Evidence Based Resources- Palliative and Critical Care

Darrel A. Owens PhD, ACHPN, CNS

In the not-so-recent past, the practice of providing palliative care to critically ill patients and families was a foreign concept in most institutions.  This practice is now increasing as critical care clinicians begin to recognize the benefits of integrating critical and palliative care.  Palliative care clinicians across the United States are using a variety of strategies to increase the number of critically ill patients and these patient’s families served by their programs.

Over the last 40 years, the number of intensive care units (ICU) in the United States has grown exponentially.  This growth has occurred in large part because of the advances in medical knowledge and technology.  By 1985, more than 90% of all US hospitals had at least one ICU, and expenditures for critical care consumed approximately 11% of all acute care costs, for a total of almost $15 billion.1  By 1998, it was estimated that ICU care accounted for 34% of hospital budgets and that critical care expenditures exceeded $62 billion annually.

Death in the ICU is a common occurrence; some evidence suggests that approximately 20% of deaths in the US occur after a stay in the ICU.1, 2 Other studies have shown that approximately half of all patients with a chronic illness who die in a hospital receive care in the ICU within 3 days of their deaths.3 Most deaths in the ICU involve the withholding of withdrawal of life-sustaining therapies.3-6  These numbers suggest that the withholding and withdrawal of life-sustaining measures are critical components to the overall quality of ICU care.3 Despite this, other studies suggest that end-of-life care in the ICU is less than optimal, with pain and symptom management and family communication especially problematic.3,7-9

A review of the literature found a limited number of evidence-based articles that specifically addressed the integration of palliative and critical care.10-13  Most literature focuses on the need for a better integration of the two specialties and documents deficits in pain and symptom management and communication.  An informal survey of palliative care providers whose practice is primarily in the acute care setting found that the percentage of critically ill patients they served ranged from many to none.  Different programs reported varied levels of success concerning their ability to improve access to critically ill patients, with no correlation identified between institution types, for example, community versus academic medical center.

One consistent method that has been used to integrate palliative care is the implementation of a screening process whereby palliative care clinicians screen admissions to the ICU on a daily basis.  The ability of palliative care providers to screen ICU is dependent on many factors.  Most importantly, palliative care clinicians need a collaborative relationship with their critical care colleagues.  A solid and trusting relationship is the foundation upon which a mutually agreed upon screening process can be established.  Recent examples of such a process include the Detroit Receiving Hospital10,11 and the University of Washington’s Harborview Medical Center in Seattle. Although there are several palliative care programs that use screening and assessment tools for critically ill patients, outcome data have yet to be published regarding their successes or failures.

A review of the evidence has identified the need for better integration of critical and palliative care.  To date, no integration strategy has emerged as a best practice.  Current evidence suggests that some screening process, as discussed above, can improve access to services, which is a good starting point.  The first steps to integrating palliative and critical care include assessing institutional culture, knowing the stakeholders, and building collaborative relationships with critical care providers.  Palliative and critical care can and should be integrated, and palliative care clinicians must take an active but nonthreatening role in the integration process.

Summary of the Evidence

  • The evidence supporting better integration of palliative and critical care is significant.
  • There are few studies what actually address the ways to integrate palliative and critical care.
  • Routine screening of critical care admissions by palliative clinicians has demonstrated an increase in access to palliative care for critically ill patients and their families.
  • The following are useful web sites related to the integration of palliative and critical care:

References

  1. Luce JM, Prendergast TJ. The changing nature of death in the ICU. In: Curtis JR, Rubenfeld GD, eds. Managing death in the intensive care unit: the transition from cure to comfort. New York, NY, Oxford University Press;2001:19-28.
  2. McDonagh JR, Elliott TB, Engelberg RA, et al.  Family satisfaction with family conferences about end-of-life care in the intensive care unit: increased proportion of family speech is associated with increased satisfaction. Crit Care Med. 2001; 29:N22-N26.
  3. Treece PD, Engelberg RA, Crowley L, et al.  Evaluation of a standardized order form for the withdrawal of life support in the intensive care unit. Crit Care Med. 2004;32:1141-1146.
  4. Prendergast TJ, Classens ME, Luce JM. A national survey of end-of-life care for critically ill patients. Am J Respir Crit Care Med. 1998;158:1163-1167.
  5. Cook DJ, Guyatt G, Rocker G, et al.  Cardiopulmonary resuscitation directives on admission to the intensive care unit: an international observational study.  Lancet. 2001;358:1941-1945.
  6. Esteban A, Gordo F, Solsona JF, et al.  Withdrawing and withholding life support in the intensive care unit: a Spanish prospective multi-centre student.  Intensive care Med. 2001;27:1744-1749.
  7. Desbiens NA, Wu, AW. Pain and suffering the seriously ill hospitalized patients.  J Am Geriatr Soc. 2000;48:S183-S186.
  8. Nelson JE, Meier D, Oei EJ, et al. Self-reported symptom experience of critically ill cancer patients receiving intensive care. Crit Care Med. 2001;29:277-282.
  9. Hofman JC, Wenger NS, Davis RB, et al. Patients preferences for communication with physicians about end-of-life decisions. Ann Intern Med.1997;127:1-12.
  10. Campbell ML, Guzman JA. Impact  of a proactive approach to improve end-of-life care in a medical ICU. Chest.2003;123:266-271.
  11. Campbell ML, Guzman JA. A proactive approach to improve end-of-life care in a medical intensive care unit for patients with terminal dementia. Crit Care Med. 2004;32:1839-1843.
  12. Rady MY, Johnson DJ.  Admission to intensive care unit at the end-of-life: is it an informed decision? Palliat Med. 2004; 18:705-711.
  13. Carlet J, Thijs LG, Antonelli M, et al.  Challenges in end-of-life care in the ICU Statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium; April 2003. Intensive Care Med. 2004;30:770-784.

About the Author

Darrell A. Owens, PhD, ACHPN, CNS, is Clinical Assistant Professor and Director of Palliative Care, University of Washington Harborview Medical Center, Seattle WA. He is also an Associate Editor for the Journal of Hospice and Palliative Nursing and Coordinates, “Evidence for Practice.”

Journal of Hospice and Palliative Nursing - Featured Journal
May/June 2006
Volume 8 Number 3
Pages 135 - 136
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