TABLE 23-1 Comparing Palliative Care and Hospice | ||||||||||||||||||
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TABLE 23-2 Guide for Effective Family Meetings | ||||||||
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Integrative and Palliative Care in the Intensive Care Unit
Integrative and Palliative Care in the Intensive Care Unit
Jennifer Reidy
Julia M. Gallagher
Suzana K. Everett Makowski
I. OVERVIEW
A. General principles: Integrated critical and palliative care improves quality, patient/family satisfaction, and use of ICU resources at end of life.
1. Comprehensive ICU toolkit (www.capc.org/ipal/ipal-icu).
2. Definitions of palliative care and hospice (Table 23-1).
II. PROGNOSTICATION/GOALS OF CARE
A. General principles: Prognostication is crucial for framing medical decisions. Goals-of-care discussions match the values of patients and families with clinical realities and likely treatment outcomes.
1. Tools for assessing pre-ICU prognosis include:
a. “ePrognosis” (www.eprognosis.org/).
b. Charlson Comorbidity Index: online calculators available.
c. Telephone call to primary care physician (PCP) or primary subspecialist.
2. Tools for assessing ICU prognosis.
a. Acute Physiologic and Chronic Health Evaluation (APACHE IV).
b. Simplified Acute Physiologic Score (SAPS).
c. Mortality Prediction Model (MPM).
d. Sequential Organ Failure Assessment (SOFA) score.
e. For diagnosis of brain death, see Chapter 132.
III. STRATEGIES FOR EFFECTIVE COMMUNICATION AND DECISION MAKING
A. General principles: Structured family meetings are the most effective ICU interventions in end-of-life care.
B. Indications: routine meetings in first 2 to 3 days; chronic critical illness; poor prognosis; family and/or staff conflict; major care decision.
C. Procedure: format and steps (see Table 23-2).
1. Pearls.
a. Listen: Avoid lecturing; try to sit with strong emotion.
b. Be patient: Do not rush to share information before listening; allow people time to process when asking them to make decisions.
c. Involve family: Promote consensus and decrease stress/guilt for surrogate decision makers.
d. Make a recommendation: After eliciting a patient’s values/goals and building relationships, the ICU team should make clear, strong recommendations about care options.
2. When patient lacks capacity to make decisions, use patients’ previously stated wishes (advance directives) and substituted judgment.
a. Explain surrogates’ role in defining what patients would want if they could speak and understand their situation.
b. If no health care proxy (HCP), state law outlines chain of legal decision makers. If no family, clinicians may use a “best interests” approach; hospitals often seek legal guardianship.
D. Postprocedure: If intractable conflict related to ethical, religious, and cultural values (such as preservation of life at all costs).
1. See “managing conflict”—Table 23-2.
2. Involve consultants in palliative care and ethics.
3. Consider a “harm reduction” approach.
