Integrating palliative care into the ICU: a lasting and developing legacy

Palliative Care in the Intensive Care Unit: The Standard of Care

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.

Triggers of intensive care patients with palliative care needs from nurses' perspective: a mixed methods study

PURPOSE

Triggers have been developed internationally to identify intensive care patients with palliative care needs. Due to their work, nurses are close to the patient and their perspective should therefore be included. In this study, potential triggers were first identified and then a questionnaire was developed to analyse their acceptance among German intensive care nurses.

METHODS

For the qualitative part of this mixed methods study, focus groups were conducted with intensive care nurses from different disciplines (surgery, neurosurgery, internal medicine), which were selected by convenience. Data were analysed using the "content-structuring content analysis" according to Kuckartz. For the quantitative study part, the thus identified triggers formed the basis for questionnaire items. The questionnaire was tested for comprehensibility in cognitive pretests and for feasibility in a pilot survey.

RESULTS

In the qualitative part six focus groups were conducted at four university hospitals. From the data four main categories (prognosis, interprofessional cooperation, relatives, patients) with three to 15 subcategories each could be identified. The nurses described situations requiring palliative care consults that related to the severity of the disease, the therapeutic course, communication within the team and between team and patient/relatives, and typical characteristics of patients and relatives. In addition, a professional conflict between nurses and physicians emerged. The questionnaire, which was developed after six cognitive interviews, consists of 32 items plus one open question. The pilot had a response rate of 76.7% (23/30), whereby 30 triggers were accepted with an agreement of ≥ 50%.

CONCLUSION

Intensive care nurses see various triggers, with interprofessional collaboration and the patient's prognosis playing a major role. The questionnaire can be used for further surveys, e.g. interprofessional triggers could be developed.

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.

Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit

End-of-life care (EOLC) exemplifies the joint mission of intensive and palliative care (PC) in their human-centeredness. The explosion of technological advances in medicine must be balanced with the culture of holistic care. Inevitably, it brings together the science and the art of medicine in their full expression. High-quality EOLC in the ICU is grounded in evidence, ethical principles, and professionalism within the framework of the Law. Expert professional statements over the last two decades in India were developed while the law was evolving. Recent landmark Supreme Court judgments have necessitated a review of the clinical pathway for EOLC outlined in the previous statements. Much empirical and interventional evidence has accumulated since the position statement in 2014. This iteration of the joint Indian Society of Critical Care Medicine-Indian Association of Palliative Care (ISCCM-IAPC) Position Statement for EOLC combines contemporary evidence, ethics, and law for decision support by the bedside in Indian ICUs.

How to cite this article

Mani RK, Bhatnagar S, Butola S, Gursahani R, Mehta D, Simha S, et al. Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit. Indian J Crit Care Med 2024;28(3):200-250.

[Comfort Terminal Care in the intensive care unit: recommendations for practice]

BACKGROUND AND OBJECTIVE

The Working Group on Ethics in Anesthesia and Intensive Care Medicine of the Austrian Society for Anesthesiology Resuscitation and Intensive Care Medicine (ÖGARI) already developed documentation tools for the adaption of therapeutic goals 10 years ago. Since then the practical implementation of Comfort Terminal Care in the daily routine in particular has raised numerous questions, which are discussed in this follow-up paper and answered in an evidence-based manner whenever possible.

RESULTS

The practical implementation of pain therapy and reduction of anxiety, stress and respiratory distress that are indicated in the context of Comfort Terminal Care are described in more detail. The measures that are not (or no longer) indicated, such as oxygen administration and ventilation as well as the administration of fluids and nutrition, are also commented on. Furthermore, recommendations are given regarding monitoring, (laboratory) findings and drug treatment and the importance of nursing actions in the context of Comfort Terminal Care is mentioned. Finally, the support for the next of kin and the procedure in the time after death are presented.

DISCUSSION

A change in treatment goals with a timely switch to Comfort Terminal Care enables good and humane care for seriously ill patients and their relatives at the end of life and the appreciation of their previous life with the possibility of positive experiences until the end.

Futile life-sustaining treatment in the intensive care unit - nurse and physician experiences: meta-synthesis

BACKGROUND

Continuing futile life-sustaining treatment prolongs patients' suffering and family members' and medical staff's psychological distress. Additionally, continuing futile treatment is inefficient in healthcare resource distribution. Although the withdrawal of futile life-sustaining treatment is ideal, the prevalence is variable.

OBJECTIVE

To synthesise nurses' and physicians' experiences with continuing futile life-sustaining treatment in the intensive care unit.

DESIGN

This meta-synthesis was conducted following the thematic synthesis. The Preferred Reporting Items for Systematic Review and Meta-Analyses and Enhancing transparency in reporting the synthesis of qualitative research statement were used in reporting the synthesis of qualitative research statements.

METHODS AND DATA SOURCES

A systematic search was conducted following the inclusion and exclusion criteria in APA PsycINFO, CINAHL Plus, EMBASE, MEDLINE, PubMed and Web of Science in May 2023. Two reviewers independently screened and extracted the data. The extracted data were analysed using thematic analysis of qualitative research.

FINDINGS

A total of 16 studies were finally included, and 141 quotes were extracted and analysed. The main findings were categorised into four themes: (1) contextual and cultural diversity, (2) perceptions of futile treatment, (3) professional roles and responsibilities, and (4) emotional distress.

CONCLUSION

The study highlights the influence of culture, religion and family members, as well as perceptions of futile treatment among clinicians, on continuing futile life-sustaining treatment. Also, nurses' awareness of their roles and responsibilities in ensuring patients' comfort at end of life was revealed. This study informs future research to explore the experiences of futile life-sustaining treatment across various contexts.

Easing Suffering for ICU Patients and Their Families: Evidence and Opportunities for Primary and Specialty Palliative Care in the ICU

Intensive care unit (ICU) admissions are often accompanied by many physical and existential pressure points that can be extraordinarily wearing on patients and their families and surrogate decision makers (SDMs). Multidisciplinary palliative support, including physicians, advanced practice nurses, nutritionists, chaplains and other team members, may alleviate many of these sources of potential suffering. However, the palliative needs of ICU patients undoubtedly exceed the bandwidth of current consultative specialty palliative medicine teams. Informed by standard-of-care palliative medicine domains, we review common ICU symptoms (pain, dyspnea and thirst) and their prevalence, sources and their treatment. We then identify palliative needs and impacts in the domains of communication, SDM support and transitions of care for patients and their families through their journey in the ICU, from discharge and recovery at home to chronic critical illness, post-ICU disability or death. Finally, we examine the evidence for strategies to incorporate specialty palliative medicine and palliative principles into ICU care for the improvement of patient- and family-centered care. While randomized controlled studies have failed to demonstrate measurable improvement in pre-determined outcomes for patient- and family-relevant outcomes, embracing the principles of palliative medicine and assuring their delivery in the ICU is likely to translate to overall improvement in humanistic, person-centered care that supports patients and their SDMs during and following critical illness.

Identification of Palliative Care Needs and Mental Health Outcomes Among Family Members of Patients With Severe Acute Brain Injury

Importance

Family members of patients with severe acute brain injury (SABI) are at risk for poor psychological outcomes.

Objective

To explore the utility of the early use of a palliative care needs checklist in identifying care needs of patients with SABI and family members who are at risk of poor psychological outcomes.

Design, Setting, and Participants

This prospective cohort study included patients with SABI in an intensive care unit (ICU) for 2 days or more and a Glasgow Coma Scale score of 12 or lower and their family members. This single-center study was conducted at an academic hospital in Seattle, Washington, from January 2018 to June 2021. Data were analyzed from July 2021 to July 2022.

Exposure

At enrollment, a 4-item palliative care needs checklist was completed separately by clinicians and family members.

Main Outcomes and Measures

A single family member for each enrolled patient completed questionnaires assessing symptoms of depression and anxiety, perception of goal-concordant care, and satisfaction in the ICU. Six months later, family members assessed their psychological symptoms, decisional regret, patient functional outcome, and patient quality of life (QOL).

Results

A total of 209 patient-family member pairs (family member mean [SD] age, 51 [16] years; 133 women [64%]; 18 Asian [9%], 21 Black [10%], 20 [10%] Hispanic, and 153 White [73%] participants) were included. Patients had experienced stroke (126 [60%]), traumatic brain injury (62 [30%]), and hypoxic-ischemic encephalopathy (21 [10%]). At least 1 need was identified for 185 patients or their families (88%) by family members and 110 (53%) by clinicians (κ = -0.007; 52% agreement). Symptoms of at least moderate anxiety or depression were present in 50% of family members at enrollment (87 with anxiety and 94 with depression) and 20% at follow-up (33 with anxiety and 29 with depression). After adjustment for patient age, diagnosis, and disease severity and family race and ethnicity, clinician identification of any need was associated with greater goal discordance (203 participants; relative risk = 1.7 [95% CI, 1.2 to 2.5]) and family decisional regret (144 participants; difference in means, 17 [95% CI, 5 to 29] points). Family member identification of any need was associated with greater symptoms of depression at follow-up (150 participants; difference in means of Patient Health Questionnaire-2, 0.8 [95% CI, 0.2 to 1.3] points) and worse perceived patient QOL (78 participants; difference in means, -17.1 [95% CI, -33.6 to -0.5] points).

Conclusions and Relevance

In this prospective cohort study of patients with SABI and their families, palliative care needs were common, although agreement on needs was poor between clinicians and family members. A palliative care needs checklist completed by clinicians and family members may improve communication and promote timely, targeted management of needs.