Registrar triage, communication and moral distress during end-of-life care rapid response team calls in a teaching hospital

Abstract

Background: Approximately one-third of rapid response teams (RRT) involve end-of-life care (EOLC) issues. Intensive care unit (ICU) registrar experience in such calls is underinvestigated.

Aims: To evaluate the proportion of RRT calls triaged as relating to EOLC issues, issues around communication regarding prognostication, registrar self-reported moral distress and associations between RRT EOLC classification and patient outcomes.

Methods: Prospective observational study of RRT calls in a tertiary referrals hospital between December 2016 and January 2017 using a standardised case report form and data from an electronic RRT database.

Results: There were 401 RRT calls in the study period, and data were available for 270 (67%) calls, of which 72%, 10% and 18% were triaged as 'obviously not EOLC call', 'obvious EOLC call' and 'uncertain EOLC call' respectively. Most discussions regarding prognostication occurred between registrars, and more than half (55%) were with a covering doctor. Consensus on prognostication was achieved in 93% cases. Registrars reported distress in 19% of calls that obviously related to EOLC and 22% of calls that were uncertain, compared with <1% of calls that were obviously not relating to EOLC. Inhospital mortality was 6%, 67% and 39% for obviously not EOLC, obvious EOLC and uncertain EOLC calls respectively.

Conclusions: EOLC issues occur commonly in RRT calls and are often associated with moral distress to ICU registrars. Although consensus on prognostication is usually achieved, conversations often involve covering doctors. These issues impact on the ICU registrar experience of RRT calls and require further exploration.

Keywords: end-of-life care; intensive care; medical emergency team; rapid response team; registrar distress.