Icahn School of Medicine at Mount Sinai, New York, NY, USA
Background
With rapidly expanding populations and advances made in modern medicine, the average life expectancy has shown a steady increase over the last decade. ICUs have seen a surge in the elderly population with life‐threatening illnesses but despite modern treatment options ICU mortality remains high.
It is estimated that approximately 20% of deaths in the USA occur during or shortly after an ICU admission. Of patients who are discharged from the ICU, a sizable population suffers from further physical and neurocognitive symptoms, limiting their quality of life.
Understanding palliative care
Palliative care in the ICU has shown significant growth in the last decade. With its early integration within the ICU treatment model, it has shown improvement in not only symptom management at the end of life, but also in overall patient and family satisfaction.
The World Health Organization definition of palliative care emphasizes its most critical role: to prevent and reduce suffering by means of early identification, assessment, and treatment of pain and other problems (e.g. physical, psychosocial).
Palliative care gained further recognition after a landmark 2010 randomized trial which followed patients with metastatic non‐small cell lung cancer with and without initiation of early palliative care. This trial showed that early palliative care led to a significantly improved quality of life and mood. The palliative care arm also found a decrease in aggressive care at the end of life and a longer overall survival period. Although the setting of this trial was carried out in the outpatient and primary care setting it demonstrated the importance of early goal‐directed discussion with patients/surrogates regarding their illness with management consistent with their wishes.
Benefits
The role of palliative care within the ICU is to assist the patient and family in making value‐based decisions. Such a model of decision making focuses on establishing goals of care, addressing patient symptoms, and providing family support.
The palliative consult team is able to provide emotional support and counseling during withdrawal of artificial life‐sustaining therapies (that serve to prolong the dying process) and are especially helpful in improving continuity of care in a field that is frequently fragmented.
Many studies have shown a positive association between palliative care and reduction in ICU length of stay, better utilization of hospital resources, reduction in ICU costs, and ultimately a decrease in the use of potentially inappropriate therapies.
These studies also found that early communication about patient prognosis and treatment options provided family satisfaction, reduced family anxiety, guilt, and PTSD.
Recommended model of palliative care in the ICU
Clinical practice guidelines offered by the Center to Advance Palliative Care (CAPC) are one way to apply a standardized method of integrating early palliative care in the management of critically ill patients with advanced illness.
These clinical practice guidelines follow the standards from the National Quality Forum in its Framework and Preferred Practices for Palliative and Hospice Care, and from the National Consensus Project for Quality Palliative Care. These standards were operationalized by the CAPC with its Improving Palliative Care in the ICU (IPAL‐ICU) project.
The IPAL‐ICU model involves hardwiring palliative care into the ICU system, creation of screening criteria to initiation a palliative consult (i.e. advanced malignancy, severe cognitive impairment, multiorgan failure, prolonged ICU hospitalization, conflict or lack of goals of care), guideline formation, and most importantly a set of desired outcome measures.
The ultimate goal of creating the IPAL‐ICU treatment model is to achieve four key points:
Timely communication with patient and family.
Develop clinical decisions based on patient preference, goals, and values.
Provide patient care focusing on providing symptom relief and comfort.
Providing family care with open access and ICU support.
The guideline encourages multidisciplinary rounds as part of the ‘integrative model’ to occur on a daily basis to gather updates on patients’ medical progress while in the ICU and also to screen new potential patients that may benefit from early palliative care. Once a patient has been admitted to the ICU with an expected 5 day or longer course, a screening process should begin to identify palliative care criteria and a discussion should be initiated with patient and family about advance care planning.
As recommended by the IPAL‐ICU algorithm, palliative care communication should begin on ICU day 1 with a focus on establishing a good patient and physician relationship. By ICU days 1–3, the team should have identified an appropriate medical decision maker, discussed acute life‐threatening conditions, and investigated advance directive and code status. Information should be provided to the patient and family regarding these matters with the use of educational leaflets and videos.
While it may be difficult to prognosticate a patient’s condition during the first few days of an ICU admission, the goal of the initial meeting is to develop a rapport and to come to an understanding of their current state of health.
By ICU day 3, there should be an ICU family meeting to address further questions regarding the patient’s condition as well as to offer social work and spiritual support. Here it is important to assess if further need for palliative care is present, and an official palliative care consult should be placed accordingly. An official consult would then lead to an interdisciplinary family meeting. Weekly follow‐up meetings to further discuss goals of care and the possibility of end‐of‐life care are recommended (Algorithm 10.1).
Algorithm 10.1Final workflow incorporating guidelines from the IPAL‐ICU project
Devices and withdrawal of artificial life support
Discontinuation of any medical treatment that is not in line with the patient’s goals of care should occur in a thoughtful fashion with consideration given to promoting comfort and reducing anxiety.
The most commonly performed withdrawal of care within the ICU is the liberation from mechanical ventilation. Though it may seem routine, a well‐established protocol can help facilitate a smooth transition for ventilatory withdrawal. Such a protocol should focus on addressing location of ventilator withdrawal, anticipation and treatment of patient symptoms such as pain and dyspnea, and addressing family anxiety.
Other mechanical life‐sustaining devices should also be considered when discussing withdrawal of care. Mechanical circulatory support devices, pacemakers, and defibrillators fall under this category and should be deactivated if a decision is made to withdraw care. Similar to symptom control after ventilator withdrawal, opioids, anxiolytics, and anticholinergic agents should be provided for patient comfort.
Reading list
Angus DC, et al. Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med 2004; 32(3):638–43.
Azoulay E, et al. Risk of post‐traumatic stress symptoms in family members of intensive care unit patients. Am J Respir Crit Care Med 2005; 171(9):987–94.
Cook D, Rocker G. Dying with dignity in the intensive care unit. N Engl J Med 2014; 370(26):2506–14.
Nelson JE, et al. for the Improving Palliative Care in the Intensive Care Unit Project. Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: a report from the IPAL‐ICU Project (Improving Palliative Care in the ICU). Crit Care Med 2010; 38(9):1765–72.
O’Mahony S, et al. Preliminary report of the integration of a palliative care team into an intensive care unit. Palliat Med 2010; 24(2):154–65.
Swetz KM, Mansel JK. Ethical issues and palliative care in the cardiovascular intensive care unit. Cardiol Clin 2013; 31:657–68.
Temel JS, et al. Early palliative care for patients with metastatic non‐small‐cell lung cancer. N Engl J Med 2010; 363:733–42.
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