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Palliative Care in the ICU

Christine C. Toevs, MD, MA (Bioethics), FACS, FCCM

Palliative medicine is the discipline that focuses on all aspects of the person relative to medicine: physical, spiritual, and emotional. The purpose of palliative care is to prevent and relieve patient suffering and to help patients and their families set informed goals for medical treatment. Palliative care is provided along with life-prolonging treatment or as the primary focus of treatment.

The ICU is one of the primary places where medical care is provided in the United States. Regrettably, more than 20% of all deaths in the United States occur in an ICU and up to 70% of hospital deaths occur in the ICU or shortly after an ICU stay. The majority of deaths in the ICU involve a decision to withhold or withdraw life-sustaining therapies. The purpose of this chapter is to discuss the importance of palliative care in comprehensive patient-centered care in the ICU.¹

Palliative Care in the ICU

Despite all of the advances in medical therapy and extending life, many patients still die in an ICU or shortly after an ICU stay,² and clinicians are often unaware of patients’ wishes regarding end-of-life care. A number of studies have noted the need for improved communication in the ICU and the use of palliative care to improve communication and to focus on patient-centered care.

Billings and colleagues³ at the Massachusetts General Hospital examined the role of palliative care in the ICU. They noted that palliative care specialists have experience with family conflict, difficult decisions regarding goals of care, family meetings, and interdisciplinary teamwork. The authors noted that palliative care uses different skills in a setting that strives for “great saves” and that this potentially creates conflict with the ICU team. Despite the presence of palliative care specialists in the ICU, clear communication with families continues to be an issue, given the logistics of the ICU: multiple sources of information, multiple family members wanting information at different times of the day even when a family spokesperson has been designated, and lack of coordination and consistency in information given to the families. The authors acknowledge there are no easy ways to improve communication in the ICU and that palliative care is one mechanism for helping patients and families during their ICU stay.

In 2006, the Robert Wood Johnson Foundation proposed a list of quality measures for palliative care in the critically ill.⁴ This consensus group recommended 18 measures: 14 assess processes of care at the patient level and 4 evaluate the structural aspect of critical care delivery. These measures include assessment of patient decisional capacity, identification of surrogate decision maker within 24 hours of ICU admission, identification of advance directive, and documentation of goals of care. Other measures include documentation of pain assessment and management, respiratory distress assessment and management, appropriate pain and sedation protocols, and use of pain medication and sedatives during withdrawal of mechanical ventilation. Mularski et al⁴ stated that these measures can be used as part of an overall quality improvement initiative within the ICU.

Curtis and colleagues² at the University of Washington in Seattle evaluated the use of palliative care in the ICU. They investigated a quality improvement initiative for palliative care in the ICU and family and nurse satisfaction with end-of-life care. Although their study did not demonstrate a change in the family’s perception of ICU care, there was a significant improvement in the nurses’ ratings of patients’ quality of death and dying. The investigators also noted a significant reduction in ICU length of stay before death. Although the use of palliative care did not change the family’s perception of end-of-life care in the ICU, it did change the nurses’ perception of patient care. The investigators concluded that interventions directly related to the family may be required to improve family ratings.

Part of the initiative at the University of Seattle involves improving the skills of the ICU clinician concerning palliative care.⁵ To this end the university has structured an intervention for ICU physicians that includes education, local champions, data feedback, academic detailing, and system supports. This educational intervention was also used to change the culture in the ICU concerning death and dying and to help practitioners focus on patient-centered care. Treece et al⁵ noted that many ICU physicians recognize the value of palliative care skill sets but need education and support.

A variety of methods have been investigated to improve communication in the ICU and to reduce ICU length of stay and treatment intensity. Scheunemann and colleagues⁶ reviewed randomized controlled trials of interventions to improve communication. The authors noted that printed information, structured communications by the ICU team, ethics consultation, and palliative care consultation have been shown to improve family emotional outcomes and reduce ICU length of stay and treatment intensity. The authors specifically reviewed 4 randomized controlled trials of palliative care consultation. They concluded that physician involvement is necessary for any successful intervention and that interventions led by social workers and nurses are less likely to be successful.

The American Academy of Critical Care Medicine published a consensus statement of recommendations for end-of-life care in the ICU.⁷ They recommended that ICU physicians be competent in all aspects of end-of-life care, including ethics, withdrawal of life-sustaining treatments, use of sedatives and analgesics to relieve suffering, and techniques to improve communication with families during this time.

Mularski and colleagues⁸ evaluated pain management in the ICU. They noted that pain assessment and management “fall within the comprehensive scope of palliative care that should be provided concurrently with curative interventions and supportive care in the ICU.” (p. 1360) They also noted that every patient in the ICU would benefit from palliative medicine consultation to address pain assessment and management. Because the ICU relies on an interdisciplinary model in order to deliver care, the use of palliative medicine to “help patients and their families avoid suffering while pursuing healing or comfortable dying in the ICU” (p. 1366) is beneficial.

Nelson moderated a roundtable discussion about palliative medicine in the ICU with several leaders in the field.⁹ This discussion emphasized the need for multidisciplinary support for the patients and families, of which palliative care is one component. The group reiterated that palliative care entails not only end-of-life care but also management of symptoms in the ICU that intensivists often overlook (fatigue, thirst, anxiety, and pain).

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