key: cord-0928759-jel6wkrx authors: Simpson, Nicholas; Milnes, Sharyn; Steinfort, Daniel title: Don't forget shared decision‐making in the COVID‐19 crisis date: 2020-06-14 journal: Intern Med J DOI: 10.1111/imj.14862 sha: c0d50120b91825b71e1a92a9bb0a576493832554 doc_id: 928759 cord_uid: jel6wkrx Mechanical ventilation as a resource is limited and may lead to poor outcomes in at‐risk populations. Critical care supports may not be preferred by those at risk of deterioration in the COVID‐19 setting. Patient‐centred communication and shared decision‐making should continue to remain central to clinical practice. As countries around the world prioritise the accumulation of ventilators and make plans to ration their use, it seems important not to neglect simpler measures which may have greater impact on the ability of our healthcare systems to deliver the best standard of care to the most patients. We believe two important considerations regarding shared decision-making should continue to guide institutional planning and clinical decision-making during this period. Engaging in shared decision-making may result in less frequent requests for critical care supports A high proportion of patients referred to Australian Intensive Care Units may have a life limiting illness (LLI). 1 Many people would prefer to avoid invasive treatments, particularly if near or at the end of life. 2 While clinicians tend to default to treatment modalities, patients more frequently value functional outcomes, rarely favouring longevity alone. 3 Research analysing patient outcomes after critical illness in the elderly suggest a high mortality and lower levels of function. 4 Multiple studies in populations with LLI have shown improved quality of life outcomes following goals of care and end-of-life discussions with benefits including better quality of life, less aggressive medical interventions near death and even increased survival. 5, 6 Many patients want to discuss realistic information with clinicians in order to make personalised decisions. 5 Patient-centred goals of care discussion programmes have been shown to decrease critical care level intervention as a goal of choice, particularly in groups with LLI. 6 While the aim of such programmes is not to decrease access to intensive care beds, increased critical care resource may be a side-effect of providing goal concordant care. In this context patient-centred shared decision-making may be one of the most important pandemic tools of all. It is important that patients are offered current realistic information about the risks and benefits of advanced respiratory supports for COVID-19 in order to participate in their own healthcare decisions. Emerging data suggest that advanced respiratory support is, at the least, not a universal panacea, with mechanical ventilation (MV) in some series associated with a mortality exceeding 50%. 7, 8, 11 Acute respiratory distress syndrome (ARDS) in COVID-19 is strongly associated with MV and death 12 and a failure of conservative oxygenation strategies appears to be a predictor of poor outcome 7 with disproportionate mortality in the elderly. 9 The risks of MV should be considered during the explanation and planning phase of shared decisionmaking, particularly in vulnerable groups such as those with LLI or the elderly. 10, 13, 14 These risks include the potential loss of the ability to communicate with family and friends or make further decisions at the end of life or the burdens of prolonged critical care. Information about likely outcomes is also relevant, given our knowledge of the cognitive and functional burdens of ARDS survivors. 15,16 A single organ support (MV) should be considered in the context of a whole person outcome. 17 Many, in this context, may choose alternatives to advanced respiratory support. It is important to explore what other pathways may look like, including palliative care, or a defined trial of therapies, with a clear shared understanding as to what an acceptable outcome might be. MV as a resource is limited and may lead to poor outcomes in at-risk populations. Critical care supports may not be preferred by those at risk of deterioration in the COVID-19 setting. Patient-centred communication and shared decision-making should continue to remain central to clinical practice, particularly as, for some groups, alternative treatments may offer a better chance of a good functional outcome or a less invasive death. In the current pandemic, we would suggest the ongoing participation of clinicians in values-based shared decision-making, armed with current information specific to each patient, in order to guide informed choice. This will assist the provision of goalconcordant care and avoidance of individual harms. As an important side-effect this approach may preserve critical care resources and better inform choices around allocation. Prevalence, goals of care and long-term outcomes of patients with life-limiting illness referred to a tertiary ICU Hope, truth, and preparing for death: perspectives of surrogate decision makers Patient values informing medical treatment: a pilot community and advance care planning survey Functional trajectories among older persons before and after critical illness Communication about serious illness care goals Effect of communication skills training on outcomes in critically ill patients with life-limiting illness referred for intensive care management: a before-and-after study Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a singlecentered, retrospective, observational study ICNARC report on COVID-19 in critical care Casefatality rate and characteristics of patients dying in relation to COVID-19 in Italy Acute respiratory failure in the elderly: diagnosis and prognosis COVID-19 in critically ill patients in the Seattle region -case series Retrieval medicine and pre-hospital care in remote Australia are challenging, requiring competencies in major trauma, high-risk obstetrics, critical care in adults and children, severe mental health-related agitation and envenomation. They keep a city-based retrieval and pre-hospital care doctor on their toes. Cultural fluencies to enhance care for Aboriginal and remote communities are critical during the long hours taken for the patient journey from the accident scene or clinic to definitive care.Australia, the world's largest island and smallest continent, occupies a vast 8 million km 2 . Its aeromedical retrieval and flying clinic services aim to provide highquality healthcare to isolated communities 1 disadvantaged by the tyranny of distance. This persisting disadvantage is writ large over barren arid terrain, even nowadays requiring hours of air transfer to access a major hospital. The 'mantle of safety' conferred by Australia's fabled and world's first Royal Flying Doctor's Service (RFDS) confers some assurance for people who live and work in the outback. The transfer times to definitive care for critically ill or injured patients ranges from the blink of the eye 30 min on a helicopter in the East of England, to long hours on a medically-configured plane Brisbane or Alice Springs-bound. Such long-haul retrieval is regularly requested from towns west of Roma in Queensland, and the many clinics and homesteads scattered over several million square miles served by the Central Australian Retrieval Service (Fig. 1) .As a retrieval and pre-hospital physician that has worked on rotary and fixed wing aircraft in Queensland, Alice Springs and the United Kingdom, I know that delays to definitive care due to inaccessibility or isolation of an accident scene or clinic imposes higher deterioration and death risk. This is more of an issue for major trauma, 2,3 critical illness such as sepsis, 4 as well as ischaemic stroke 5 and ST elevation myocardial infarctions 6 suited for time critical reperfusion procedures.J. Ting has worked as a retrieval and pre-hospital physician in Australia, the UK and the Northern Territory. He continues in this role as a locum consultant with the Central Australian Retrieval Service. Funding: None. Conflict of interest: None.