Surprisingly, in my past month in the intensive care unit (ICU), I spent more than half the time talking to family members about goals of care. In a previous post, my attending had a great quote about survival in the ICU. If one-third of your patients survive the ICU stay, you’re doing hall of fame work. So if only one-third of patients are surviving on a good day, then why am I spending most of my time speaking to families about goals of care? Shouldn’t I be spending more time treating the patients?
Thing is, most of the patients that come to the unit are already one foot out the door. The patients are usually connected to a breathing machine (respiratory system failure) and require medications to maintain blood pressure (cardiovascular system failure). That’s two organ systems. This well-known study showed that two organ system failure for more than one day had a 60% in hospital mortality rate. Three or more organ system failure has a greater than 90% mortality rate.
Not to sound harsh, but a majority of the care we do in the ICU is futile. There’s a 90% chance that the patient will die regardless of any intervention we do, and even if they do survive, the quality of life is very poor. The ones that survive are, for the most part, married to the hospital. Most have to enter a several week-long rehabilitation program, go to a dialysis center for 3-4 hours for 3 times a week, have intravenous antibiotics 1-2 hours a couple of times a day for several weeks at home, etc. If there was any brain injury, any return of baseline neurological status is nonexistent.
Don’t get me wrong, there are some miracle survivors. But that’s exactly what they are, miracles.
So back to the question – why do I spend most of my time talking to families of goals of care? Well, I can tell you that the answer is not because I gave up on my patients. The answer is actually far from it. I think my attending has us spend most of our time talking to them for this very reason – the 80/20 rule.In 1906, an economist in Italy named Vilfredo Pareto noticed that 20% of the people owned 80% of the land in Italy. He then noticed something similar in his garden – 20% of the peapods produced 80% of the peas. This later came to be called Pareto’s principle, or the 80/20 rule, in which 20% of our efforts leads to 80% of our results.
The rule didn’t just apply to Italian land and peapods. In computers, Microsoft focused on the top 20% of software bugs to fix 80% of system errors. In business, 80% of a company’s profits come from 20% of its products. In hospitals, 80% of the most difficult clinical problems come from 20% of the patients. It’s a natural phenomenon.
So how does the 80/20 rule apply to the ICU?
If my patient has a 90% chance of dying regardless of what I do, what can I do to be more effective? I can talk to the family, educate them on the illness, share with them their grief, guide them through this scary period, and prepare them for what happens next. The family can tell me stories of how they were before the hospital: how kind they were, what jokes they used to say, where they were a year ago. We laugh and we cry. We sit in silence in the room. We listen to beeps from the monitor. We feel the ventilator blow gusts of air in and out of the patient.
If it’s the patient’s time, we can make the patient comfortable and let nature take its course. Or we can try to take a shot and be as aggressive as possible to win a miracle. Either way, it’s a win. It’s a win for myself, a win for the family, and most importantly, a win for the patient.
How to make the 80/20 rule work for you:
- Make a list of everything you do on a daily basis. By everything, I mean everything! (time on Facebook, cleaning the dishes, working on projects, etc.)
- Evaluate the list, and choose the top three things that will produce the most results.
- Focus on those top three things and make them your priority.
How did it work? Share your success below!