Improving palliative care in intensive care units: identifying strategies and interventions that work

Dying to be better: Outlining the growing benefits of palliative care training in intensive care medicine

A core part of an intensivist's work involves navigating the challenges of End of Life Care. While rates of survival from critical illness have gradually improved, 15%-20% of our patients die during their hospital admission, and a further 20% die within a year. 80% of our patients lack capacity to express their wishes with regard to treatment escalation planning. The critical care unit can be an excellent place to provide a good death, however the very nature of critical illness provides some obstacles to this. Prognostic uncertainty, time-pressured critical decision making, and lack of meaningful contact with a patient and their loved ones are but a few. In this article, we compare the ethos of critical care and palliative care medicine and explore how training in both of these specialities could be brought closer together and more formalised such that the intensivists of the future are more strongly equipped with the skills to shape a critical care unit to overcome these challenges and provide the best care to these patients, many of whom may be in the final phase of their life.

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.

Giving a voice to patients at high risk of dying in the intensive care unit: a multiple source approach

PURPOSE

Data are scarce regarding the experience of critically ill patients at high risk of death. Identifying their concerns could allow clinicians to better meet their needs and align their end-of-life trajectory with their preferences and values. We aimed to identify concerns expressed by conscious patients at high risk of dying in the intensive care unit (ICU).

METHODS

Multiple source multicentre study. Concerns expressed by patients were collected from five different sources (literature review, panel of 50 ICU experts, prospective study in 11 ICUs, in-depth interviews with 17 families and 15 patients). All qualitative data collected were analyzed using thematic content analysis.

RESULTS

The five sources produced 1307 concerns that were divided into 7 domains and 41 sub-domains. After removing redundant items and duplicates, and combining and reformulating similar items, 28 concerns were extracted from the analysis of the data. To increase accuracy, they were merged and consolidated, and resulted in a final list of 15 concerns pertaining to seven domains: concerns about loved-ones; symptom management and care (including team competence, goals of care discussions); spiritual, religious, and existential preoccupations (including regrets, meaning, hope and trust); being oneself (including fear of isolation and of being a burden, absence of hope, and personhood); the need for comforting experiences and pleasure; dying and death (covering emotional and practical concerns); and after death preoccupations.

CONCLUSION

This list of 15 concerns may prove valuable for clinicians as a tool for improving communication and support to better meet the needs of patients at high risk of dying.

Attitudes of Physicians toward Palliative Care in Intensive Care Units: A Nationwide Cross-Sectional Survey in Japan

CONTEXT

Palliative care is an essential component of comprehensive care for patients with critical illnesses. In Japan, little is known about palliative care in intensive care units (ICUs), and palliative care approaches are not widespread.

OBJECTIVE

This study aimed to better understand the attitudes of physicians toward palliative care and the utilization and needs of specialized palliative care consultations in ICUs in Japan.

METHODS

A nationwide, self-administered questionnaire was distributed ICU physician directors in all hospitals with ICUs.

RESULTS

Questionnaires were distributed to 873 ICU physician directors; valid responses were received from 436 ICU physician director (50% response rate). Among the respondents, 94% (n = 411) felt that primary palliative care should be strengthened in ICUs; 89% (n = 386) wanted ICU physicians to collaborate with specialists, such as palliative care teams (PCTs); and 71% (n = 311) indicated the need for specialized palliative care consultations; however, only 38% (n = 166) actually consulted, and only 6% (n = 28) consulted more than 10 patients in the past year. Physicians most commonly consulted PCT for patients with serious end-of-life illness (24%) (n = 107), intractable pain (21%) (n = 92), and providing psychological support to family members (43%, n = 187). The potential barriers in providing primary and specialized palliative care included being unable to understand the patients' intentions (54%, n = 235), lack of knowledge and skills in palliative care (53%, n = 230), and inability to consult with PCTs in a timely manner (46%, n = 201).

CONCLUSIONS

These data suggest a need for primary palliative care education in ICUs and improved access to specialized palliative care consultations.

Palliative care in intensive care units: why, where, what, who, when, how

Palliative care is patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering when “curative” therapies are futile. In the Intensive Care Unit (ICU), critically ill patients receive life-sustaining therapies with the goal of restoring or maintaining organ function. Palliative Care in the ICU is a widely discussed topic and it is increasingly applied in clinics. It encompasses symptoms control and end-of-life management, communication with relatives and setting goals of care ensuring dignity in death and decision-making power. However, effective application of Palliative Care in ICU presupposes specific knowledge and training which anesthesiologists and critical care physicians may lack. Moreover, logistic issues such protocols for patients’ selection, application models and triggers for consultation of external experts are still matter of debate.

The aim of this review is to provide the anesthesiologists and intensivists an overview of the aims, current evidence and practical advices about the application of palliative care in ICU.

Criterion validity and inter-rater reliability of a palliative care screening tool for patients admitted to an emergency department intensive care unit

OBJECTIVE

The use of palliative care (PC) screening criteria to trigger PC consultations may optimize the utilization of PC services, improve patient comfort, and reduce invasive and futile end-of-life care. The aim of the present study was to assess the criterion validity and inter-rater reliability of a PC screening tool for patients admitted to an emergency department intensive care unit (ED-ICU).

METHOD

Observational retrospective study evaluating PC screening criteria based on the presence of advanced diagnosis and the use of two "surprise questions" (traditional and modified). Patients were classified at ED-ICU admission in four categories according to the proposed algorithm.ResultA total of 510 patients were included in the analysis. From these, 337 (66.1%) were category 1, 0 (0.0%) category 2, 63 (12.4%) category 3, and 110 (21.6%) category 4. Severity of illness (Simplified Acute Physiology Score III score and mechanical ventilation), mortality (ED-ICU and intrahospital), and PC-related measures (order for a PC consultation, time between admission and PC consultation, and transfer to a PC bed) were significantly different across groups, more evidently between categories 4 and 1. Category 3 patients presented similar outcomes to patients in category 1 for severity of illness and mortality. However, category 3 patients had a PC consultation ordered more frequently than did category 1 patients. The screening criteria were assessed by two independent raters (n = 100), and a substantial interrater reliability was found, with 80% of agreement and a kappa coefficient of 0.75 (95% confidence interval = 0.62, 0.88).Significance of resultsThis study is the first step toward the implementation of a PC screening tool in the ED-ICU. The tool was able to discriminate three groups of patients within a spectrum of increasing severity of illness, risk of death, and PC needs, presenting substantial inter-rater reliability. Future research should investigate the implementation of these screening criteria into routine practice of an ED-ICU.

Dying in intensive care units of India: Commentaries on policies and position papers on palliative and end-of-life care

PURPOSE

This study critically examines the available policy guidelines on integration of palliative and end-of-life care in Indian intensive care units to appraise their congruence with Indian reality.

MATERIALS AND METHODS

Six position statements and guidelines issued by the Indian Society for Critical Care Medicine and the Indian Association of Palliative Care from 2005 till 2015 were examined. The present study reflects upon the recommendations suggested by these texts.

RESULT

Although the policy documents conform to the universally set norms of introducing palliative and end-of-life care in intensive care units, they hardly suit Indian reality. The study illustrates local complexities that are not addressed by the policy documents. This include difficulties faced by intensivists and physicians in arriving at a consensus decision, challenges in death prognostication, hurdles in providing compassionate care, providing "culture-specific" religious and spiritual care, barriers in effective communication, limitations of documenting end-of-life decisions, and ambiguities in defining modalities of palliative care. Moreover, the policy documents largely dismiss special needs of elderly patients.

CONCLUSION

The article suggests the need to reexamine policies in terms of their attainability and congruence with Indian reality.

Use of a supportive care pathway for end-of-life care in an intensive care unit: a qualitative study

BACKGROUND

Providing palliative care support in intensive care settings is beneficial, however, barriers to delivering high-quality end-of-life care remain. To address this, pathways have been used to improve the quality of palliative care in generalist settings. This study describes the views of health professionals using a supportive care pathway in intensive care.

DESIGN

Qualitative semi-structured interviews were conducted with ten health professionals working in a surgical intensive care unit. The data were analysed thematically.

RESULTS

Participants were positive about the effect of the supportive care pathway on patient care, particularly in enabling consensus in care planning. Some expressed concerns including the difficulty of identifying the 'correct patients' for the pathway, the risk of it becoming a 'self-fulfilling prophecy', and a euphemism for dying.

CONCLUSION

Pathways are one potential mechanism for guiding care planning and communicating the goals of care to colleagues, patients and families, thus contributing to improvements in palliative care.

An Interhospital, Interdisciplinary Needs Assessment of Palliative Care in a Community Critical Care Context

AIM

There is a paucity of data on the provision of palliative care in the critical care settings of smaller community hospitals. This study aimed to identify the gaps that affect the provision of palliative care in a community critical care setting.

SETTING

The study was set in a 10-bed, open intensive care unit and emergency department at a community hospital.

METHODS

Mixed methods were used. Quantitative data included those drawn from databases and surveys; qualitative data included those collected from interviews, focus groups, and onsite walk-throughs and were analyzed with inductive coding techniques.

RESULTS

Gaps were identified in palliative care, goals of care and end-of-life discussions, and resources. Community hospital healthcare professionals did not fully appreciate their essential contribution to the provision of palliative care in the intensive care unit. In addition, there was a lack of expertise, and a lack of interest in gaining expertise, in palliative/end-of-life care.

CONCLUSION

Interrelated needs in a complex interprofessional, interhospital context were captured. Further studies are required to obtain data on palliative practice in the care of critically ill patients in various community hospital contexts.

A Comparison of Outcomes among Hospital Survivors with and without Severe Comorbidity Admitted to the Intensive Care Unit

Little is known about the experiences of patients with severe comorbidity discharged from Intensive Care Units (ICUs). This project aimed to determine the effects of an ICU stay for patients with severe comorbidity by comparing 1) quality of life (QOL), 2) the symptom profile of hospital survivors and 3) health service use after hospital discharge for patients admitted to ICU with and without severe comorbidity. A case-control study was used. Patients with severe comorbidity were matched to a contemporaneous cohort of ICU patients by age and severity of illness. Assessment tools were the Medical Outcome Study 36-item short-form and European Organisation for Research and Treatment of Cancer QLQ-C15-PAL questionnaires for QOL and the Symptom Assessment Scale for symptom distress. A proportional odds assumption was performed using an ordinal regression model. The difference in QOL outcome was the dependent variable for each pair. Health service use after discharge from ICU was monitored with patient diaries. Patients aged 18+ years admitted to an ICU in a metropolitan teaching hospital between 2011 and 2012 were included. We recruited 30 cases and 30 controls. QOL improved over the six months after hospital discharge for patients with and without severe comorbidity ( P <0.01) within the groups but there was no difference found between the groups ( P >0.3). There was no difference in symptoms or health service use between patients with and without severe comorbidity. ICU admission for people with severe comorbidity can be appropriate to stabilise the patient's condition and is likely to be followed by some overall improvement over the six months after hospital discharge.

Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients

OBJECTIVE

The purpose of this study was to examine the effect of proactive palliative care consultation on length of stay for high-risk patients in the medical intensive care unit (MICU).

DESIGN

A prospective pre/post nonequivalent control group design was used for this performance improvement study.

SETTING

Seventeen-bed adult MICU.

PATIENTS

Of admissions to the MICU, 191 patients were identified as having a serious illness and at high risk of dying: 65 patients in the usual care phase and 126 patients in the proactive palliative care phase. To be included in the sample, a patient had to meet one of the following criteria: a) intensive care admission following a current hospital stay of >or=10 days; b) age >80 yrs in the presence of two or more life-threatening comorbidities (e.g., end-stage renal disease, severe congestive heart failure); c) diagnosis of an active stage IV malignancy; d) status post cardiac arrest; or e) diagnosis of an intracerebral hemorrhage requiring mechanical ventilation.

INTERVENTIONS

Palliative care consultations.

MEASUREMENTS AND MAIN RESULTS

Primary measures were patient lengths of stay a) for the entire hospitalization; b) in the MICU; and c) from MICU admission to hospital discharge. Secondary measures included mortality rates and discharge disposition. There were no significant differences between the usual care and proactive palliative care intervention groups in respect to age, gender, race, screening criteria, discharge disposition, or mortality. Patients in the proactive palliative care group had significantly shorter lengths of stay in the MICU (8.96 vs. 16.28 days, p = .0001). There were no differences between the two groups on total length of stay in the hospital or length of stay from MICU admission to hospital discharge.

CONCLUSIONS

Proactive palliative care consultation was associated with a significantly shorter MICU length of stay in this high-risk group without any significant differences in mortality rates or discharge disposition.

Where do we go from here? A palliative care perspective

Key principles of palliative care shed light on future opportunities and challenges for improving patient care and family support within critical care. Interdisciplinary team approaches to patient comfort and family support, coordination and continuity of care, communication as an ethical and therapeutic modality, assistance with emotional, social and spiritual experience, including issues of life completion, bereavement support to families and attention to staff well-being are all foci for future clinical and programmatic development and research. By collaborating to care well for the critically ill or injured patients and extend support for their families, the disciplines of critical care and palliative care can complete one another.