Abstract
Background
What Occurs in an ICU Palliative Care Consultation
• Assess/treat distressing physical, psychological, and spiritual symptoms/problems.
• Communicate information about prognosis and treatment options to patient/family in concert with ICU, primary care and subspecialty colleagues.
• Establish/clarify goals of care that are realistic and appropriate in relation to the patient's condition, values, and preferences, and help match treatments to these goals.
• Formulate a transition care plan that accounts for prognosis, goals of care, and patient/family needs.
• Provide support for the families.
• Support the ICU medical team in making clinically, ethically, and emotionally challenging decisions.
Research Data on Benefits of Palliative Care ICU Consultation
• Early identification of a dying trajectory leading to decreased time for institution of patient- and family-centered, comfort-focused treatment goals.3,4
• Movement of appropriate patients to lower-intensity care sites (ward, palliative care unit, home hospice).5,6
• Reduction in ICU length of stay for adult patients.3,4,7,8
• Reduction in the cost of care, without an increase in mortality, due to early establishment of realistic treatment goals leading to reduction in use of high-cost ICU resources/interventions.3,4,7,9
• Support for staff in challenging and emotionally draining/morally distressing patient/family care situations.
• Reduction in the need for ICU admission through establishment of treatment goals that preclude future ICU admission.8,9
• Continuity of care when the patient transitions from the ICU to ward or palliative care unit as the palliative care team follows the patient.
ICU/Palliative Care Collaboration
A range of options exist for integrating palliative care services into the ICU. At one extreme, ICU staff consult a palliative care specialist team for problems the ICU staff deems appropriate for consultative advice on an ad hoc basis. At the other extreme, the ICU embeds systems in place to provide ICU-led generalist palliative care services to all ICU patients, utilizing palliative care specialists for complex problems. Embedding systems that ensure the meeting of the needs of all patients includes screening all patients on admission and daily for unmet palliative care needs, early identification of a surrogate, timely symptom management, and routinely scheduled family meetings to discuss goals of care.
High-quality outcomes related to patient and family experience and to health care utilization should be tracked within the framework of available resources.1,10
When to Use Specialist Palliative Care Services
Consultations can either be initiated on a case-by-case basis by ICU or other primary clinicians, or triggered proactively using a system to identify patients at high risk for unmet needs.3,4,7,11 Key indications for consultation include:
• Difficult-to-control physical symptoms despite usual treatment approaches.
• Patients/surrogates wish to explore non-ICU supportive care options such as hospice services.
• Staff have questions about the appropriateness of life-sustaining therapies in the setting of advanced complex illnesses.
• There are complex family dynamics impacting decisions about use of life-sustaining treatments.
• There are disagreements among staff or between staff and patients/surrogates about prognosis and/or use of life-sustaining treatments.
• Patients are being readmitted to the ICU more frequently within a given time frame.
Summary
Specialist palliative care consultations, together with integration of palliative care principles into the care of all ICU patients, can improve the patient/family experience, reduce length of stay, improve ICU throughput without increasing mortality, and lower health care costs.
Additional Resources
Center to Advance Palliative Care ICU screening tools/policies are available at: www.capc.org/ipal-icu/improvement-and-clinical-tools/.