Easing Suffering for ICU Patients and Their Families: Evidence and Opportunities for Primary and Specialty Palliative Care in the ICU

Abstract

Intensive care unit (ICU) admissions are often accompanied by many physical and existential pressure points that can be extraordinarily wearing on patients and their families and surrogate decision makers (SDMs). Multidisciplinary palliative support, including physicians, advanced practice nurses, nutritionists, chaplains and other team members, may alleviate many of these sources of potential suffering. However, the palliative needs of ICU patients undoubtedly exceed the bandwidth of current consultative specialty palliative medicine teams. Informed by standard-of-care palliative medicine domains, we review common ICU symptoms (pain, dyspnea and thirst) and their prevalence, sources and their treatment. We then identify palliative needs and impacts in the domains of communication, SDM support and transitions of care for patients and their families through their journey in the ICU, from discharge and recovery at home to chronic critical illness, post-ICU disability or death. Finally, we examine the evidence for strategies to incorporate specialty palliative medicine and palliative principles into ICU care for the improvement of patient- and family-centered care. While randomized controlled studies have failed to demonstrate measurable improvement in pre-determined outcomes for patient- and family-relevant outcomes, embracing the principles of palliative medicine and assuring their delivery in the ICU is likely to translate to overall improvement in humanistic, person-centered care that supports patients and their SDMs during and following critical illness.

An Evolutionary Concept Analysis of the “Fighter” in the Intensive Care Unit

“…In addition, many ICU patients progress to chronic critical illness, requiring prolonged mechanical ventilation, extended lengths of stay due to sepsis or septic shock and frequent ICU readmissions, and experiencing consequences of multiorgan failure 1,2 . Chronic critical illness is also associated with high hospitalization costs, frequent post–acute-care use, and transitions back to the ICU, as well as poor quality of life and long-term survival 3 …”

“…1,2 Chronic critical illness is also associated with high hospitalization costs, frequent post-acute-care use, and transitions back to the ICU, as well as poor quality of life and long-term survival. 3 When the likelihood of meaningful recovery in the ICU is low, patients and families face difficult choices and decisions about goals of care (GOC) and continuing life-prolonging measures or shifting to a palliative approach focusing on symptom management. 4 Goals-of-care conversations are often used to elicit what matters most to the patient and family unit.…”