The Union health ministry has released guidelines intended to curb arbitrary decisions on admissions into and discharge from intensive care units (ICUs) amid concerns about inappropriate care imposing strain on families’ finances and scarce medical resources.
The guidelines, released by the Directorate General of Health Services (DGHS), specify sets of standard criteria for admissions and discharge as well as circumstances under which patients should not be moved into ICUs such as “terminally-ill patients with a medical judgement of futility”.
A 24-member panel of critical care medicine specialists from government and private hospitals drew up an “expert consensus statement” that the DGHS — a wing of the health ministry — has recommended as guidelines for hospitals across India.
“We’re hoping widespread adoption of standardised criteria for admissions and discharge will ensure that only those who will genuinely benefit from ICU are under ICU care,” said Srinivas Samavedam, a critical care medicine expert in Hyderabad and a panel member.
The criteria for ICU admissions include altered levels of consciousness, respiratory distress, clinical features of shock, acute illness requiring organ support, and patients who have undergone major surgery and need monitoring, among other conditions.
The discharge criteria include the return of physiological parameters to near normal or patient’s baseline levels, reasonable stability of acute illness, and when a patient or family agrees to ICU discharge for a treatment-limiting decision and palliative care.
The guidelines specify that critically ill patients in the following categories should “not be admitted” into ICUs:
- Any disease with a treatment-limitation plan
- Anyone with a living will or advanced directive against ICU care
- Terminally ill patients with a medical judgement of futility
- Patients or their next of kin provide informed refusal to be admitted into the ICU
- Low-priority criteria in case of a pandemic or disaster situation where there is a limitation of resources such as beds, workforce or equipment
Surveys across European ICUs have estimated that around 20 per cent of patients in ICUs may not benefit from aggressive ICU care. “We don’t have similar surveys here in India, but the issue of no benefit from ICU care in advanced illness must be addressed,” said R.K. Mani, a critical care medicine specialist in New Delhi and panel member.
“We want these guidelines to promote dialogues between the medical community and patients or their families — a dialogue that allows patients or their families to take well-informed decisions about ICU care,” Mani said.
Mani and other critical care specialists have long argued, for instance, that a decision to move patients in their 80s with terminal cancer who experience respiratory distress into an ICU for ventilator care would be questionable.
“Many of us believe it would be inappropriate in such cases to bulldoze a patient or the family and move the patient into ICU,” Mani told this newspaper. “It would only stretch the suffering of the patient and it could destroy a family financially.
