Table 2 “Patient” factors and illustrative quotes

Severity of Illness

“People are so much sicker because we keep them alive through so much (interventions), and then they have so many more comorbidities. You kind of wonder when are we not really doing a good thing anymore?” Nurse

“Typically patients get readmitted because they decompensate. Sometimes it’s from the same underlying process that led them to ICU in the first place, especially if they have terrible underlying disease like we have in our (transplant) ICU. There’s a lot of things we can’t fix, so they’ll bounce back and forth relatively often.” Nurse

“The (transplant) patients are just a sick population. They have the (highest) potential of getting an infection at any time. Those are the most common readmissions (that) we see over and over.” Nurse

Undefined goals of care

“There’s a range of complexity on the medical service, and you’re always going to have those patients that are clearly near the end of their life, and any acute issue on somebody with that level of comorbidity could be considered ICU level kind of stuff. I don’t think the right answer is that all those people should be in the ICU (and) I’m not sure it’s to their benefit. (Care providers) need to do better with palliation and everything else.” Consultant Physician

“For (patient’s) code status, we do a good job, but not always with other aspects of goals of care. This is because sometimes there’s a conflict between the acute issues and the big picture of things. I think we need to be better in communication with the primary team and have more care conferences to discuss goals of care so everyone’s on the same page.” Nurse

“We have had multiple patients who have terrible underlying disease that there isn’t any cure for, and we’re trying to manage their symptoms, but unless you can cure the underlying problem, you can’t make them better, and so palliative care is something we always try to address in those types of situations if it’s (deemed) futile. (But) if the patient or the family is not ready to (have the discussion), that will frequently lead to multiple readmissions, which we’ve seen on this unit many times.” Nurse