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Palliative Care in the ICU: Spotting and Surmounting the Obstacles


Family ratings of ICU experience, quality of dying and death Canada and US ... Savings in ancillary services and pharmacy costs. Morrison RS (unpublished data) ... – PowerPoint PPT presentation

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Title: Palliative Care in the ICU: Spotting and Surmounting the Obstacles

Palliative Care in the ICUSpotting and
Surmounting the Obstacles
  • Judith Nelson, MD, JD
  • Mount Sinai School of Medicine
  • March 2006

Overview of Presentation
  • Empirical Evidence
  • Commentary
  • Palliative Care Consultation
  • Routine Quality Monitoring/Feedback

Death in ICUs
  • Among patients dying in hospitals, half in ICUs
    within 3 days of death one-third have 10 ICU
    days during final hospitalization
  • Each year, 1 in 5 Americans ( gt 500,000 people)
    die in ICU or after ICU tx during terminal hosp
    admission (Angus, CCM 2004)
  • Even with optimal care, mortality for common ICU
    conditions ranges from ? 30 (sepsis, ARDS) to
    ? 75 (MV gt 75 yrs)
  • ?Typically, more death in ICUs than
    anywhere else in the hospital

Existing Evidence Unmet Palliative Needs
  • Communication is deficient, quantitatively and
  • Many patients experience symptom distress,
    underestimated and undertreated by caregivers
  • Prevailing practices (e.g. w/d of LST) are
    inconsistent, irrational
  • Clinicians and others are troubled by the current
  • J Intens Care Med 1999 Crit Care Med 2001
  • - Crit Care Peer

  • Commitment
  • Priority
  • Domains
  • Benefit
  • Philanthropy

Why, then, is change so slow and difficult?
Can we accelerate the process?
Barriers and Beholders
  • Survey Evidence
  • Critical care nurses in AACN
  • Kirchhoff. Am J Crit Care 2000.
  • Nurses and physicians in WV ICUs
  • Moss. W Va Med J 2005.
  • Nursing and physician directors of US ICUs
  • Nelson. (In peer review.)
  • Opinion/Literature Review
  • European perspective
  • Fassier. Curr Opin Crit Care 2005.
  • North American views
  • White. Curr Opin Crit Care 2005.
  • Nelson. Crit Care Med (Supp) 2001
    Crit Care Med (Supp) 2006
    (in press).

End-of-Life CareA National Survey of ICU
  • JE Nelson, DJ Cook, DC Angus, L Weissfeld, M
    Danis, KA Puntillo, D Deal, M Levy
  • For the Robert Wood Johnson Foundation
    Critical Care Peer Workgroup of
    Promoting Excellence in End-of-Life Care

Questionnaire Mailed to RN/MD Directors of
600 ICUs in Random, National Sample
  • Format Possible barriers (32 items)
  • Institutional/ICU, Clinician (MD/RN),
  • 1- a huge barrier to 5- not a barrier at all
  • Validity Clinically sensible and reliable

Nationally-Representative Respondent Cohort
  • 468 of 600 (78) ICUs
  • 428 hospitals
  • 590 of 1205 (49) ICU directors
  • 406 (65.1 ) nursing directors
  • 184 (31.7 ) physician directors

Rating Large/Huge
Mean (S.D.) Rating
National ICU Survey
Barrier to EOL Care
Unrealistic Pt/Family Expectations 46.1 2.5 (1.0)
Patients Unable to Participate 43.9 2.7 (0.9)
Insuffic Training in Commun (MD) 35.6 2.9 (1.1)
Competing Demands on Clinicians (MD) 35.4 3.0 (1.1)
Lack of Advance Directives 32.0 2.9 (1.0)
Disagreement Within Families 31.2 2.9 (0.9)
Inadequate ICU/Family Commun (MD) 27.8 3.1 (1.1)
Fear of Legal Liab for WH/WD LST (MD) 26.3 3.3 (1.2)
Unrealistic Clinician Expectations (MD) 25.1 3.3 (1.1)
Suboptimal Space for Family Mtgs 24.1 3.5 (1.2)
Nurse-Physician Concordance
  • N 85 pairs of responses from MDs and RNs
    representing same ICUs
  • No statistically significant differences re
  • Both disciplines considered MDs to pose greater
    barriers than RNs

Patient and Family Perspectives?
  • Family needs
  • communication, patient comfort
  • Family ratings of ICU experience, quality of
    dying and death Canada and US
  • No direct information published re perceived
    barriers, relative magnitude or importance
  • ? Perspectives of patients and families are
    essential, though difficult to obtain

Core Factors
  • Death denial ? unrealistic expectations
  • Prognostic uncertainty ? paralysis
  • Patient autonomy ? burden, conflict
  • Silos of disciplines, specialties ? fragmented

? ? Slow Change
  • For most patients, two fundamental facts ensure
    that the transition to death will remain
    difficult. First is the
  • widespread and deeply held desire not to be dead.
  • Second is medicines inability to predict the
    future to give patients a precise and reliable
  • When death is the alternative, many patients who
    have only a small amount of hope will pay a high
    price to continue the struggle.
  • Finucane TE. JAMA 1999 2821670.

Prognostic Uncertainty
  • Possibility of survival, in baseline,
    even good health
  • Poor prognosis ? certain death
  • Median predicted 2-month survival of SUPPORT
    patients 20 on day before death, 50 week
    before death
    -Lynn J, New Horizons, 1997

Autonomous Decision-Making
  • Fewer than 10 of ICU patients can participate in
    treatment decisions.
  • Easy to drown in a sea of surrogates, whose
    levels of anxiety and depression impair their own
    capacity for decision-making.
  • -Pochard, CCM 2001 291893
  • -Pochard, JCC 2005 2090

Palliative Care in the ICU
  • Integrative
  • Interdisciplinary
  • Family (and Patient) - Centered

Integrative Palliative Care
  • Incorporated in comprehensive critical care for
    all patients, including those pursuing
    life-prolonging treatments
  • Not simply a sequel to failed intensive care, but
    a synchronous, synergistic, component of ICU

Models for Integrating Palliative Care in the ICU
  • Increased attention to and competency in
    palliative care within the ICU team
  • Increased input from non-ICU palliative care
  • Ends of spectrum, not mutually exclusive

Promoting Palliative Care Excellence in Intensive
Care RWJ Foundation
  • Four demonstration projects
  • U Wash, MGH, Lehigh Valley Hosp, UMDNJ
  • Each project suggests a cultural change in
    critical care settings that fuses palliative care
    into existing practice patterns, and includes
    educating ICU staff and embedding palliative care
    practice in daily hospital routines.

Specific Strategies to Improve EOL Carein ICUs
(National ICU Director Survey)
Strategy Available Helpful
EOL care quality monitoring 26.5 85.5
Bereavement program 29.4 96.7
Regular i/d family mtgs 35.1 92.6
Training in EOL communic 40.0 94.1
Role-modeling by exper clinicians 41.0 95.2
Access to PC Consultants 45.9 88.3
  • Palliative Care Consultation in the ICU
  • Crossing A Cultural Divide

Morrison et al. J Palliat Med (12/05).
Evidence of Benefit
  • Studies show improvements in
  • care quality and costs
  • ? Better control of pain and other
  • ? Higher patient and family satisfaction
  • ? Shorter ICU and hospital length of stay
  • ? Savings in ancillary services and pharmacy
  • Campbell. Chest 2003 123266-71.
  • Higginson. J Pain Sympt Manage 2003
  • Finlay. Ann Oncol 2003 13 Suppl257-64.

Before-After Study of Proactive Palliative Care
Consult in MICU
  • Palliative care consult (NP/MD)
  • Anoxic encephalopathy after cardiac arrest
  • MODS gt3 organs for gt3 days
  • Goals of the consult
  • Communicate prognosis to family
  • Identify patient preferences
  • Discuss treatment options with family
  • Implement palliative care strategies

Campbell, Chest 2003 123266.
Palliative Care Consults in MICU
  • Both diagnostic groups
  • ? time from identification of diagnosis to
    comfort care goals (4-5 days)
  • Anoxic encephalopathy
  • ? ICU and hospital LOS (3-4 days) vs. historical
    control group

Campbell, Chest 2003 123266.
Other Successful Interventions
  • Lilly CM. An intensive communication intervention
    for the critically ill. Am J Med 2000 109 469.
  • Schneiderman LJ. Effect of ethics consultations
    on nonbeneficial life-sustaining treatments in
    the intensive care setting a RCT. JAMA 2003

Mount Sinai Experience 7/04-6/05
  • For patients with PC consultation vs.
    DRG/age-matched controls without
  • ? ICU length of stay, especially for long-stay
  • Both for survivors and non-survivors
  • Savings in ancillary services and pharmacy costs

Morrison RS (unpublished data).
Palliative Care Consultation in the ICU
  • Collaboration is improving - but closed door,
    parallel play, relay-racing, and conflict
  • Respective roles require further definition
  • Locally-appropriate balance needed between
    internal ICU capability and expert input on
    complex or refractory problems

More is More vs. Less is More
  • Both ICU and PCCS to adjust approach
    more or less is more
  • Understand the setting/culture, screen pro-
    actively, respond rapidly, maintain visibility,
    learn the language, respect the
    expertise, offer assistance to ICU (M. Campbell)
  • If you are selling death, you will have very few
    customers (D. Meier)
  • Curtis JR, Rubenfeld. Improving palliative care
    for patients in the intensive care unit. J Pall
    Med 2005 8 840.

Monitoring Palliative Care Quality Honing Our
Domains of ICU End-of-Life Care Quality
  • Patient- and family-centered decision-making
  • Communication
  • Continuity of care
  • Emotional and practical support
  • Symptom management and comfort care
  • Spiritual support
  • Emotional and organizational support for ICU

Clarke et al. Crit Care Med 2003 312255-2262.
VHAs Transformation of the ICU
ProjectPalliative Care Bundle of Quality
  • VHA, Inc. Cooperative network of gt 25 of
    US not-for-profit, academic and community
  • TICU Performance improvement project, gt
    60 ICUs have participated to date

VHAs Palliative Care Bundle
  • Bundle Core set of best practices
    applied together for maximum effect on quality
  • TICU ICUs implemented bundles of quality
    indicators for sepsis, CRBI, vent mgt
  • striking and sustained QI with compliance
  • Palliative Care Bundle in advanced stage of
  • First tool for ongoing, routine, monitoring and
    performance feedback

Development Team
  • J Nelson, MD, JD, P Pronovost, MD, PhD,
  • C Mullerkin, MSW, LCSW, L Adams, MS
  • TICU Clinical Teams, Measurement Team,
    Faculty/Staff Colleagues

Development Process
  • Elicited input from multiple ( 60) TICU ICUS -
    diverse disciplines, perspectives (RN, MD, SW,
    resp therapy, pharmacy, admin)
  • Using strongest available evidence and judgment,
    project team narrowed content for abbreviated,
    feasible tool

External Review
  • Interdisciplinary panel of national experts
    outside TICU
  • National Consensus Proj for Quality Pall Care
  • National Quality Forum
  • RWJF Promoting Excellence in ICU EOL Care
  • Center to Advance Palliative Care
  • Rand Corporation (AHRQ project)

VHA Palliative Care Bundle
  • Day 1
  • (1) Identify decision-maker
  • (2) Address AD status
  • (3) Address CPR status
  • (4) Distribute info leaflet
  • (5) Assess pain regularly
  • (6) Manage pain optimally
  • Day 3
  • (7) Offer social work support
  • (8) Offer spiritual support
  • Day 5
  • (9) Family meeting

(10) Organizational ICU Assessment Family
meeting room
  • Data collection tool
  • Detailed specifications e.g.
  • - numerators and denominators
  • - interdisciplinary family meeting
  • - family information leaflet

  • Process vs outcome measures
  • E.g., whether SW offered, not whether accepted or
    effective whether meeting occurred, not whether
    informative or satisfactory
  • Medical record review vs. direct observation
  • Practical, relevant, action trigger
  • Subset of indicators
  • Avoid undue measurement burden, while relying on
    strongest available evidence

Pilot Data Collection November 2005
  • 16 ICUs Med/Surg (5), Mixed (4), Med (4), Surg
    (3) 10 hospitals, N 94
  • Information Leaflet 43.2
  • Social Work Support 61.1
  • Spiritual Support 37.5
  • Interdiscipl Fam Meeting 40.0

Further Testing of Measuresas Quality Indicators
  • Patient/family perspective
  • Impact on selected outcomes
  • System redesign for implementation

  • Improving the Quality of EOL Care in the ICU
    Interventions that Work (2/06) ? CCM Supp 06
  • Am Coll CC Med Updating Recommendations for EOL
    Care in the ICU (original CCM 2001)
  • VHA Palliative Care Bundle of Quality Measures
  • RWJ Grantees Emerging Reports
  • Collaborations between AAHPM and critical care
    professional societies
  • Communication Skills Training

The fastest way to our objectives is to
observe the speed limits.