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Wiencek C. Palliative Care in the Intensive Care Unit: The Standard of Care. AACN Adv Crit Care 2024; 35:112-124. [PMID: 38848570 DOI: 10.4037/aacnacc2024525] [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] [Indexed: 06/09/2024]
Abstract
Intensive care unit-based palliative care has evolved over the past 30 years due to the efforts of clinicians, researchers, and advocates for patient-centered care. Although all critically ill patients inherently have palliative care needs, the path was not linear but rather filled with the challenges of blending the intensive care unit goals of aggressive treatment and cure with the palliative care goals of symptom management and quality of life. Today, palliative care is considered an essential component of high-quality critical care and a core competency of all critical care nurses, advanced practice nurses, and other intensive care unit clinicians. This article provides an overview of the current state of intensive care unit-based palliative care, examines how the barriers to such care have shifted, reviews primary and specialist palliative care, addresses the impact of COVID-19, and presents resources to help nurses and intensive care unit teams achieve optimal outcomes.
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Affiliation(s)
- Clareen Wiencek
- Clareen Wiencek is Professor of Nursing, University of Virginia School of Nursing, 202 Jeanette Lancaster Way, Charlottesville, VA 22908
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Campbell ML, Yarandi HN. Effectiveness of an Algorithmic Approach to Ventilator Withdrawal at the End of Life: A Stepped Wedge Cluster Randomized Trial. J Palliat Med 2024; 27:185-191. [PMID: 37594769 PMCID: PMC10825265 DOI: 10.1089/jpm.2023.0128] [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] [Accepted: 07/27/2023] [Indexed: 08/19/2023] Open
Abstract
Background: The transition to spontaneous breathing puts patients who are undergoing ventilator withdrawal at high risk for developing respiratory distress. A patient-centered algorithmic approach could standardize this process and meet unique patient needs because a single approach (weaning vs. one-step extubation) does not capture the needs of a heterogenous population undergoing this palliative procedure. Objectives: (1) Demonstrate that the algorithmic approach can be effective to ensure greater patient respiratory comfort compared to usual care; (2) determine differences in opioid or benzodiazepine use; (3) predict factors associated with duration of survival. Design/Settings/Measures: A stepped-wedge cluster randomized design at five sites was used. Sites crossed over to the algorithm in random order after usual care data were obtained. Patient comfort was measured with the Respiratory Distress Observation Scale© (RDOS) at baseline, at ventilator off, and every 15-minutes for an hour. Parenteral morphine and lorazepam equivalents from the onset of the process until patient death were calculated. Results: Usual care data n = 120, algorithm data n = 48. Gender and race were evenly distributed. All patients in the usual care arm underwent a one-step ventilator cessation; 58% of patients in the algorithm arm were weaned over an average of 18 ± 27 minutes as prescribed in the algorithm. Patients had significantly less respiratory distress in the intervention arm (F = 10.41, p = 0.0013, effective size [es] = 0.49). More opioids (t = -2.30, p = 0.023) and benzodiazepines (t = -2.08, p = 0.040) were given in the control arm. Conclusions: The algorithm was effective in ensuring patient respiratory comfort. Surprisingly, more medication was given in the usual care arm; however, less may be needed when distress is objectively measured (RDOS), and treatment is initiated as soon as distress develops as in the algorithm. Clinical Trial Registration number: NCT03121391.
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Mazzu MA, Campbell ML, Schwartzstein RM, White DB, Mitchell SL, Fehnel CR. Evidence Guiding Withdrawal of Mechanical Ventilation at the End of Life: A Review. J Pain Symptom Manage 2023; 66:e399-e426. [PMID: 37244527 PMCID: PMC10527530 DOI: 10.1016/j.jpainsymman.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 05/10/2023] [Accepted: 05/19/2023] [Indexed: 05/29/2023]
Abstract
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.
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Affiliation(s)
- Maria A Mazzu
- University of New England College of Osteopathic Medicine (M.A.M.), Biddeford, Maine, USA
| | | | - Richard M Schwartzstein
- Beth Israel Deaconess Medical Center (R.M.S., S.L.M., C.R.F.), Boston, Massachusetts, USA; Harvard Medical School (R.M.S., S.L.M., C.R.F.), Boston, Massachusetts, USA
| | - Douglas B White
- University of Pittsburgh School of Medicine (D.B.W.), Pittsburgh, Pennsylvania, USA
| | - Susan L Mitchell
- Beth Israel Deaconess Medical Center (R.M.S., S.L.M., C.R.F.), Boston, Massachusetts, USA; Harvard Medical School (R.M.S., S.L.M., C.R.F.), Boston, Massachusetts, USA; Hebrew SeniorLife, Marcus Institute for Aging Research (S.L.M., C.R.F.), Boston, Massachusetts, USA
| | - Corey R Fehnel
- Beth Israel Deaconess Medical Center (R.M.S., S.L.M., C.R.F.), Boston, Massachusetts, USA; Harvard Medical School (R.M.S., S.L.M., C.R.F.), Boston, Massachusetts, USA; Hebrew SeniorLife, Marcus Institute for Aging Research (S.L.M., C.R.F.), Boston, Massachusetts, USA.
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Le Dorze M, Barthélémy R, Giabicani M, Audibert G, Cousin F, Gakuba C, Robert R, Chousterman B, Perrigault PF. Continuous and deep sedation until death after a decision to withdraw life-sustaining therapies in intensive care units: A national survey. Palliat Med 2023; 37:1202-1209. [PMID: 37306034 DOI: 10.1177/02692163231180656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Continuous and deep sedation until death is a much highly debated end-of-life practice. France is unique in having a regulatory framework for it. However, there are no data on its practice in intensive care units (ICUs). AIM The aim is to describe continuous and deep sedation in relation to the framework in the specific context of withdrawal of life-sustaining therapies in ICUs, that is, its decision-making process and its practice compared to other end-of-life practices in this setting. DESIGN AND SETTING French multicenter observational study. Consecutive ICU patients who died after a decision to withdraw life-sustaining therapies. RESULTS A total of 343 patients in 57 ICUs, 208 (60%) with continuous and deep sedation. A formalized procedure for continuous and deep sedation was available in 32% of the ICUs. Continuous and deep sedation was not the result of a collegial decision-making process in 17% of cases, and did not involve consultation with an external physician in 29% of cases. The most commonly used sedative medicines were midazolam (10 [5-18] mg h-1) and propofol (200 [120-250] mg h -1). The Richmond Agitation Sedation Scale (RASS) was -5 in 60% of cases. Analgesia was associated with sedation in 94% of cases. Compared with other end-of-life sedative practices (n = 98), medicines doses were higher with no difference in the depth of sedation. CONCLUSIONS This study shows a poor compliance with the framework for continuous and deep sedation. It highlights the need to formalize it to improve the decision-making process and the match between the intent, the practice and the actual effect.
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Affiliation(s)
- Matthieu Le Dorze
- Department of Anesthesia and Critical Care Medicine, DMU PARABOL, Lariboisière Hospital, AP-HP Nord, Paris, France
- Université Paris-Saclay, CESP U1018, Inserm, Paris, France
- Université de Paris, UMR-S 942 (MASCOT), Inserm, Paris, France
| | - Romain Barthélémy
- Department of Anesthesia and Critical Care Medicine, DMU PARABOL, Lariboisière Hospital, AP-HP Nord, Paris, France
- Université de Paris, UMR-S 942 (MASCOT), Inserm, Paris, France
| | - Mikhael Giabicani
- Department of Anaesthesia and Critical Care, AP-HP, Beaujon Hospital, Paris, France
- Sorbonne Université, Inserm, Centre de Recherche des Cordeliers, Laboratoire ETREs, Paris, France
| | - Gérard Audibert
- Department of Anaesthesia and Critical Care Medicine, CHRU Nancy, Université de Lorraine, Nancy, France
| | - François Cousin
- Centre national des soins palliatifs et de la fin de vie (CNSPFV), Paris, France
| | - Clément Gakuba
- Department of Anesthesia and Critical Care Medicine, Caen, France
| | - René Robert
- Médecine Intensive Réanimation, CHU Poitiers, F-86000, Poitiers, France
- Université de Poitiers, CIC Inserm ALIVE, F-86000, Poitiers, France
| | - Benjamin Chousterman
- Department of Anesthesia and Critical Care Medicine, DMU PARABOL, Lariboisière Hospital, AP-HP Nord, Paris, France
- Université de Paris, UMR-S 942 (MASCOT), Inserm, Paris, France
| | - Pierre-François Perrigault
- Department of Anesthesia and Critical Care Medicine, Gui de Chauliac University Hospital, Université de Montpellier, Montpellier, France
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Sloss R, Mehta R, Metaxa V. End-of-Life and Palliative Care in a Critical Care Setting: The Crucial Role of the Critical Care Pharmacist. PHARMACY 2022; 10:pharmacy10050107. [PMID: 36136840 PMCID: PMC9498871 DOI: 10.3390/pharmacy10050107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 08/23/2022] [Accepted: 08/26/2022] [Indexed: 11/16/2022] Open
Abstract
Critical care pharmacists play an important role in ICU patient care, with evidence showing reductions in drug prescribing errors, adverse drug events and costs, as well as improvement in clinical outcomes, such as mortality and length of ICU stay. Caring for critically ill patients around the end of their life is complicated by the acute onset of their illness and the fact that most of them are unable to communicate any distressing symptoms. Critical care pharmacists are an integral part of the ICU team during a patient’s end-of-life care and their multifaceted role includes clinical support for bedside staff, education, and training, as well as assistance with equipment and logistics. In this article, we highlight the important role of the ICU pharmacist using a ‘real-life’ clinical case from our hospital.
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Affiliation(s)
- Rhona Sloss
- Pharmacy Department, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK
- Department of Critical Care Medicine, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK
- Correspondence:
| | - Reena Mehta
- Pharmacy Department, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK
- Department of Critical Care Medicine, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK
- Faculty of Life Sciences and Medicine, School of Cancer & Pharmaceutical Sciences, King’s College London, London WC2R 2LS, UK
| | - Victoria Metaxa
- Department of Critical Care Medicine, King’s College Hospital NHS Foundation Trust, London SE5 9RS, UK
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Cao W, Li C, Zhang Q, Tong H. Perceptions on the current content and pedagogical approaches used in end-of-life care education among undergraduate nursing students: a qualitative, descriptive study. BMC MEDICAL EDUCATION 2022; 22:553. [PMID: 35842629 PMCID: PMC9288025 DOI: 10.1186/s12909-022-03625-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 07/08/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND With the aging of the population, high rates of cancer and comorbidity complexity, the end-of-life care for patients will be ever more important. Nurses have always played an essential role in end-of-life care. Insufficient education and training in end-of-life care has been regarded as a major reason of inadequate symptom recognition, symptom management, and communication which results in mental trauma for both the patient's family and attending health care providers. Undergraduate nurses do end-of-life care as part of their clinical learning. However, undergraduate nurses' perceptions of the education they received about end-of-life care are not documented. OBJECTIVE This study aimed to critically explore the current state of education regarding end-of-life care from the perspectives of undergraduate nurses. METHODS We used a descriptive qualitative design. Face-to-face semi-structured interviews were conducted from May to August 2020, with a purposive sample of 15 fourth-year undergraduate nurses who finished the internship. Data were transcribed verbatim and analyzed using content analysis. FINDINGS Three main themes relating to undergraduate nurses' experiences of end-of-life care education emerged from the thematic analysis: 1) Universities provide foundational knowledge about end-of-life care, but it still needs improvement; 2) Clinical practice consolidates and drives undergraduate nurses' knowledge, skills and confidence about end-of-life care; and 3) cultural attitudes of patients' family toward disease and death sometimes impedes learning and knowledge translation about end-of-life care. CONCLUSION Undergraduate nursing students benefit from not only theoretical content delivered in the university setting but also practice happened on clinical placement. The current undergraduate curriculum, related to end-of-life care, is disjointed. Meanwhile, undergraduate nurses' learning and knowledge translation of end-of-life care are impeded by cultural attitudes toward disease and death.
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Affiliation(s)
- Wenjing Cao
- Nursing School, Xiangnan University, Chenzhou, Hunan, China
| | - Chunyan Li
- Nursing School, Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Qianqian Zhang
- Nursing School, Xiangnan University, Chenzhou, Hunan, China
| | - Huiru Tong
- Foreign Language Department, Guangxi University of Chinese Medicine, Nanning, Guangxi, China.
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Laserna A, Cuenca JA, Fowler C, Duran-Crane A. Pain management during the withholding and withdrawal of life support in critically ill patients at the end of life: a response to a comment. Intensive Care Med 2021; 47:491-492. [PMID: 33635354 DOI: 10.1007/s00134-020-06344-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Andres Laserna
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, NY, USA.
| | - John A Cuenca
- Department of Critical Care, Division of Anesthesiology, Critical Care and Pain, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cosmo Fowler
- Department of Medicine, Case Western Reserve University-MetroHealth Medical Center, Cleveland, OH, USA
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Withholding and withdrawal of life support in critically ill patients at the end of life: pain is not the only symptom to manage. Intensive Care Med 2021; 47:489-490. [PMID: 33575833 PMCID: PMC7877903 DOI: 10.1007/s00134-020-06345-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2020] [Indexed: 11/21/2022]
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Epker JL, Valkenburg AJ, Kompanje EJO. Double data and dubious conclusions, 'Houston do we have a problem?'. Intensive Care Med 2021; 47:487-488. [PMID: 33527155 PMCID: PMC8035097 DOI: 10.1007/s00134-020-06315-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2020] [Indexed: 12/01/2022]
Affiliation(s)
- J L Epker
- Department of Intensive Care Medicine, Erasmus MC, Rotterdam, The Netherlands.
| | - A J Valkenburg
- Department of Intensive Care Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - E J O Kompanje
- Department of Intensive Care Medicine, Erasmus MC, Rotterdam, The Netherlands
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