Margaret L. Campbell

Recommendations for end-of-life care in the intensive care unit: A consensus statement by the American College of Critical Care Medicine

Background:These recommendations have been developed to improve the care of intensive care unit (ICU) patients during the dying process. The recommendations build on those published in 2003 and highlight recent developments in the field from a U.S. perspective. They do not use an evidence grading system because most of the recommendations are based on ethical and legal principles that are not derived from empirically based evidence. Principal Findings:Family-centered care, which emphasizes the importance of the social structure within which patients are embedded, has emerged as a comprehensive ideal for managing end-of-life care in the ICU. ICU clinicians should be competent in all aspects of this care, including the practical and ethical aspects of withdrawing different modalities of life-sustaining treatment and the use of sedatives, analgesics, and nonpharmacologic approaches to easing the suffering of the dying process. Several key ethical concepts play a foundational role in guiding end-of-life care, including the distinctions between withholding and withdrawing treatments, between actions of killing and allowing to die, and between consequences that are intended vs. those that are merely foreseen (the doctrine of double effect). Improved communication with the family has been shown to improve patient care and family outcomes. Other knowledge unique to end-of-life care includes principles for notifying families of a patient’s death and compassionate approaches to discussing options for organ donation. End-of-life care continues even after the death of the patient, and ICUs should consider developing comprehensive bereavement programs to support both families and the needs of the clinical staff. Finally, a comprehensive agenda for improving end-of-life care in the ICU has been developed to guide research, quality improvement efforts, and educational curricula. Conclusions:End-of-life care is emerging as a comprehensive area of expertise in the ICU and demands the same high level of knowledge and competence as all other areas of ICU practice.

Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: A report from the IPAL-ICU Project (Improving Palliative Care in the ICU)

Objective:To describe models used in successful clinical initiatives to improve the quality of palliative care in critical care settings. Data Sources:We searched the MEDLINE database from inception to April 2010 for all English language articles using the terms “intensive care,” “critical care,” or “ICU” and “palliative care”; we also hand-searched reference lists and author files. Based on review and synthesis of these data and the experiences of our interdisciplinary expert Advisory Board, we prepared this consensus report. Data Extraction and Synthesis:We critically reviewed the existing data with a focus on models that have been used to structure clinical initiatives to enhance palliative care for critically ill patients in intensive care units and their families. Conclusions:There are two main models for intensive care unit-palliative care integration: 1) the “consultative model,” which focuses on increasing the involvement and effectiveness of palliative care consultants in the care of intensive care unit patients and their families, particularly those patients identified as at highest risk for poor outcomes; and 2) the “integrative model,” which seeks to embed palliative care principles and interventions into daily practice by the intensive care unit team for all patients and families facing critical illness. These models are not mutually exclusive but rather represent the ends of a spectrum of approaches. Choosing an overall approach from among these models should be one of the earliest steps in planning an intensive care unit-palliative care initiative. This process entails a careful and realistic assessment of available resources, attitudes of key stakeholders, structural aspects of intensive care unit care, and patterns of local practice in the intensive care unit and hospital. A well-structured intensive care unit-palliative care initiative can provide important benefits for patients, families, and providers.

A proactive approach to improve end-of-life care in a medical intensive care unit for patients with terminal dementia.

Objectives:To compare usual care with a proactive case-finding approach for critically ill patients with terminal dementia using an inpatient palliative care service. Design:Prospective comparison to historical control. Setting:Urban, university-affiliated hospital. Patients:Total of 52 men and women with end-stage dementia, 26 subjects in each control and intervention group. Interventions:Proactive case-finding by the palliative care service was done to offer early assistance to the intensive care unit staff about the treatment of patients with terminal dementia. Results were compared with data obtained retrospectively. Measurements and Main Results:Measurements included age, gender, Acute Physiology and Chronic Health Evaluation Score, Therapeutic Intervention Scoring System, mortality, intensive care unit and hospital lengths of stay, frequency, timing, and goals of do-not-resuscitate orders. The proactive, case-finding approach decreased hospital and medical intensive care unit length of stay. More important, a proactive palliative intervention decreased the time between identification of the poor prognosis and the establishment of do-not-resuscitate goals, decreased the time terminal demented patients remained in the intensive care unit, and reduced the use of nonbeneficial resources, thus reducing patient burden and the cost of care while having the potential to afford the patient and family increased comfort and psychoemotional support. Conclusions:Proactive interventions from a palliative care consultant within this subset of patients improved end-of-life care and decreased use of superfluous resources.

Patient responses during rapid terminal weaning from mechanical ventilation: a prospective study.

OBJECTIVE To describe and analyze patient responses to rapid terminal weaning from mechanical ventilation. DESIGN A prospective, descriptive, correlational study. SETTING An urban, university-affiliated, trauma/emergency hospital. PATIENTS A convenience sample of 31 adult patients experiencing withdrawal of mechanical ventilation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Physiologic (peripheral oxygen saturation, end-tidal CO2, heart rate, and respiratory rate) and comfort (electroencephalogram [EEG], Bizek Agitation Scale, and the COMFORT scale) measures were collected at baseline, during, and after the terminal weaning procedure. Clinical status was measured using the Acute Physiology and Chronic Health Evaluation score, Glasgow Coma Scale, and PaO2/F(IO2). Duration of survival after the wean inversely correlated with illness severity but did not correlate with consciousness, use of analgesia/sedation, or pulmonary function. Respiratory rate and oxygen saturation changed significantly during the wean but not end-tidal CO2. Patients remained comfortable with little or no analgesia/sedation, in a predominantly comatose sample. Subjective measures of comfort strongly correlated with objective data from bispectral analysis of EEG. CONCLUSIONS Patients with altered consciousness or coma can be kept comfortable during a rapid terminal weaning procedure with morphine and benzodiazepines in low doses. Comfort can be reliably evaluated using subjective scales.

Choosing and using screening criteria for palliative care consultation in the ICU: A report from the improving palliative care in the ICU (IPAL-ICU) advisory board

Objective:To review the use of screening criteria (also known as “triggers”) as a mechanism for engaging palliative care consultants to assist with care of critically ill patients and their families in the ICU. Data Sources:We searched the MEDLINE database from inception to December 2012 for all English-language articles using the terms “trigger,” “screen,” “referral,” “tool,” “triage,” “case-finding,” “assessment,” “checklist,” “proactive,” or “consultation,” together with “intensive care” or “critical care” and “palliative care,” “supportive care,” “end-of-life care,” or “ethics.” We also hand-searched reference lists and author files and relevant tools on the Center to Advance Palliative Care website. Study SelectionTwo members (a physician and a nurse with expertise in clinical research, intensive care, and palliative care) of the interdisciplinary Improving Palliative Care in the ICU Project Advisory Board presented studies and tools to the full Board, which made final selections by consensus. Data ExtractionWe critically reviewed the existing data and tools to identify screening criteria for palliative care consultation, to describe methods for selecting, implementing, and evaluating such criteria, and to consider alternative strategies for increasing access of ICU patients and families to high-quality palliative care. Data SynthesisThe Improving Palliative Care in the ICU Advisory Board used data and experience to address key questions relating to: existing screening criteria; optimal methods for selection, implementation, and evaluation of such criteria; and appropriateness of the screening approach for a particular ICU. Conclusions:Use of specific criteria to prompt proactive referral for palliative care consultation seems to help reduce utilization of ICU resources without changing mortality, while increasing involvement of palliative care specialists for critically ill patients and families in need. Existing data and resources can be used in developing such criteria, which should be tailored for a specific ICU, implemented through an organized process involving key stakeholders, and evaluated by appropriate measures. In some settings, other strategies for increasing access to palliative care may be more appropriate.

A Respiratory Distress Observation Scale for Patients Unable To Self-Report Dyspnea

BACKGROUND Standard measures of dyspnea rely on self-report. Cognitive impairment and nearness to death may interfere with symptom distress reporting leading to underrecognition and overtreatment or undertreatment. Previous psychometric testing of the Respiratory Distress Observation Scale (RDOS) demonstrated internal consistency and convergent validity with dyspnea self-report and discriminant validity with pain and no dyspnea. Additional testing was needed with patients unable to self-report. The aim of this study was to establish further the reliability and construct validity of a revised RDOS. METHODS An observational design was used with 89 consecutive patients referred for inpatient palliative care consultation and at risk for dyspnea who had one or more of lung cancer, chronic obstructive pulmonary disease (COPD), heart failure, or pneumonia. Patients were observed and the RDOS scored once each day for up to three days after the initial consultation. Other measures included: dyspnea self-report, neurologic diagnoses, opioid or benzodiazepine use, peripheral oxygen saturation, end-tidal carbon dioxide level, consciousness, cognitive state, nearness to death, and patient demographics. RESULTS Perfect interrater reliability across data collectors was achieved. No differences in RDOS scoring were found by patient demographics. RDOS was associated with use of oxygen (p < 0.01), oxygen saturation (p < 0.01) and nearness to death (p < 0.01). A significant decrease in RDOS was found over time corresponding with treatment (p < 0.01). The reliability of this 8-item scale using Cronbach alpha is 0.64. CONCLUSIONS Declining consciousness and/or cognition are expected when patients are near death. The RDOS performed well when tested with terminally ill patients who were at risk for respiratory distress, most of whom could not self-report dyspnea. The tool is sensitive to detect changes over time and measure response to treatment. The RDOS is simple to use; scoring takes less than 5 minutes. The RDOS has clinical and research utility to measure and trend respiratory distress and response to treatment.

Experience with an end-of-life practice at a university hospital

OBJECTIVE To describe a 10-yr experience with an end-of-life practice in a hospital. DESIGN A nonexperimental, prospective, descriptive design was used to record variables from a convenience sample of patients transferred to the Comprehensive Supportive Care Team. SETTING Detroit Receiving Hospital is an urban, university-affiliated, Level I trauma/emergency hospital. PATIENTS Patients who are not expected to survive hospitalization, and for whom a decision has been made to focus care on palliative interventions, are candidates for care by this practice. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patient demographics, including the following information: age, gender; diagnoses; illness severity; mortality rate; and disposition. Measures of resource utilization included: referral sources; Therapeutic intervention Scoring System values; bed costs; and length of hospital stay. Satisfactory patient/family care with a measurable reeducation in the use of resources can be achieved in the hospital setting. CONCLUSIONS A hands-on approach to the care of dying patients by this specialty, palliative care service has provided patients, families, and clinicians with the type of support needed for satisfactory end-of-life care. A summary of our experience may be useful to others.

Integrating Palliative Care in the ICU: The Nurse in a Leading Role.

Palliative care is increasingly recognized as an integral component of comprehensive intensive care for all critically ill patients, regardless of prognosis, and for their families. Here we discuss the key role that nurses can and must continue to play in making this evidence-based paradigm a clinical reality across a broad range of ICUs. We review the contributions of nurses to implementation of ICU safety initiatives as a model that can be applied to ICU palliative care integration. We focus on the importance of nursing involvement in design and application of work processes that facilitate this integration in a systematic way, including processes that ensure the participation of nurses in discussions and decision making with families about care goals. We suggest ways that nurses can help to operationalize an integrated approach to palliative care in the ICU and to define their own essential role in a successful, sustainable ICU palliative care improvement effort. Finally, we identify resources including The IPAL-ICU ProjectTM, a new initiative by the Center to Advance Palliative Care that can assist nurses and other healthcare professionals to move such efforts forward in diverse critical care settings.

Integrating Palliative Care in the Surgical and Trauma Intensive Care Unit: A Report From the Improving Palliative Care in the Intensive Care Unit (IPAL-ICU) Project Advisory Board and the Center to Advance Palliative Care

Objective:Although successful models for palliative care delivery and quality improvement in the intensive care unit have been described, their applicability in surgical intensive care unit settings has not been fully addressed. We undertook to define specific challenges, strategies, and solutions for integration of palliative care in the surgical intensive care unit. Data Sources:We searched the MEDLINE database from inception to May 2011 for all English language articles using the term “surgical palliative care” or the terms “surgical critical care,” “surgical ICU,” “surgeon,” “trauma” or “transplant,” and “palliative care” or “end-of- life care” and hand-searched our personal files for additional articles. Based on review of these articles and the experiences of our interdisciplinary expert Advisory Board, we prepared this report. Data Extraction and Synthesis:We critically reviewed the existing literature on delivery of palliative care in the surgical intensive care unit setting focusing on challenges, strategies, models, and interventions to promote effective integration of palliative care for patients receiving surgical critical care and their families. Conclusions:Characteristics of patients with surgical disease and practices, attitudes, and interactions of different disciplines on the surgical critical care team present distinctive issues for intensive care unit palliative care integration and improvement. Physicians, nurses, and other team members in surgery, critical care and palliative care (if available) should be engaged collaboratively to identify challenges and develop strategies. “Consultative,” “integrative,” and combined models can be used to improve intensive care unit palliative care, although optimal use of trigger criteria for palliative care consultation has not yet been demonstrated. Important components of an improvement effort include attention to efficient work systems and practical tools and to attitudinal factors and “culture” in the unit and institution. Approaches that emphasize delivery of palliative care together with surgical critical care hold promise to better integrate palliative care into the surgical intensive care unit. (Crit Care Med 2012; 40:–1206)

Palliative care in the ICU: relief of pain, dyspnea, and thirst—A report from the IPAL-ICU Advisory Board

AbstractPurposePain, dyspnea, and thirst are three of the most prevalent, intense, and distressing symptoms of intensive care unit (ICU) patients. In this report, the interdisciplinary Advisory Board of the Improving Palliative Care in the ICU (IPAL-ICU) Project brings together expertise in both critical care and palliative care along with current information to address challenges in assessment and management.MethodsWe conducted a comprehensive review of literature focusing on intensive care and palliative care research related to palliation of pain, dyspnea, and thirst.ResultsEvidence-based methods to assess pain are the enlarged 0–10 Numeric Rating Scale (NRS) for ICU patients able to self-report and the Critical Care Pain Observation Tool or Behavior Pain Scale for patients who cannot report symptoms verbally or non-verbally. The Respiratory Distress Observation Scale is the only known behavioral scale for assessment of dyspnea, and thirst is evaluated by patient self-report using an 0–10 NRS. Opioids remain the mainstay for pain management, and all available intravenous opioids, when titrated to similar pain intensity end points, are equally effective. Dyspnea is treated (with or without invasive or noninvasive mechanical ventilation) by optimizing the underlying etiological condition, patient positioning and, sometimes, supplemental oxygen. Several oral interventions are recommended to alleviate thirst. Systematized improvement efforts addressing symptom management and assessment can be implemented in ICUs.ConclusionsRelief of symptom distress is a key component of critical care for all ICU patients, regardless of condition or prognosis. Evidence-based approaches for assessment and treatment together with well-designed work systems can help ensure comfort and related favorable outcomes for the critically ill.