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A growing body of research touts the benefits of palliative care for patients, families, and even providers. However, when evaluated through randomized clinical trials, the results tend to lean toward mediocre.
Palliative Care News spoke with experts in the field to unpack the reasons behind those results and identify the obstacles that are getting in the way of a more effective approach.
Obstacles facing palliative care in the ICU
One challenge to bear in mind is that some of the measures used in the literature are imprecise due to the traumatic, emotional nature of the event. Families and decision-makers face an extremely difficult time when a loved one enters the ICU — potentially the worst time of their lives. This certainly has an impact on clinical survey ratings.
“I think the measures we have, it’s not so much that they’re wrong, but they certainly are imprecise,” Dr. Kathleen M. Akgün, associate section chief of pulmonary, critical care and sleep medicine and MICU Director at Yale School of Medicine, told Palliative Care News. “It’s not blood pressure. It’s how somebody feels about stuff 30 days, three months, six months [out]. There can be some variation in how someone feels from day to day. I think that we shouldn’t underestimate the impact of some almost post-traumatic stress symptoms in how participants respond to surveys following palliative care interventions.”
Another major factor is the sheer volume of patients entering the ICU with more complex care needs.
More older and sicker patients are being admitted to ICUs than ever before. Medical advances have enabled people to live longer, but those patients are also coping with more life-limiting illnesses and complications. This is a growing problem challenging the health care system within the last few decades.
“Older doctors have never seen this,” said Dr. Kei Ouchi, associate professor of emergency medicine at Harvard Medical School/Brigham and Women’s Hospital. “So, I think they have a harder time involving palliative care initially because they equate palliative care to end of life care. Younger physicians are definitely more open [to it].”
Poor understanding of palliative care
ICU staff work diligently to preserve the lives of the patient they serve. If they have not received intentional education about palliative care and the right clinical relationships within the ICU have not been developed, some ICU providers may view palliative care as antithetical to the work they are so rigorously and intentionally performing, emphasized a 2022 study co-authored by Ouchi.
To some extent, clinicians from various specialities may want to protect their turf in terms of managing their patients’ care.
“There are concerns by some intensivists, and fairly so, that they won’t have as much of a leading role in deciding what happens or what maybe should happen for patients,” Akgün said.
Of course, misconceptions also abound among the general public. According to Ouchi, public perception sees palliative care as a pathway to the patient’s death, rather than an essential part of the health care journey. This can cause some to be resistant to working with palliative care, despite the potential benefits.
Financial, workforce inhibitors
In most instances, palliative care is not a revenue driver due to the nation’s patchwork or reimbursement systems. Fee-for-service reimbursement through Medicare only covers physician services rather than the full scope of interdisciplinary care, and coverage through value-based programs like Medicare Advantage are not available in many markets.
“It is extremely hard for palliative programs to actually even break even related to the services that they offered,” Dr. Christopher Comfort, CEO of Calvary Hospital, told Palliative Care News. “Many organizations … look at the provisions of palliative services as actually a loss leader that will never be adequately reimbursed until reimbursement of palliative programs occurs instead of reimbursement visit by visit from physicians participating in palliative care.”
The labor shortage compounds these problems. Even if palliative care becomes more accepted with improved reimbursement structures, the health care system does not have enough palliative-trained clinicians to meet the growing demand, Ouchi said.
“We’re all faced with a limited specialty palliative care workforce. So, we have had to be thoughtful and innovative about how we’re going to actually ensure that we’re reaching those patients in the ICU with unmet palliative care needs,” said Dr. Laura Gelfman, deputy director of quality and clinical information at Mount Sinai Health System’s Department of Geriatrics and Palliative Medicine.
And, even if there are palliative care providers available, Akgün noted, the delivery of services may be challenged by a lack of diversity, resulting in “subtle, unrecognized cues that palliative care providers may be missing or unintentionally delivering.”
Opportunities for palliative care
While the obstacles to palliative care in the ICU are significant, they are not insurmountable. The opportunities for palliative care to grow and benefit patients, families, providers and health systems vary, but are achievable and customizable for each health system’s culture.
Education about palliative care is important across the entire care continuum — from patients and families to providers to the C-suite and beyond. A greater awareness of palliative care’s services, continuity of care and goals will drive more interest and quicker adoption.
Mount Sinai Health System embedded a physician/registered nurse palliative care team into their MICU and experienced positive results from the mutual education that occurred.
“I think one of the biggest things that has helped us expand and develop this exposure [to palliative care] is education,” said Dr. Ankita Mehta, associate professor and director of palliative care for the Mount Sinai Health System Critical Care Institute. “The more people know what palliative care can do … the different aspects that can be addressed and how patients and families can benefit, leads to more and more interactions, more benefits and more expansions.”
Other opportunities lie in emphasizing the benefits of palliative care for providers. In Mehta and Gelfman’s study of Mount Sinai’s embedded palliative care team, early access to palliative care increased the likelihood of having documented medical decision makers and goals of care. This relieves pressure off of critical care teams when significant medical decisions must be made.
“Some ICU docs find it very welcome to have the assistance and input for palliative care to help with some of the decision making,” Akgün said.
Additionally, palliative care can help to initiate and facilitate introductory conversations earlier in treatment that lead to easier hard conversations down the line, she shared.
Also, to increase acceptance of palliative care, relationships matter.
“Really a lot of what palliative care is, is both building relationships with the clinical team and building relationships with patients and families. And that I think is what moves the needle in terms of receptivity and letting us in the room,” Gelfman said. “In many respects the COVID pandemic really transformed [the way we worked]. We were working side-by-side, in really close collaboration. And as horrible as it was, you could argue that a silver lining was that we built even stronger relationships and saw each other’s value.”
All ICUs and health systems are distinct with unique cultures, so best practices in integrating palliative care will look different across the United States. Whether embedded, integrative, consultative or mixed, the variety of options allow health systems to determine which palliative care model and communication strategies best fit their needs.
“One of the things that we’ve seen, even as an embedded team in the ICU, is that seeing patients early on in their ICU admission rather than later, has helped us build rapport with patients and their families, have a better understanding of patient values, and has helped this guide and work with patients and families for next steps,” Mehta said.
In the study of Mount Siani’s embedded palliative care, patients with an embedded palliative care study were seen significantly earlier and were less likely to die in the hospital.
Humanism in medicine
Meanwhile, palliative care focuses on developing relationships, communication and patient values and goals, all which can bring a human element to the clinical side of medicine.
“Humanism in medicine may be one of the most memorable factors for a patient or family member receiving care,” Akgün said. “We can improve ICU experiences if we just keep it simple, be curious and do so with empathy.”
Palliative care providers can build relationships by regularly requesting invitations to the ICU. This will develop relationships and establish their value to both patients and ICU staff, according to Akgün.
From their consistent presence in the MICU, Mehta said, “We’ve seen that our ICU teams here value the skill sets we bring as a team — from helping with symptom management to helping support families and at the same time working with them, and the rest of the team.”
Despite palliative care many times being a loss leader, providers should emphasize the decreased length of stay and intensity of care that it leads to, according to Akgün.
“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.
