient. This plan considers the patient and family preferences regarding heroic measures, issues of patient comfort, and the psychosocial requirements of the patient and family (Table 1).

If this plan is acceptable to the patient and/or family, patient responsibility is transferred to the CSCT and the patient is moved from the MICU to a private room on a general medical ward where the nurse: patient ratio is approximately 1:4. Several of the medical wards at Detroit Receiving Hospital are capable of providing the nursing and respiratory care required for these patients. The patient is seen daily by the CSCT staff physician and clinical nurse specialist, and frequent contact with the family is maintained. The care plan is frequently reevaluated and assessed for efficacy. Provision is made for returning the patient to the referring service if a more aggressive approach to treatment becomes warranted.

Data Collection

To evaluate the effect of the CSCT on LOS and intensity of interventions for hopelessly ill MOF patients, we compared a group of MOF patients treated before the CSCT (October 1984 to September 1985) to a group treated by the CSCT (January 1986 to April 1988). Only patients who had received all of their critical care management in the MICU were considered for analysis. Patients with primary diagnoses related to surgical procedures, trauma, burns, or acute cardiac events were excluded. In the MICU all of the patients described herein were treated by one of five faculty intensivists working on a rotational basis. Four of the intensivists were present during both study periods.

The Before CSCT group was identified by chart review for diagnoses of specific organ failures. The CSCT group was identified from CSCT records. Patients in both groups who had clinical diagnoses consistent with MOF were screened according to the organ failure criteria developed by Knaus et al.[2] These criteria were selected for the present study because they are precisely defined, objective measurements of severe organ dysfunction. They are not, however, the sole criteria we employ clinically in assessing the patient with MOF. The Knaus criteria are as follows:

I. Cardiovascular failure (presence of one or more of the following):

A. Heart rate [is less than or equal to] 54/min

B. Mean arterial blood pressure [is less than or equal to] 49 mm Hg

C. Occurrence of ventricular tachycardia and/or ventricular fibrillation

D. Serum pH [is less than or equal to] 7.24 with a [PaCO.sub.2] of [is less than or equal to] 6.5 kPa (49 mm Hg)

II. Respiratory failure (presence of one or more of the following):

A. Respiratory rate [is less than or equal to] 5/min or [is greater than or equal to] 49/min

B. [PaCO.sub.2] [is greater than or equal to] 6.7 kPa (50 mm Hg)

C. (A-a)[O.sub.2] [is greater than or equal to] 46.7 kPa

(D[A-a][O.sub.2]=95 [FIo.sub.2]-[PaCO.sub.2]-[PaO.sub.2]).

D(A-a)[O.sub.2]=[is greater than or equal to] 350 mm Hg;

D(A-a)[O.sub.2]=713 [FIo.sub.2]-[PaCO.sub.2]-[PaO.sub.2].

D. Dependent on mechanical ventilator on the fourth day of organ failure; eg, not applicable for the initial 72 h of organ failure.(*1)

III. Renal failure (presence of one or more of the following): [unkeyable]

A. Urine output <0.48 L/24 h or <0.16 L/8 h

B. Serum BUN [is greater than or equal to] 35.7 mmole/L of urea (100 mg/100 ml)

C. Serum creatinine [is greater than or equal to] 310 [unkeyable]mole/L (3.5 mg/100 ml)

IV. Hematologic failure (presence of one or more of the following):

A. WBC [is less than or equal to] 1 x [10.sup.9]/L (1,000 cu mm)

B. Platelets [is less than or equal to] 20 x [10.sup.9]/L (20,000 cu mm)

C. Hematocrit [is less than or equal to] 0.20 (20%)

V. Neurologic failure

Glasgow Coma Score[3] [is less than or equal to] 6 (in absence of sedation at any one point in day).

Glasgow Coma Score: Sum of best eye opening, best verbal, and best motor responses. Scoring of responses is as follows: (points)

Eye--Open: spontaneously (4), to verbal command (3), to pain (2); no response (1)

Motors--Obeys verbal command (6); response to painful stimuli: localizes pain (5), flexion-withdrawal (4), decorticate rigidity (2); no response (1); movement without any control (4)

Verbal--Oriented and converses (5), disoriented and converses (4), inappropriate words (3), incomprehensible sounds (2), no response (1). If intubated, use clinical judgment for verbal responses as follows: patient generally unresponsive (1), patient's ability to converse in question (3), patient appears able to converse (5)

We enrolled 20 randomly selected patients in each group who met the criteria for three or more organ failures on at least one day of the four-day period prior to a change in resuscitation status to "Do Not Resuscitate" (DNR), or prior to death, if no change occurred. This interval was chosen to avoid bias from enrolling patients who might have developed MOF because of treatment limitations. Using the same definitions of organ failure, we determined the number of organ failures present during each day of a patient's MICU stay. These data were used to identify the time of onset of MOF (three or more organ failures).

Acute physiology and chronic health evaluation II (APACHE) scores[4] were calculated from data collected on the day of admission to the MICU. The APACHE score is based on the extent of derangement of 12 physiologic measurements, age, and long-term health status. Higher scores reflect greater severity of disease. LOS in MICU, on a medical ward under the care of the CSCT or on a medical teaching service, was also determined.

Therapeutic interventions were quantitated using the Therapeutic Intervention Scoring System (TISS).[5] This system assigns 1 to 4 points to 80 potential interventions. Greater intensity of therapy results in a higher TISS score. TISS scores were determined daily from two days prior to a change in resuscitation status until two days after the patient had been transferred to a ward teaching service or the CSCT.

Statistics

All data are shown as the mean [+ or -] SD. To compare the two groups, the unpaired t test was used. Before/after comparison within each group was made by paired t test. Statistical significance was established at the p=0.05 level.

RESULTS

Patient Description

The descriptive features of patients in the two study groups are shown in Table 2. The mean age and gender distribution were similar for the Before CSCT and CSCT groups. A few patients in each group had no identifiable family. The incidence of alcoholism and other drug abuse was similar for both groups and reflects the population that this institution serves. The small number of patients with malignancies in each group is consistent with the emergency/trauma nature of this institution. The most common clinical diagnoses for both groups were sepsis and the adult respiratory distress syndrome (ARDS). [TABULAR DATA OMITTED]

The mean APACHE score for the patients treated by the CSCT was higher than (p<0.05) the score of the Before CSCT group, reflecting greater severity of illness. The distribution of specific organ failures was similar for the two groups. Respiratory, renal, and cardiovascular failure occurred most frequently. Additionally, several patients (four in the Before CSCT group and three in the CSCT group) had liver failure, manifested by hepatic encephalopathy. Although liver dysfunction is not included in the organ failure criteria developed by Knaus et al[2] and was not considered in this study, we suspect that it contributed to the adverse course of affected patients.

Length of Stay

Differences in LOS between the Before CSCT and CSCT groups are shown in Table 3. Six patients in the Before CSCT and three patients in the CSCT group were admitted to a general medical ward and later transferred to the MICU. All other patients were admitted directly to the MICU. There was no difference between the groups in the MICU LOS. When the onset of MOF was considered, however, the Before CSCT patients had a significantly longer LOS in the MICU after the development of MOF. The length of time that patients exhibited MOF before a change in resuscitation status occurred was also significantly longer for the Before CSCT group. Two patients in the Before CSCT group did not have any changes in their resuscitation status throughout their course.

Only four patients in the Before CSCT group were transferred to medical ward teaching services. The remaining 16 Before CSCT patients died in the MICU. Total hospital LOS was not significantly different for the two groups. Mortality was 100 percent for each group. [TABULAR DATA OMITTED]

Interventions

Table 4 depicts the TISS scores for the two groups. During treatment in the MICU, the TISS scores of both groups were similar and both groups demonstrated a significant decrease in score that was associated with a change in resuscitation status. The largest decrement in TISS score (from 31 to 10 points) occurred in the group of patients transferred from the MICU to the CSCT. In contrast, the four patients in the Before CSCT group who were transferred to medical ward teaching services continued to receive intensive intervention (TISS score range 18 to 32) when compared to the patients cared for on a medical ward by the CSCT (TISS score range 4 to 17) (p<0.01). [TABULAR DATA OMITTED]

DISCUSSION

Prior to the development of the CSCT, the majority of hopelessly ill MOF patients remained in the MICU until death, utilizing scarce critical care resources that could be allocated to patients with more favorable prognoses. We suspect that MICU personnel may find treating hopelessly ill patients demoralizing, particularly if a consistent, humane philosophy of care is not evident. Such a response could contribute to "ICU burnout." More important, the MICU environment and its focus of care are not conducive to meeting the requirements of the hopelessly ill MOF patient and his or her family for visitation, comfort, privacy, etc.

Although we observed no difference in total length of stay, the LOS in MICU after onset of MOF has been significantly reduced since the development of the CSCT. This change is the result of many factors. Although the pathophysiology of MOF remains obscure and is likely to be complex, clinicians are becoming increasingly aware of the clinical entity of MOF and its outcome. Prognosis is related to both the number of involved organ systems and the duration of organ failure.[2,6,7] Over the past few years the health care community has also gained considerable experience in ethical decision making. These issues are now treated more forthrightly.[8,9] In our institution, the availability of the CSCT has provided a treatment alternative that permits continued intensive but noninvasive patient care related to comfort measures rather than patient abandonment, once the decision is made to forgo further heroic measures.

The TISS scores indicate that the number of measurable interventions for MOF patients remains relatively high in all settings other than the CSCT. In contrast, a TISS score of 10 for MOF patients on the CSCT is within the level of support that can be provided on many general medical units.[5] We have observed that MOF patients have needs that require innovative therapeutic plans. A consistent and effective approach to the problems of the MOF patient has been implemented by nursing in-service education. We have also found that the presence of an identifiable team has facilitated discussion about the many ethical and management questions raised by such patients. The CSCT has been well received in our institution, and CSCT patients are now readily accepted by nursing units.

CONCLUSION

We believe that the health care community must address the many issues raised by the hopelessly ill, technology-dependent patient. We now recognize that a substantial group of patients exists for whom such technology represents only a burdensome intrusion into the process of dying.[10,11] Furthermore, it is likely that there will be increasing pressure to make more optimal use of health care resources. Both fiscal and ethical concerns seem to mandate closer scrutiny of our interventions, weighing the expense, pain, and burden of a treatment plan against the likely benefit. However, after a decision to forgo aggressive life-prolonging efforts is made, the health care community has the obligation to offer ordinary care that will mitigate suffering. For some patients this will require innovation in health care delivery. We have found that the CSCT addresses many of these issues in our institution and believe that the concept of a multidisciplinary CSCT may have applications in other settings.

ACKNOWLEDGMENTS: The authors thank Edward Thomas, Iris Taylor, R.N., and Sister Janet Hudspeth O.P., M.A., of Detroit Receiving Hospital-University Health Center; and Mary Thill-Baharozian, R.N., Mohammed Bazzi, M.D., Gregory Berger, M.D., Douglas Campbell, M.D., Lavoisier Cardozo, M.D., Robert Frank, M.D., Marilyn Haupt, M.D., and James Kruse, M.D.

([unkeyable]) Assistant Professor of Medicine.

([unkeyable]) Clinical Nurse Specialist, Detroit Receiving Hospital.

(Section) Professor of Medicine.

A preliminary report of this work was presented at the 17th Annual Scientific Symposium, Society of Critical Care Medicine, Orlando, Fla, May 31, 1988 (Crit Care Med 1988; 16:410).

(*1) For the purposes of meeting this criterion, the first day of organ failure is the first day that any ONE organ system is failing.

([unkeyable]) Excluding patients receiving long-term dialysis before hospital admission.

REFERENCES

1 Carlson RW, Devich L, Frank RR. Development of a comprehensive supportive care team for the hopelessly ill on a university hospital medical service. JAMA 1988; 259:378-83

2 Knaus WA, Draper EA, Wagner DP, Zimmerman JE. Prognosis in acute organ-system failure. Ann Surg 1985; 202:685-93

3 Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a practical scale. Lancet 1974; 2:81-4

4 Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med 1985; 13:818-29

5 Keene AR, Cullen DJ. Therapeutic intervention scoring system: update 1983. Crit Care Med 1983; 11:1-3

6 Bell RC, Coalson JJ, Smith JD, Johanson WG. Multiple organ system failure and infection in adult respiratory distress syndrome. Ann Intern Med 1983; 99:293-98

7 Shellman RG, Fulkerson WJ, DeLong E, Piantadosi CA. Prognosis of patients with cirrhosis and chronic liver disease admitted to the medical intensive care unit. Crit Care Med 1988; 16:671-78

8 President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Deciding to forgo life-sustaining treatment: a report on the ethical, medical and legal issues in treatment decisions. Washington, DC: US Government Printing Office, 1983

9 Bioethics Committee of the American College of Emergency Physicians. Medical, moral, legal, and ethical aspects of resuscitation for the patient who will have minimal ability to function or ultimately survive. Ann Emerg Med 1985; 14:919-26

10 Blackhall LJ. Must we always use CPR? N Engl J Med 1987; 317:1281-85

11 Tomlinson T, Brody H. Ethics and communication in do-not-resuscitate orders. N Engl J Med 1988; 318:43-6

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