According to this wikipedia article on Intensive-Care Medicine…
If this is true, where do the patients whose condition is irreversible and does not have much chance of surviving go to?
I was always under the impression that the most critically ill (close to dying) patients were sent to the ICU.
I don’t think that is true at least in the immediate term. If you are that critically ill and end up in the emergency room, the ICU is the place they send you because that is the last course of action available. I ended up in the ICU for two weeks about 8 months ago from a sudden and acute problem. I was the youngest one there and conscious the whole time so I got to see what was going on. Most people made it out but several did not. However, it is incredibly expensive to be in ICU. I have my own medical insurance statements but I won’t share the exact dollar amounts. It varies widely by patient anyway depending on things like surgeries and other care needed. In any case, tens of thousands of dollars a week would be a reasonable estimate.
However, it is probably accurate to say that they don’t put most patients in the ICU for the long-term for conditions that are almost certainly terminal. It isn’t cost effective or comfortable for the patient and family. That is what hospice or in-home nursing care is for. Most people with conditions like advanced AIDS or cancer want to die in a more comfortable setting than an intensive clinical hospital unit so that is where the other options are made available often coordinated by professionals like hospital social workers and nurses. That may be what you are referring to.
I can tell you that wasn’t true when my mum was dying. She came into the ER with a massive heart attack and they gave me the odds at ZERO of her surviving. Yet she spent the next 13 hours in the CICU unit.
I also worked in the ER reception of two different hospitals and I would over hear the doctors saying so and so has no chance of surviving and they were sent to the ER till the expired.
Now it could be different. My mum died in 1980 and the hospitasl I worked at was in 1982 and 1994, so it could be different now.
I can tell you one thing, when they let anyone see you in ICU or CICU it’s a bad sign. Both hospitals had a strict policy of family only in ICU/CIUC but if the person had no chance or little chance, they’d throw the door open to almost anyone so they could say their last goodbyes
Recall that Intensive Care addresses specific immediately life threatening conditions, (and also that the article notes that a lot of people still die in ICU).
The “surviving” part refers to the immediate condition. If a patient has metastatized pancreatic cancer and is brought in with a heart attack, they will be sent to ICU (or its cardiac equivalent), so that they still have the chance to survive a few months with their cancer.* If they are brought in in the last stages of the pancreatic cancer, they will probably be given a bed in a normal ward and administered palliative medicine to reduce pain. (The heart/lung machines in ICU would do them no good, anyway.)
If a patient has been determined to be clearly terminal, and intensive care futile, the decision of where they go is usually determined in consultation with the family here in the US. A number of factors weigh into the decision.
If the family wants “everything done” no matter what, typically the patient is left in the ICU indefinitely. It’s unusual for a hospital to unilaterally withhold intensive care, no matter how futile, against a family’s wishes. On rare occasion this does happen, and when it does, it becomes a whole brouhaha with family, hospital administrators, doctors, pastors and occasionally attorneys all jumbled up in the mix. But it’s so unusual as to often make the news when it does happen.
If, after a meeting with family, the patient’s condition is not considered to be likely to be improved by continued intensive care, the first decision point is how proximately they will die. If they are likely to die within hours, then they are sometimes just left in the ICU. If the bed is badly needed, on rare occasions such terminal patients might be transferred to a floor bed, having essentially been made DNR.
If the patient is not going to be helped by the ICU, but is not going to die anytime soon, then the first decision point is (usually) whether or not to keep them on a ventilator. Most patients in this category are ventilator-dependent, and you are probably familiar with all the further brouhaha around “pulling the plug.” (Can the patient decide; is there a living will; what does the family want…on and on). If a decision is made to remove ventilator support and the patient does not die, or if the decision is to keep the patient on the ventilator but not in the ICU, then the patient usually goes to the step-down unit or the floor, and from there if they just sort of piddle along, to long-term care. Long-term care varies according to location and patient prospects. As an example, a patient might be in a very specialized long-term care facility on a ventilator in a coma for years.
This is a very cursory overview, but I hope it helps. It’s not so much a matter of the chances of surviving. It’s how fast they are going to die despite everything being done. In the US, generally no stone is left unturned no matter how dismal the prospects and often no matter how old the patient; this is one of the reasons our end of life care is so astronomically expensive. It’s more a matter of how soon the patient dies–or is expected to die.
Thanks for the answers you guys.
Markxxx, that’s interesting and scary to read. When I had a relative in the ICU last year, they let everyone and their grandma see her. Only two at a time though. Her ICU doctor kept telling us to tell her that we loved her eventhough she was in a coma. She did survive, however I guess she was that close to death at one point. :eek: 
Just anecdotal, I was in the neuro ICU in Hartford, CT many years ago for 6 days. I got a little round of applause and some teary eyes when I walked out. One nurse explained that I was the first one to leave the unit alive for the last two weeks. Lots of head trauma auto crashes and massive strokes in the other beds.
Did you actually WALK out of the ICU or are you using that figuratively? That’s quite unusual in and of itself in my, admittedly, limited experience.
Just so no one’s scared if they’re allowed to visit a family member in ICU, you should realize that different hospitals have policies that vary all over the place in flexibility. I, my boy friend, and my mother spent a lot of time visiting my dad in ICU after he had a stroke. My dad was completely lucid, and, apparently having people around had a good effect on him. The general policy was that family members only could visit any time day or night–subject, I think, to the nurses’ discretion. One nurse told me that they were generally flexible in their interpretation of “family members” too.
The ICU is generally available to people with little chance of recovery. However, there is some variability between hospitals, countries, intensivists, etc.
As an emerg doc, we like to get sick patients to the ICU after doing what we can to resuscitate them and start lines and treatments. Complicated patients require lots of nursing care and monitoring and tie up much emergency room staff and resources. But ICU beds are not always available. Furthermore, good intensivists are skilled at managing the expectations of families as well as discussing futile cases. Dying cancer patients, for example, are often better served by being admitted to a palliative ward with more privacy for families and different specialists.
Ultimately, good intensivists don’t try to fill up the ICU with people they cannot help. Sometimes these patients end upo in the ICU anyway because of the wishes of the patient or decision makers. Sometimes the intensivist or hospital might be motivated by profit. Often, it is not clear whether a serious case is futile and thus a trial of ICU is reasonable.
As Chief Pedant says, there are many other types of long term care apart from the ICU – medical wards, home care, hospices, etc. In shorter term cases, sometimes they stay in the ER or are admitted to a medical or surgical ward, or a stepdown ICU unit where the care is between the usual wards and a full ICU.
I actually walked out - across the hall to the not-quite-so-intensive care section. Walked out of the hospital after another four days.
I had a series of intense headaches along with massive spikes in blood pressure. I had every test known (late 1960s). Spinal taps showed some blood/other but never definitive (amounts so small as to have been introduced by the tap). Dye injection into brain arteries showed an unusual (but not completely rare) branching. Instead of a tree branching (big arteries into smaller into capilliaries); I was more of bush arangement (arteries directly spliting into small branches).
They never found an explanation. The headaches and pressure spikes stopped after the first 6 days. I was wiped out (fatigued/tired) but was back to normal activity in another couple of months.
Very different here to the USA. DNR and ICU admission is a medical decision- there will usually be a discussion with the family, but with the clear understanding that decisions are made on a medical basis by the medical team on the basis of the patient’s best interest.
ICU is almost certainly out of the question for anyone with a chronic, terminal condition, and usually to anyone over 80.
Dementia patients don’t go to ICU.
Stroke patients (unless they require ventilation or have been thrombolysed) won’t go to ICU.
I worked in a hospital that had over 100 medical beds, about 75 surgical beds and a reasonable sized OB/Gyn department.
It has a 6 bed ICU, a 6 bed CICU, a 12 bed coronary care step down unit, and a 6 bed respiratory step down unit. Patients spend a long time in the high dependncy beds so they are always in demand.
Trauma, neuro, ortho, renal and oncology went to the regional tertiary centre- so basically we got asthma, COPD, diabetes, heart disease, infectious diseases and strokes- and the cancer patients when the oncologists have decided that further active treatment is futile.
Our typical ICU patient was a deliberate overdoser, a diabetic in a coma, a person with liver failure waiting in vain for a transplant or a young person with a severe pneumonia. Mostly young, with acute, potentially reversible issues.
You had a heart attack, you got lysed or cathed and sent to CICU, you have COPD you had CPAP on the respiratory ward. Our ICU was reserved for the “worst of the worst”. If you were in our ICU you were almost certainly needing at least two out of three of intubated and ventilated, dialysis and cardiac monitoring- with a reasonable chance of recovery (i.e. no-one on the medical staff willing to DNR you…yet).