CHAPTER 17: Incorporating Palliative Care in the ICU

KEY POINTS

• The patient and family are the focus of palliative care.

• Palliative care seeks to improve the quality of life of patients with life-threatening illness by relieving suffering.

• Palliative interventions can replace or complement care intended to extend life.

• Critical care clinicians must become skilled at providing primary palliative care and working with specialty palliative care providers.

• Two features characterize excellent ICU communication: a structured approach to family conferences and providing printed informational materials.

• In most countries, deaths in ICU are preceded by withdrawing or withholding some aspect of life-sustaining treatment.

• Conflict regarding goals of care between intensivists and patients (or surrogates) can be reduced by proactive communication and early involvement of interdisciplinary consultants.

THE ROLE OF PALLIATIVE CARE IN THE ICU

Defining and Understanding Palliative Care

Palliative care is a unique approach and a distinct model of clinical care when focusing on patients with serious, life-threatening illness and is characterized by three main principles.¹ The first principle is to improve the quality of life through the relief of suffering in each of its major domains: physical, emotional, psychosocial, and spiritual. Thus, follows the second principle that palliative care is provided by an interdisciplinary team which generally includes the professions of medicine, nursing, social work/counseling, and chaplaincy. The third principle is that the patient and family are the focus of care rather than only the patient. Palliative care in the ICU context is often delivered through a combination of “primary palliative care” delivered by ICU clinicians and “specialty palliative care” incorporating palliative care specialists.² An important feature of palliative care for 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 critical care and palliative care.

Given the substantial risk of suffering and death for many critically ill and injured patients, ICU clinicians can enhance important aspects of patient and family outcomes by considering how to integrate these principles into their practices. In the last two decades, critical care has increasingly valued the importance of symptom management,^3–5 emotional and psychological outcomes,⁶ and psychosocial support.^7–9 More generally, investigation into health-related quality of life following critical illness has identified important deficiencies,^10,11 especially when considered in the context of the substantial resources invested. For example, critical care costs are estimated to be approximately $100 billion annually¹² and a large proportion of this spending is for the patients who die in the ICU despite the use of advanced technologies and therapeutic interventions. In the context of end of life, a national assessment among Medicare beneficiaries has found that 30% of beneficiaries have an ICU admission in the last month of life.¹³ Another study has found that 20% of all deaths in the United States occur in the ICU or shortly thereafter.¹⁴ These findings support the ...