1
|
Salins N, Dhyani VS, Mathew M, Prasad A, Rao AP, Damani A, Rao K, Nair S, Shanbhag V, Rao S, Iyer S, Gursahani R, Mani RK, Bhatnagar S, Simha S. Assessing palliative care practices in intensive care units and interpreting them using the lens of appropriate care concepts. An umbrella review. Intensive Care Med 2024; 50:1438-1458. [PMID: 39141091 PMCID: PMC11377469 DOI: 10.1007/s00134-024-07565-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 07/17/2024] [Indexed: 08/15/2024]
Abstract
PURPOSE Intensive care units (ICUs) have significant palliative care needs but lack a reliable care framework. This umbrella review addresses them by synthesising palliative care practices provided at end-of-life to critically ill patients and their families before, during, and after ICU admission. METHODS Seven databases were systematically searched for systematic reviews, and the umbrella review was conducted according to the guidelines laid out by the Joanna Briggs Institute (JBI). RESULTS Out of 3122 initial records identified, 40 systematic reviews were included in the synthesis. Six key themes were generated that reflect the palliative and end-of-life care practices in the ICUs and their outcomes. Effective communication and accurate prognostications enabled families to make informed decisions, cope with uncertainty, ease distress, and shorten ICU stays. Inter-team discussions and agreement on a plan are essential before discussing care goals. Recording care preferences prevents unnecessary end-of-life treatments. Exceptional end-of-life care should include symptom management, family support, hydration and nutrition optimisation, avoidance of unhelpful treatments, and bereavement support. Evaluating end-of-life care quality is critical and can be accomplished by seeking family feedback or conducting a survey. CONCLUSION This umbrella review encapsulates current palliative care practices in ICUs, influencing patient and family outcomes and providing insights into developing an appropriate care framework for critically ill patients needing end-of-life care and their families.
Collapse
Affiliation(s)
- Naveen Salins
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | | | - Mebin Mathew
- Karunashraya Bangalore Hospice Trust, Bangalore, India
| | | | - Arathi Prahallada Rao
- Department of Health Policy, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India.
| | - Anuja Damani
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Krithika Rao
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Shreya Nair
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Vishal Shanbhag
- Department of Critical Care Medicine, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Shwethapriya Rao
- Department of Critical Care Medicine, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Shivakumar Iyer
- Department of Critical Care Medicine, Bharati Vidyapeeth University Medical College, Pune, India
| | | | | | - Sushma Bhatnagar
- Oncoanaesthesia and Palliative Medicine, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | | |
Collapse
|
2
|
Martz K, Alderden J, Bassett R, Swick D. Outcomes Associated With a Nurse-Driven Palliative Care Screening Tool in the Intensive Care Unit. Crit Care Nurse 2021; 40:23-29. [PMID: 32476026 DOI: 10.4037/ccn2020702] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Access to specialty palliative care delivery in the intensive care unit is inconsistent across institutions. The intensive care unit at the study institution uses a screening tool to identify patients likely to benefit from specialty palliative care, yet little is known about outcomes associated with the use of screening tools. OBJECTIVE To identify outcomes associated with specialty palliative care referral among patients with critical illness. METHODS Records of 112 patients with positive results on palliative care screening were retrospectively reviewed to compare outcomes between patients who received a specialty palliative care consult and those who did not. Primary outcome measures were length of stay, discharge disposition, and escalation of care. RESULTS Sixty-five patients (58%) did not receive a palliative care consult. No significant differences were found in length of hospital or intensive care unit stay. Most patients who experienced mechanical ventilation did not receive a palliative care consultation (χ2 = 5.14, P = .02). Patients who were discharged to home were also less likely to receive a consult (χ2 = 4.1, P = .04), whereas patients who were discharged to hospice were more likely to receive a consult (χ2 = 19.39, P < .001). CONCLUSIONS Unmet needs exist for specialty palliative care. Understanding the methods of identifying patients for specialty palliative care and providing them with such care is critically important. Future research is needed to elucidate the factors providers use in their decisions to order or defer specialty palliative care consultation.
Collapse
Affiliation(s)
- Kim Martz
- Kim Martz is Associate Professor Emeritus, Boise State University School of Nursing, Faculty Mentor, St Luke's Health System, Boise, Idaho
| | - Jenny Alderden
- Jenny Alderden is an assistant professor, University of Utah College of Nursing, Salt Lake City, Utah
| | - Rick Bassett
- Rick Bassett is an adult clinical nurse specialist, St Luke's Health System
| | - Dawn Swick
- Dawn Swick is a staff nurse, St Luke's Health System
| |
Collapse
|
3
|
Moynihan KM, Snaman JM, Kaye EC, Morrison WE, DeWitt AG, Sacks LD, Thompson JL, Hwang JM, Bailey V, Lafond DA, Wolfe J, Blume ED. Integration of Pediatric Palliative Care Into Cardiac Intensive Care: A Champion-Based Model. Pediatrics 2019; 144:peds.2019-0160. [PMID: 31366685 PMCID: PMC6855829 DOI: 10.1542/peds.2019-0160] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2019] [Indexed: 01/04/2023] Open
Abstract
Integration of pediatric palliative care (PPC) into management of children with serious illness and their families is endorsed as the standard of care. Despite this, timely referral to and integration of PPC into the traditionally cure-oriented cardiac ICU (CICU) remains variable. Despite dramatic declines in mortality in pediatric cardiac disease, key challenges confront the CICU community. Given increasing comorbidities, technological dependence, lengthy recurrent hospitalizations, and interventions risking significant morbidity, many patients in the CICU would benefit from PPC involvement across the illness trajectory. Current PPC delivery models have inherent disadvantages, insufficiently address the unique aspects of the CICU setting, place significant burden on subspecialty PPC teams, and fail to use CICU clinician skill sets. We therefore propose a novel conceptual framework for PPC-CICU integration based on literature review and expert interdisciplinary, multi-institutional consensus-building. This model uses interdisciplinary CICU-based champions who receive additional PPC training through courses and subspecialty rotations. PPC champions strengthen CICU PPC provision by (1) leading PPC-specific educational training of CICU staff; (2) liaising between CICU and PPC, improving use of support staff and encouraging earlier subspecialty PPC involvement in complex patients' management; and (3) developing and implementing quality improvement initiatives and CICU-specific PPC protocols. Our PPC-CICU integration model is designed for adaptability within institutional, cultural, financial, and logistic constraints, with potential applications in other pediatric settings, including ICUs. Although the PPC champion framework offers several unique advantages, barriers to implementation are anticipated and additional research is needed to investigate the model's feasibility, acceptability, and efficacy.
Collapse
Affiliation(s)
- Katie M. Moynihan
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital Boston, Massachusetts;,Department of Pediatrics, Medical School, Harvard University, Boston, Massachusetts
| | - Jennifer M. Snaman
- Department of Pediatrics, Medical School, Harvard University, Boston, Massachusetts;,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Erica C. Kaye
- Division of Quality of Life and Palliative Care, Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee
| | - Wynne E. Morrison
- Pediatric Advanced Care Team, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; Departments of,Anesthesiology and Critical Care and
| | - Aaron G. DeWitt
- Pediatric Advanced Care Team, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; Departments of,Anesthesiology and Critical Care and
| | - Loren D. Sacks
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California
| | - Jess L. Thompson
- Department of Cardiothoracic Surgery, Children’s Heart Center, University of Oklahoma, Oklahoma City, Oklahoma; and
| | - Jennifer M. Hwang
- Pediatric Advanced Care Team, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; Departments of,Pediatrics, Perelman School of Medicine, The University of Pennsylvania and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Valerie Bailey
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital Boston, Massachusetts
| | - Deborah A. Lafond
- PANDA Palliative Care Team, Children’s National and School of Medicine, The George Washington University, Washington, District of Columbia
| | - Joanne Wolfe
- Department of Pediatrics, Medical School, Harvard University, Boston, Massachusetts;,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Elizabeth D. Blume
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital Boston, Massachusetts;,Department of Pediatrics, Medical School, Harvard University, Boston, Massachusetts
| |
Collapse
|
4
|
Mun E, Umbarger L, Ceria-Ulep C, Nakatsuka C. Palliative Care Processes Embedded in the ICU Workflow May Reserve Palliative Care Teams for Refractory Cases. Am J Hosp Palliat Care 2016; 35:60-65. [PMID: 28273756 DOI: 10.1177/1049909116684821] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
CONTEXT Palliative Care Teams have been shown to be instrumental in the early identification of multiple aspects of advanced care planning. Despite an increased number of services to meet the rising consultation demand, it is conceivable that the numbers of palliative care consultations generated from an ICU alone could become overwhelming for an existing palliative care team. OBJECTIVE Improve end-of-life care in the ICU by incorporating basic palliative care processes into the daily routine ICU workflow, thereby reserving the palliative care team for refractory situations. METHODS A structured, palliative care, quality-improvement program was implemented and evaluated in the ICU at Kaiser Permanente Medical Center in Hawaii. This included selecting trigger criteria, a care model, forming guidelines, and developing evaluation criteria. MAIN OUTCOME MEASURES These included the early identification of the multiple features of advanced care planning, numbers of proactive ICU and palliative care family meetings, and changes in code status and treatment upon completion of either meeting. RESULTS Early identification of Goals-of-Care, advance directives, and code status by the ICU staff led to a proactive ICU family meeting with resultant increases in changes in code status and treatment. The numbers of palliative care consultations also rose, but not significantly. CONCLUSIONS Palliative care processes could be incorporated into a daily ICU workflow allowing for integration of aspects of advanced care planning to be identified in a systematic and proactive manner. This reserved the palliative care team for situations when palliative care efforts performed by the ICU staff were ineffective.
Collapse
Affiliation(s)
- Eluned Mun
- 1 Department of Physician Services, The Rehabilitation Hospital of the Pacific, Honolulu, HI, USA
| | - Lillian Umbarger
- 2 Department of Intensive Care Unit, Kaiser Permanente Medical Center, Honolulu, HI, USA
| | - Clementina Ceria-Ulep
- 3 Department of School of Nursing and Dental Hygiene, University of Hawaii at Manoa, Honolulu, HI, USA
| | - Craig Nakatsuka
- 4 Department of Palliative Care, Kaiser Permanente Medical Center, Honolulu, HI, USA
| |
Collapse
|