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Governance 

Governance
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date: 25 October 2020

The decision to admit patients to intensive care or discharge them, is a daily task for intensivists, a life-changing event for patients and families, and a major strategic issue for health care systems worldwide. Decisions must often be made rapidly, in conditions of uncertainty, involving substituted judgements about relative risks and benefits, framed by sociocultural factors that are not well characterized. The outcomes are strongly influenced by available resources, staffing, and skills throughout the patient pathway. The decision to admit should be based on the severity of illness, chronic health and physiological reserve, and therapeutic susceptibility, informed by the patient’s wishes. Discharge decisions are equally complex and involve balancing the needs of individual patients against those of society. Scoring systems and guidelines can aid decision making. The process involves collaboration between intensivist, referring team, patient, and family. The provision of futile care is usually driven by family expectations and lack of agreement among the treating team. Discussions involve value judgements. Effective admission and discharge processes will minimize avoidable morbidity, mortality, and readmissions, and maximize family and patient satisfaction, and cost-efficacy. However, reaching the most effective level of practice involves balances and compromises. Experienced clinical judgement remains a key element in defining suitability of individual patients for ICU admission and discharge.

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