Palliative Care in the Surgical ICU

Evidence Guiding Withdrawal of Mechanical Ventilation at the End of Life: A Review

OBJECTIVE

Distress at the end of life in the intensive care unit (ICU) is common. We reviewed the evidence guiding symptom assessment, withdrawal of mechanical ventilation (WMV) process, support for the ICU team, and symptom management among adults, and specifically older adults, at end of life in the ICU.

SETTING AND DESIGN

Systematic search of published literature (January 1990-December 2021) pertaining to WMV at end of life among adults in the ICU setting using PubMed, Embase, and Web of Science. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed.

PARTICIPANTS

Adults (age 18 and over) undergoing WMV in the ICU.

MEASUREMENTS

Study quality was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

Out of 574 articles screened, 130 underwent full text review, and 74 were reviewed and assessed for quality. The highest quality studies pertained to use of validated symptom scales during WMV. Studies of the WMV process itself were generally lower quality. Support for the ICU team best occurs via structured communication and social supports. Dyspnea is the most distressing symptom, and while high quality evidence supports the use of opiates, there is limited evidence to guide implementation of their use for specific patients.

CONCLUSION

High quality studies support some practices in palliative WMV, while gaps in evidence remain for the WMV process, supporting the ICU team, and medical management of distress. Future studies should rigorously compare WMV processes and symptom management to reduce distress at end of life.

Family Perceptions of Palliative Care and Communication in the Surgical Intensive Care Unit

Few data exist on palliative care for trauma and acute care surgery patients. This pilot study evaluated family perceptions and experiences around palliative care in a surgical intensive care unit (SICU) via mixed methods interviews conducted from February 1, 2020, to March 5, 2020, with 5 families of patients in the SICU. Families emphasized the importance of clear, honest communication, and inclusiveness in decision-making. Many interviewees were unable to recall whether goals-of-care discussions had occurred, and most lacked understanding of the patients' illnesses. This study highlights the significance of frequent communication and goals-of-care discussions in the SICU.

Effects of pain management program on the length of stay of patients with decreased level of consciousness: A clinical trial

Background:

Critical care patients are at higher risk for untreated pain. Pain has persistent and untreated effects on most of the body systems and results in development of complications, chronic pain, and increased length of stay. The aim of this study was to determine the effects of the implementation of a pain management program on the length of stay in patients with decreased level of consciousness, admitted in Al-Zahra hospital intensive care units (ICUs) in 2013.

Materials and Methods:

In this clinical trial, 50 subjects with decreased level of consciousness were selected by convenient sampling from the ICU wards of Al-Zahra hospital, Isfahan, Iran and were randomly assigned to two groups of study and control. Pain management program was applied on the study group and routine care was implemented in the control group. Data including demographic data and length of stay of patients in the ICUs were collected and analyzed using descriptive statistics and Chi-square test, independent t-test, and paired t-test.

Results:

Results showed that out of 50 subjects attending the study, there were 40% female and 60% male subjects in study, and 52% female and 48% male subjects in control group. (P = 0.395). Overall mean length of stay of the patients in the ICUs was significantly lower in the case group [3.2 (1.4)] days compared to the control group [7.4 (4.8) days] (P < 0.001).

Conclusions:

This study showed that overall mean length of stay of patients in the ICUs was significantly lower in the study group compared to the control group. It is suggested to use this program for patients in ICUs with decreased level of consciousness after a general surgery.

[Limitation of therapeutic effort: Approach to a combined view]

Over the past few decades, we have been witnessing that increasing fewer people pass away at home and increasing more do so within the hospital. More specifically, 20% of deaths now occur in an intensive care unit (ICU). However, death in the ICU has become a highly technical process. This sometimes originates excesses because the resources used are not proportionate related to the purposes pursued (futility). It may create situations that do not respect the person's dignity throughout the death process. It is within this context that the situation of the clinical procedure called "limitation of the therapeutic effort" (LTE) is reviewed. This has become a true bridge between Intensive Care and Palliative Care. Its final goal is to guarantee a dignified and painless death for the terminally ill.

The Distinct Role of Palliative Care in the Surgical Intensive Care Unit

Palliative care is expanding its role into the surgical intensive care units (SICU). Embedding palliative philosophies of care into SICUs has considerable potential to improve the quality of care, especially in complex patient care scenarios. This article will explore palliative care, identifying patients/families who benefit from palliative care services, how palliative care complements SICU care, and opportunities to integrate palliative care into the SICU. Palliative care enhances the SICU team’s ability to recognize pain and distress; establish the patient’s wishes, beliefs, and values and their impact on decision making; develop flexible communication strategies; conduct family meetings and establish goals of care; provide family support during the dying process; help resolve team conflicts; and establish reasonable goals for life support and resuscitation. Educational opportunities to improve end-of-life management skills are outlined. It is necessary to appreciate how traditional palliative and surgical cultures may influence the integration of palliative care into the SICU. Palliative care can provide a significant, “value added” contribution to the care of seriously ill SICU patients.

Changing end-of-life care practice for liver transplant service patients: structured palliative care intervention in the surgical intensive care unit

CONTEXT

Patients, families, and surgeons often have high expectations of life-saving surgery following liver transplantation (LT), despite the presence of a severe life-limiting underlying illness. Hence, transition from curative to palliative care is difficult and may create conflicts around goals of care.

OBJECTIVES

We hypothesized that early communication with physicians/families would improve end-of-life care practice in the LT service patients.

METHODS

Prospective, observational, pre/poststudy of consecutive LT service, surgical intensive care unit (SICU) patients, before and after a palliative care intervention was integrated. This included Part I (at admission), family support, prognosis, and patient preferences delineation; and Part II (within 72 hours), interdisciplinary family meeting. Data on goals-of-care discussions, do-not-resuscitate (DNR) orders, withdrawal of life support, and family perceptions were collected.

RESULTS

Seventy-nine LT patients with 21 deaths comprised the baseline group and 104 patients with 31 deaths the intervention group. Eighty-five percent of patients received Part I and 58% Part II of the intervention. Goals-of-care discussions on physician rounds increased from 2% to 38% of patient-days. During the intervention, although mortality rates were unchanged, DNR status increased (52-81%); withdrawal of life support increased (35-68%); DNR was instituted earlier; admission to DNR decreased (mean of 38-19 days); DNR to death time increased (two to four days); and SICU mean length of stay decreased (by three days). Family responses suggested more "time with family"/"time to say goodbye."

CONCLUSION

Interdisciplinary communication interventions with physicians and families resulted in earlier consensus around goals of care for dying LT patients. Early integration of palliative care alongside disease-directed curative care can be accomplished in the SICU without change in mortality and has the ability to improve end-of-life care practice in LT patients.

Nurse-perceived barriers to effective communication regarding prognosis and optimal end-of-life care for surgical ICU patients: a qualitative exploration

BACKGROUND

Integration of palliative care for intensive care unit (ICU) patients is important but often challenging, especially in surgical ICUs (SICUs), in part because many surgeons equate palliative care with terminal care and failure of restorative care. SICU nurses, who are key front-line clinicians, can provide insights into barriers for delivery of optimal palliative care in their setting.

METHODS

We developed a focus group guide to identify barriers to two key components of palliative care-optimal communication regarding prognosis and optimal end-of-life care-and used the tool to conduct focus groups of nurses providing bedside care in three SICUs at a tertiary care, academic, inner city hospital. Using content analysis technique, responses were organized into thematic domains that were validated by independent observers and a subset of participating nurses.

RESULTS

Four focus groups included a total of 32 SICU nurses. They identified 34 barriers to optimal communication regarding prognosis, which were summarized into four domains: logistics, clinician discomfort with discussing prognosis, inadequate skill and training, and fear of conflict. For optimal end-of-life care, the groups identified 24 barriers in four domains: logistics, inability to acknowledge an end-of-life situation, inadequate skill and training, and cultural differences relating to end-of-life care.

CONCLUSIONS

Nurses providing bedside care in SICUs identify barriers in several domains that may impede optimal discussions of prognoses and end-of-life care for patients with surgical critical illness. Consideration of these perceived barriers and the underlying SICU culture is relevant for designing interventions to improve palliative care in this setting.

Communication in critical care: family rounds in the intensive care unit

BACKGROUND

Communication with family members of patients in intensive care units is challenging and fraught with dissatisfaction.

OBJECTIVES

We hypothesized that family attendance at structured interdisciplinary family rounds would enhance communication and facilitate end-of-life planning (when appropriate).

METHODS

The study was conducted in the 26-bed medical intensive care unit of a tertiary care, academic medical center from April through October 2006. Starting in July 2006, families were invited to attend daily interdisciplinary rounds where the medical team discussed the plan for care. Family members were surveyed at least 1 month after the patient's stay in the unit, completing the validated "Family Satisfaction in the ICU" tool before and after implementation of family rounds.

RESULTS

Of 227 patients enrolled, 187 patients survived and 40 died. Among families of survivors, participation in family rounds was associated with higher family satisfaction regarding frequency of communication with physicians (P = .004) and support during decision making (P = .005). Participation decreased satisfaction regarding time for decision making (P = .02). Overall satisfaction scores did not differ between families who attended rounds and families who did not. For families of patients who died, participation in family rounds did not significantly change satisfaction.

CONCLUSIONS

In the context of this pilot study of family rounds, certain elements of satisfaction were improved, but not overall satisfaction. The findings indicate that structured interdisciplinary family rounds can improve some families' satisfaction, whereas some families feel rushed to make decisions. More work is needed to optimize communication between staff in the intensive care unit and patients' families, families' comprehension, and the effects on staff workload.

Addressing access to palliative care services in the surgical intensive care unit

BACKGROUND

Proactive case-finding using consultation triggers is a currently unexplored technique of increasing access to palliative care for patients in the surgical intensive care unit (SICU).

METHODS

A retrospective, pre- and postintervention study examined the effect of an initiative involving palliative care consultation in a 21-bed SICU at an urban, tertiary referral center. The initiative identified patients meeting a set of consultation triggers suggested by a group of physicians with expertise in surgical palliative care. The charts of 300 patients were reviewed retrospectively before the initiative (Group I), and 344 charts were reviewed after the initiative (Group II) for the presence of a trigger and/or subsequent palliative care consultation.

RESULTS

Triggers were rare in both groups (Group I, 5.7%; Group II, 5.5%). Palliative care consultations were also infrequent, without change before and after the intervention (Group I, 2.3%; Group II, 3.1%). There was no difference in consultations for patients meeting a trigger after the initiative (17.6% to 27.3%; P = .704).

CONCLUSION

Implementation of triggers does not increase palliative care consultations in the SICU. As an isolated intervention, triggers occur in too few patients to improve overall access to palliative care, suggesting that other methods should be further explored.

Withdrawal of life-sustaining therapy in injured patients: variations between trauma centers and nontrauma centers

BACKGROUND

We sought to identify patient and institutional variables predictive of a withdrawal of care order (WOCO) in trauma patients. We hypothesized that the frequency of WOCO would be higher at trauma centers.

METHODS

Data from the National Study on the Costs and Outcomes of Trauma were used to determine associations between WOCO status and patient characteristics, institutional characteristics, and hospital course. chi, t tests, and multivariate analysis were used to identify variables predictive of WOCO.

RESULTS

Of 14,190 patients, 618 (4.4%) had WOCO, which accounted for 60.9% of patients who died in hospital. Age (p = <0.001), race (p = <0.001), comorbidity (p = <0.001), and injury mechanism were associated with WOCO (p = 0.03). WOCO patients had higher New Injury Severity Score (p = <0.001), lower Glasgow Coma Scale motor scores (p = <0.001), and higher incidence of midline shift on head computed tomography (p = 0.01). Trauma center status (odds ratio, 1.56; 95% confidence interval, 1.06-2.30) and closed intensive care units (odds ratio, 1.53; 95% confidence interval, 1.03-2.25) were also predictive of a WOCO. There was a sizable variation (0%-16%) in the percentage of patients with WOCO across centers.

CONCLUSION

Most trauma patients who die in hospital do so after a WOCO. Although trauma center status and closed intensive care units are predictive of a WOCO, variation in the percentage of patients with WOCO across all centers speaks to the complexity of these decisions. Further investigation is needed to understand how a WOCO is applied to trauma patients.

Review Article: Goals of Care Toward the End of Life: A Structured Literature Review

Goals of care are often mentioned as an important component of end-of-life discussions, but there are diverse assessments regarding the type and number of goals that should be considered. To address this lack of consensus, we searched MEDLINE (1967—2007) for relevant articles and identified the number, phrasing, and type of goals they addressed. An iterative process of categorization resulted in a list of 6 practical, comprehensive goals: (1) be cured, (2) live longer, (3) improve or maintain function/quality of life/ independence, (4) be comfortable, (5) achieve life goals, and (6) provide support for family/caregiver. These goals can be used to articulate goal-oriented frameworks to guide decision making toward the end of life and thereby harmonize patients' treatment choices with their values and medical conditions.

Palliative care in the surgical intensive care unit: where least expected, where most needed

Despite dramatic improvements in survival from a broad range of afflictions seen in the surgical critical care unit, the problem of suffering in its many forms and its long-term consequences will remain as long as mortality characterizes the human condition. Palliative care in the surgical intensive care unit is an extension of time-honoured surgical principles and traditions that aims to relieve suffering and improve quality of life associated with serious illness as an end in it self or as part of treatment to save and prolong life.