An intensive care unit (ICU) stay often challenges everyone involved. Integrating palliative care could alleviate some of the suffering through symptom management, improved communication about goals, treatment and better training and resources for staff.
As ICU admissions in the final year of life become increasingly common, the need for better holistic critical care is growing.
Better management of symptoms
ICUs sustain the lives of critically ill patients with specialized care while treating underlying life-threatening conditions. Their valuable work often requires invasive interventions. Coupled with critical illness, these can cause complex and distressing symptoms for patients — including pain, difficulty breathing (dyspnea), thirst and depression.
Nearly 75% of patients admitted to the ICU experience distressing symptoms. More than 57% of their relatives suffer high symptom distress as well.
Palliative care providers are specially trained to identify and manage these symptoms.
“[Palliative care gets] back to some of those basics of remembering that human suffering in the bed in front of us, thinking about the symptoms that they may or may not be sharing with us, but are probably affecting them … as well as their own mortality and existential sort of concerns that might not come through when we’re addressing things like acute respiratory failure,” said Dr. Kathleen M. Akgün, from the Section of Pulmonary, Critical Care and Sleep Medicine at Yale University.
Facilitating Better Communication
Many patients in the ICU today have serious, life-limiting illnesses that may require family members to make urgent, difficult life-or-death decisions that may not be covered in written documents.
Facilitating communication early and often about realistic treatment options and the preferences and values of the patients and families is essential, Akgün said.
“For those patients [with serious, life-limiting illnesses], palliative care is super important to be involved in the ICU, because everything that we can do to potentially have that patient survive, that may not be what the patient wants,” said Dr. Kei Ouchi, associate professor of emergency medicine at Harvard Medical School/Brigham and Women’s Hospital.
“ICU survivors often experience significant functional impairments months to years after discharge,” stated a study Akgün co-authored. The communication facilitated by palliative care helps decision-makers understand the gravity of the situation and the future implications of their care choices.
“Palliative care benefits families and caregivers of patients because of all these repeated discussions about patient values and goals,” Ouchi said. “By [having those discussions], the anxiety and decisional regret [for families] decreases.”
Palliative care integration strategies
Providers recognize the value of palliative care in the ICU and have begun incorporating it through the consultative model, the integrative model or a combination of the two.
The consultative model, also known as specialty palliative care, provides palliative care services by a board-certified palliative care team at the request of the ICU team or based on pre-defined clinical triggers.
The integrative model, or primary palliative care, trains ICU teams to embed palliative care principles into daily practices and to obtain specialty palliative care support as needed.
“Some ICU docs find it welcome to have the assistance and input of palliative care to help with some of the decision making,” Akgün said. “I think a lot of us in the ICU already practice a lot of [palliative care principles] when it comes to medical decision making for people approaching the end of life. There’s a lot that we can extend up from our existing skill set as intensivists to tap into those palliative principles earlier, with a little more attention to things like symptoms and symptom burden.”
The cost-savings of palliative care
Integrating palliative care training and support may be an initial investment, but could offer long-term cost-savings.
“Family-focused, primary palliative care interventions are consistently associated with decreased critical use at the end of life,” stated a study co-authored by Ouchi. “… they are a cost-effective intervention for reducing potentially undesired critical care at the end of life and do not seem to increase overall mortality.”
The study found that triggered palliative care consultations decreased ICU and hospital length of stay and resulted in fewer interventions for DNR patients.
“It seems to indicate that we can have a much more efficient sort of throughput of patients when we have palliative care engagement for many subpopulations,” Akgün said. “I’m not saying that solves everything as a way to offload the ICU per se… But there’s certain indicators that it could help reduce time on mechanical ventilation, and decisions for changing goals of care, especially [for] patients with more chronic conditions that have continued to escalate and no definitive treatment is going to help them overcome this life-limiting condition.”
