The Two Pillars of Intensive Care Medicine (I): Medical Indication

The decision to admit a patient to the intensive care unit (ICU) is a pivotal moment during critical illness. Medical expertise in combination with the will of the patient forms the cornerstone reasons of the medical indication. This is done by balancing all potential feasible advantages versus risks as well as an assessment of reversibility of a life-threatening condition by the intensivist in concordance with the referring physician(s) and nurses involved. Advance care planning in the situation where ICU admission is not (yet) imminent is advisable whenever feasible, since it eliminates time pressure. Not admitting a patient to the ICU doesn’t mean not treating the patient. Ideally all information is present before the decision on admission is made. Currently, the decision to admit or not may cause stress to the decision-makers, especially when the decision is heavily challenged, thus entailing a higher risk of burnout for those making the decision. The admission itself will provide information about the reversibility of the critical condition and may therefore contribute to a delayed decision about a continuous medical indication for treatment in the ICU as part of a so-called time limited trial (TLT). Although probably rare, derogatory reasons for admission, including intimidation, social pressure, or availability issues, can be probed whenever the reasoning for admission is not clear from the medical and social perspective.