Page 154 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

120 PART 1: An Overview of the Approach to and Organization of Critical Care

is to improve the quality of life through the relief of suffering in each
• Lee Char SJ, Evans LR, Malvar GL, White DB. A randomized
trial of two methods to disclose prognosis to surrogate deci- of its major domains: physical, emotional, psychosocial, and spiritual.
Thus, follows the second principle that palliative care is provided by
sion makers in intensive care units. Am J Respir Crit Care Med.
2010;182(7):905-909. an interdisciplinary team that generally includes the professions of
medicine, nursing, social work/counseling, and chaplaincy. The third
• White DB, Braddock CH III, Bereknyei S, Curtis JR. Toward shared principle is that the patient and family are the focus of care rather than
decision making at the end of life in intensive care units: opportuni- the patient individually. An important feature of palliative care for
ties for improvement. Arch Intern Med. 2007;167(5):461-467. ICU clinicians to understand is that it can be offered simultaneously
with aggressive efforts to extend life and does not impose an “either-or
choice” between conventional critical care and palliative care.
REFERENCES Given the substantial risk of death for many critically ill and injured
patients, ICU clinicians can enhance important aspects of patient and
Complete references available online at www.mhprofessional.com/hall
family outcomes by considering how to integrate these principles into
their practices. Although not focused primarily on the relief of suffering,
critical care has increasingly begun to value the importance of symptom
management, emotional and psychological outcomes, and psychoso-
2-4
5
CHAPTER Providing Palliative Care and cial support. More generally, investigation into health-related quality
6-8
of life following critical illness has identified important deficiencies
9,10
18 Withholding or Withdrawing especially when considered in the context of the substantial resources
Life-Sustaining Therapy invested. For example, a prospective, cohort study of 126 patients desig-
nated as chronically dependent on mechanical ventilation found that at
Dee W. Ford 1 year only 9% were alive with a good outcome at a cost of $3.5 million
per independently functioning survivor. These findings raise the
10
J. Randall Curtis
notion that critical care may need to evolve and expand its purview into
post-ICU issues of survivorship, analogous in some ways to emerging
KEY POINTS focus on cancer survivorship. 11
Effective interdisciplinary care has proven value in intensive care
• Approximately 20% of deaths in the United States are associated units. 12,13 Furthermore, patients and families report that interdisciplinary
with or occur in an intensive care unit and a substantial majority collaboration is a key element to good end-of-life care, yet the value
14
of these deaths will have some aspect of intensive care treatment that intensivists place on nursing involvement in end-of-life decisions
either withheld or withdrawn. High-quality care for patients dying is variable as documented in an international survey. A questionnaire
in the ICU should incorporate the principles and practice of pal- completed by 1961 intensivists found that only one-third of surveyed
liative care and therefore intensive care unit clinicians should intensivists in the United States, Brazil, Japan, and Southern Europe
familiarize themselves with basic aspects of palliative care. would involve nursing in end-of-life decision making for a hypotheti-
• High-quality communication with critically ill patients and their fam- cal patient without a surrogate decision maker as compared to 62% in
15
ily is an essential skill for ICU clinicians and one component of pallia- Northern and Central Europe. In addition, interdisciplinary conflict
tive care. Communication about end-of-life issues requires navigating around end-of-life care in ICUs is associated with increased professional
cognitive, emotional, and ethical elements of decision making. burnout, depression, and posttraumatic stress among ICU clinicians,
• The use of structured, patient- and family-centered approaches to which should further prompt intensivists to work toward improving
interdisciplinary collaboration around end-of-life care in ICUs.
16-18
end-of-life communication improves outcomes among family of While the three main principles of palliative care are relevant to the
deceased ICU patients. practice of quality critical care, two recent randomized, controlled trials
• The provision of high-quality palliative care requires a multidisci- of interventions designed to integrate fundamental aspects of palliative
plinary approach to effectively address physical, psychosocial, and care such as basic communication techniques for critical care clinicians
spiritual suffering. into existing ICUs systems of care have not shown significant improve-
• An ideal model for palliative care in the ICU should include inte- ments. 19,20 These studies suggest that significant improvements may
grating principles of palliative care into routine ICU practice as require more in-depth interventions as well as involvement of palliative
well as the use of palliative care, ethics, and spiritual support teams care specialists in the care of these patients and families.
for some patients and family members. Fortunately, palliative care is emerging as a separate medical sub-
• Withdrawing or withholding life-sustaining therapy is widely specialty that can be offered in conjunction with conventional critical
accepted and common in the United States. This practice should care. Hospice and Palliative Medicine was recognized as a new medical
adhere to the standards for quality medical care including appro- subspecialty by the American Board of Medical Specialties in 2005 and
priate documentation, attention to detail, an explicit plan for in the United States the growth of palliative care programs in acute care
addressing patient, family, and clinician needs, and interdisciplin- hospitals has been substantial with 30% of US hospitals and 70% of
ary implementation. An institutional protocol may help achieve hospitals with greater than 250 beds offering palliative care programs in
21
these standards. 2005, representing a 96% increase since 2000. Palliative care consults
reduce physical and psychological suffering, 22-24 increase patient and
family satisfaction, reduce costs among patients who die, and increase
23
21
survival in outpatient populations. 24,25
THE ROLE OF PALLIATIVE CARE IN THE ICU Specific to critical care, several studies have found that proactive
■ DEFINING AND UNDERSTANDING PALLIATIVE CARE IN THE ICU approaches to palliative care and/or ethics consultations reduce both
ICU length of stay (LOS) and the use of specific, aggressive ICU thera-
Palliative care is a unique approach and a distinct model of clinical pies among patients who died in the ICU 26-30 and one multicenter, ran-
care when compared to conventional care. It focuses on patients with domized, controlled trial found that proactive ethics consultations could
serious, life-threatening illness and is characterized by three main prin- achieve reductions in hospital LOS, ICU LOS, and days of mechanical
ciples. The first principle is that the overarching goal of palliative care ventilation among decedents. Importantly, none of these investigations
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