Integrating Palliative Care Into the Care of Neurocritically Ill Patients

Abstract

Objectives To describe unique features of neurocritical illness that are relevant to provision of high-quality palliative care; To discuss key prognostic aids and their limitations for neurocritical illnesses; To review challenges and strategies for establishing realistic goals of care for patients in the neuro-ICU; To describe elements of best practice concerning symptom management, limitation of life support, and organ donation for the neurocritically ill. Data Sources A search of Pubmed and MEDLINE was conducted from inception through January 2015 for all English-language articles using the term “palliative care,” “supportive care,” “end-of-life care,” “withdrawal of life-sustaining therapy,” “limitation of life support,” “prognosis,” or “goals of care” together with “neurocritical care,” “neurointensive care,” “neurological,” “stroke,” “subarachnoid hemorrhage,” “intracerebral hemorrhage,” or “brain injury.” Data Extraction and Synthesis We reviewed the existing literature on delivery of palliative care in the neurointensive care unit setting, focusing on challenges and strategies for establishing realistic and appropriate goals of care, symptom management, organ donation, and other considerations related to use and limitation of life-sustaining therapies for neurocritically ill patients. Based on review of these articles and the experiences of our interdisciplinary/interprofessional expert Advisory Board, this report was prepared to guide critical care staff, palliative care specialists, and others who practice in this setting. Conclusions Most neurocritically ill patients and their families face the sudden onset of devastating cognitive and functional changes that challenge clinicians to provide patient-centered palliative care within a complex and often uncertain prognostic environment. Application of palliative care principles concerning symptom relief, goal setting, and family emotional support, will provide clinicians a framework to address decision-making at a time of crisis that enhances patient/family autonomy and clinician professionalism.

Palliative Care Consultations in the Neuro-ICU: A Qualitative Study

“…The most commonly elicited values were “independence” and the “ability to interact” (in a meaningful way). Of note, and consistent with the literature, 8 the majority of patients (19/25 =76%) were independent prior to hospitalization.…”

“…7 These situations challenge clinicians in the neuro-ICU in ways that might benefit from palliative care expertise. 8 Recent guidelines from the neurocritical care society recommend implementing palliative care for patients with devastating brain injury in the neuro-ICU and their surrogates. 9 However, the exact indication or best timing for specialist palliative care consultations in the neuro-ICU is unknown, and studies exploring how palliative care issues present in the neuro-ICU are limited.…”

Advance Directive Utilization Is Associated with Less Aggressive End-of-Life Care in Patients Undergoing Allogeneic Hematopoietic Cell Transplantation

“…Further, we explored the association between ACP and intensive healthcare utilization and location of death. Although ACP is unlikely to be the sole determinant in whether patients use intensive healthcare resources such as the ICU, multiple studies in other populations suggest that repeated discussions around EOL aid in mitigating intensive healthcare services, particularly at EOL [21,33,34]. Finally, although we performed a detailed chart review of individual HCT recipients, we could not account for every documented conversation around ACP or for documents that were not uploaded in the EMR.…”

Racial Differences in Palliative Care Use After Stroke in Majority-White, Minority-Serving, and Racially Integrated U.S. Hospitals

“…Withdrawal of life-sustaining treatment is common after both ICH and ischemic stroke(4, 5), and access to palliative and end-of-life care has been recognized as an important component of high-quality stroke care(6, 7). …”