Sean O'Mahony

Preliminary report of the integration of a palliative care team into an intensive care unit

Nearly half of Americans who die in hospitals spend time in the intensive care unit (ICU) in the last 3 days of life. Minority patients who die in the ICU are less likely to formalize advance directives and surviving family members report lower satisfaction with the provision of information and sensitivity to their cultural traditions at the end-of-life. This is a descriptive report of a convenience sample of 157 consecutive patients served by a palliative care team which was integrated into the operations of an ICU at Montefiore Medical Center in the Bronx, New York, from August 2005 until August 2007. The team included an advance practice nurse (APN) and social worker. A separate case—control study was conducted comparing the length of hospital stay for persons who died in the ICU during the final 6 months of the project, prior to and post-palliative care consultation for 22 patients at the hospital campus where the project team was located versus 24 patients at the other campus. Pharmaco-economic data were evaluated for 22 persons who died with and 43 who died without a palliative care consultation at the intervention campus ICU to evaluate whether the project intervention was associated with an increase in the use of pain medications or alterations in the use of potentially non-beneficial life-prolonging treatments in persons dying in the ICU. Data was abstracted from the medical record with a standardized chart abstraction instrument by an unblinded research assistant. Interviews were conducted with a sample of family members and ICU nurses rating the quality of end-of-life care in the ICU with the Quality of Dying and Death in the ICU instrument (ICUQODD), and a family focus group was also conducted. Forty percent of patients were Caucasian, 35% were African American or Afro-Caribbean, 22% Hispanic and 3% were Asian or other. Exploration of the patients’ and families’ needs identified significant spiritual needs in 62.4% of cases. Education on the death process was provided to 85% of families by the project team. Twenty-nine percent of patients were disconnected from mechanical ventilators following consultation with the Palliative Care Service (PCS), 15.9% of patients discontinued the use of inotropic support, 15.3% stopped artificial nutrition, 6.4% stopped dialysis and 2.5% discontinued artificial hydration. Recommendations on pain management were made for 51% of the project’s patients and symptom management for 52% of patients. The project was associated with an increase in the rate of the formalization of advance directives. Thirty-three percent of the patients who received PCS consultations had ‘do not resuscitate’ orders in place prior to consultation and 83.4% had ‘do not resuscitate’ orders after the intervention. The project team referred 80 (51%) of the project patients to hospice and 55 (35%) patients were enrolled on hospice, primarily at the medical center. The mean time from admission to palliative care consultation at the project site was 2.8 days versus 15.5 days at the other campus (p = 0.0184). Median survival times from admission to the medical center were not significantly different when stratified by palliative care consultation status: 12 days for the control group (95% CI 8—18) and 13.5 days for the intervention group (95% CI 8—20). Median charges for the use of opioid medications were higher (p = 0.01) for the intervention group but lower for use of laboratory (p = 0.004) and radiology tests (p = 0.027). We conclude that the integration of palliative care experts into the operation of critical care units is of benefit to patients, families and critical care clinicians. Preliminary evidence suggest that such models may be associated with improved quality of life, higher rates of formalization of advance directives and utilization of hospices, as well as lower use of certain non-beneficial life-prolonging treatments for critically ill patients who are at the end of life.

Ventilator withdrawal: procedures and outcomes. Report of a collaboration between a critical care division and a palliative care service

To describe an institutional procedure for ventilator withdrawal and to analyze patient responses to terminal extubation, the medical records of 21 patients who underwent withdrawal of mechanical ventilation according to the process followed by an interdisciplinary palliative care team were retrospectively reviewed. The cohort was a convenience sample of sequentially treated patients in a 1048-bed urban university-affiliated medical center. Sixteen of the 21 patients were on medical or surgical floors and five patients were in critical care units. Patients were assessed for discomfort, such as dyspnea, agitation, or anxiety. Sedative and analgesic medications were administered based on clinical parameters. Palliative care clinician observations of patient reports, tachypnea,use of accessory muscles, and signs of discomfort such as agitation or anxiety were recorded for the first 4 hours after extubation. Medication use and length of survival were recorded. Fifty-seven percent were symptomatic during the extubation process and required administration of either a benzodiazepine or opioid medication. The median survival of the 18 patients who died post-extubation was 0.83 hours (interquartile range 0.5-43.8). Bolus doses of opioid or benzodiazepine medications were effective for management of symptoms in about two-thirds of patients. One-third of patients required continuous infusions. Eighteen patients died following extubation in the medical center, and three of these patients were transferred to an inpatient hospice unit. Three patients (14%) survived to discharge from the hospital. The procedure followed provides a foundation for collaboration between palliative care and critical care services to ensure continuity of care across clinical settings/units.

Choices in palliative care : issues in health care delivery

Palliative Care in Acute Care Hospitals.- Palliative Care in Nursing Facilities.- Patient-Centered Palliative Care in the Home.- Hospice Care.- The Role of Cancer Rehabilitation in the Maintenance of Functional Integrity and Quality of Life.- HIV/AIDS and Palliative Care: Models of Care and Policy Issues.- Palliative Care and Chronic Obstructive Lung Disease.- Palliative Care and Chronic Heart Failure.- Palliative Care for Patients with Alzheimers Dementia: Advance Care Planning Across Transition Points.- Children and Issues Around Palliative Care.- Palliative Care and the Elderly: Complex Case Management.- The Business of Palliative Medicine: Business Planning, Models of Care and Program Development.- Palliative Care and Quality Management: The Core Principles of Quality Improvement and their Utility in Designing Clinical Programs for End of Life Care and Complex Case Management Models.- Ethics and the Delivery of Palliative Care.

MULTIDISCIPLINARY CARE OF THE TERMINALLY ILL PATIENT

This article discusses sedation, the assessment and management of physical symptoms, and symptom-assessment scales for the terminally ill patient. The evaluation of the ability of the family or community to care for a terminally ill patient in pain also is discussed.