Focus on palliative care in the ICU

Abstract

Recent studies about the provision of high-quality communication and integration of palliative care into the ICU have increased our understanding of how best to care not only for patients but also for their family. We review some of these contributions.Advancement of medical technologies has resulted in patients living longer, but an increasing number of patients are dying highly medicalized deaths. Hillman and Cardona-Morrell summarize ten societal barriers that prevent high-quality ICU care at the end of life, including unreal expectations, discomfort discussing aging and dying, increasing medical specialization, uncertainty around prognosis, lack of emphasis during medical education on palliative care, and limited training for clinicians on how to provide hope along with a realistic and compassionate picture [1]. Clear and compassionate communication about prognosis is essential to facilitate understanding and decision-making, as well as to help prepare family for a patient's death.Though numerous guidelines recommend incorporation of palliative care for critically ill patients, implementation of these recommendations is inconsistent. A prospective, before-and-after study examined integration of a palliative care clinician into daily ICU rounds [2]. This study demonstrated that, with the intervention, there was increased likelihood of ICU family meetings and shorter time to the first meeting. Hospital length of stay was shorter with the intervention and, among patients who died in the ICU, ICU length of stay was shorter, yet ICU and hospital mortality were similar. This study presents an important model for integrating palliative care into the ICU.A randomized trial of condolence letters from ICU physicians and nurses to family members 15 days after a death in the ICU had a surprising result, showing the letter was associated with increased symptoms of depression and post-traumatic stress disorder (PTSD) at 6 months [3]. This study suggests that routine condolence letters are not helpful-at least at 6 months-and highlights the importance of evaluating interventions we think will improve patient-and family-centered outcomes. Another randomized trial suggested that routine palliative care-led family meetings, conducted largely without ICU physicians, were associated with increased family symptoms of PTSD at 3 months and again highlighted the importance of evaluating interventions we assume will improve communication and support for family [4]. These studies also suggest that we may need to examine longer-term impact of interventions that, by providing support, focus family members on issues of dying and death, to determine whether a temporary increase in psychological symptoms may be associated with better long-term adjustment.Numerous studies have shown that family of critically ill patients experience high levels of symptoms of depression, anxiety, and PTSD for months after an ICU stay [5]. These symptoms have collectively been labelled "post-intensive care syndrome-family" (PICS-F). These symptoms are more c...