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I read with great interest the paper by Roberts et al1 and the accompanying editorial by Rudolf2. The study highlights important variations in the outcomes of patients with a common chronic disease, and once more illustrates that doctor:patient ratios may be an important contributor to this. It is also likely that some of the observed variation may arise as a result of variations in decision making by individual clinicians.
A recent study carried out in the eight hospitals in the Heart of England Critical Care network interviewed 98 clinicians who made end of life decisions for patients with chronic obstructive pulmonary disease (COPD).3 Each had made a median of 10 end of life decisions for COPD patients in the previous 12 months. There was considerable variability in the decision whether or not to admit identical patients to the critical care unit, with those choosing not to admit patients forming very pessimistic predictions of outcome compared with clinicians who would admit. It seems possible that poor outcomes for patients with COPD may not simply reflect a lack of resources, but also therapeutic nihilism that may have grown up over the years in response to the cognitive dissonance that arose when beds in critical care units could not be found for COPD patients in extremis. It seems likely that reversing variations in outcome will require both changes in resources and changes in clinicians’ expectations. In this respect, the GMC guidance on withholding and withdrawing life prolonging treatments4 may well be helpful, particularly section 20 which recommends that “where there is a reasonable degree of uncertainty about the appropriateness of providing a particular treatment, treatment which may be of some benefit to the patient should be started until a clearer assessment can be made”. In the Heart of England Critical Care network study over one third of clinicians would not admit a 75 year old COPD patient with single organ respiratory failure, yet in a recent study of over 3700 admissions of COPD patients of median age 67.8 years to UK intensive care units, those with single organ respiratory failure had a hospital survival of over 70%.5
It is important that chest physicians continue to be strident advocates for COPD patients admitted as emergencies, and take every opportunity to point out to their colleagues in general medicine and intensive care how well patients with COPD can do with both invasive and non-invasive ventilation.
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Authors’ reply
We thank Dr Wildman for his letter suggesting a further possible reason for the variation in outcome that we reported for the acute care of COPD patients in different hospital centres. In a further unpublished multiple regression analysis of the RCP/BTS 2001 audit we found that 26% of the variation in the outcome of death at 90 days following admission could be accounted for by factors measured in the study that included patient characteristics such as performance status and resource and organisational issues, as described in our paper.1 Dr Wildman suggests that individual clinicians might vary in determining admission to the ITU for COPD patients in respiratory failure, and suggests that respiratory physicians need to be advocates for their patients in this arena.
Attitudes and beliefs in what might be achieved are important but are difficult to measure in clinical practice. They might account for some of the variation in outcome but, if so, the therapeutic nihilism would have to vary systematically between whole hospitals to have been a factor in our study. Admission to the ITU depends on more than the individual attitude of the referring doctor. A lack of availability of beds may raise thresholds, and an institutional nihilism within the ITU may lead to rejection of suitable patients.
Perrin et al2 reported a study in which questionnaires regarding initiation of mechanical ventilation in end stage COPD patients were completed by 350 doctors subdivided by speciality (intensivists, respiratory specialists and other physicians). As in the paper by Wildman et al,3 there was considerable individual variation in decision making but no overall difference between the three types of specialist studied. However, no analysis by hospital or trust was made to identify local patterns. We believe all respiratory physicians will share Dr Wildman’s call that referring physicians should be advocates for their patients, and this has to be matched by a willingness of the ITU staff to accept such patients and the availability of beds within an ITU/HDU facility to accommodate them. Perrin’s paper provides hope of a generic match although individual disagreements may still occur. It is, however, not only admission to the ITU that matters, as in many hospitals non-invasive ventilatory support is provided on general wards by respiratory units without input from intensivists.
In the BTS/RCP 2003 national audit of the acute care of COPD patients, 95% of all acute admitting sites have now registered to participate and data collection is nearing completion. Within the clinical data gathering there is a question that attempts to document clinical decision making when a patient eligible for ventilation on blood gas criteria does not receive ventilatory support. In addition, data regarding available resources such as ITU beds, bed occupancy, and numbers of ITU candidates transferred off site will be recorded. We may be in a position to shed further light on the issues of individual versus institutional nihilism or rationing in due course.