Palliative Care in the Neuro-ICU: Perceptions, Practice Patterns, and Preferences of Neurointensivists

Bar, Barak; Creutzfeldt, Claire J.; Rubin, Michael

doi:10.1007/s12028-019-00838-w

Cited by 27 publications

(33 citation statements)

References 7 publications

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“…In UK on the other hand, they have recognized how difficult late withdrawals are and crafted detailed guidelines to support staff, families and secure the right of patients to avoid prolongation of treatment no longer in their best interest [ 19 ]. In USA neuro-palliative care is a growing field developed as a response to unmet patient and family needs [ 47 ].…”

Section: Discussionmentioning

confidence: 99%

Inter-physician variability in strategies linked to treatment limitations after severe traumatic brain injury; proactivity or wait-and-see

2021

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Background Prognostic uncertainty is a challenge for physicians in the neuro intensive care field. Questions about whether continued life-sustaining treatment is in a patient’s best interests arise in different phases after a severe traumatic brain injury. In-depth information about how physicians deal with ethical issues in different contexts is lacking. The purpose of this study was to seek insight into clinicians’ strategies concerning unresolved prognostic uncertainty and their ethical reasoning on the issue of limitation of life-sustaining treatment in patients with minimal or no signs of neurological improvement after severe traumatic brain injury in the later trauma hospital phase. Methods Interviews with 18 physicians working in a neurointensive care unit in a large Norwegian trauma hospital, followed by a qualitative thematic analysis focused on physicians’ strategies related to treatment-limiting decision-making. Results A divide between proactive and wait-and-see strategies emerged. Notwithstanding the hospital’s strong team culture, inter-physician variability with regard to ethical reasoning and preferred strategies was exposed. All the physicians emphasized the importance of team—family interactions. Nevertheless, their strategies differed: (1) The proactive physicians were open to consider limitations of life-sustaining treatment when the prognosis was grim. They initiated ethical discussions, took leadership in clarification and deliberation processes regarding goals and options, saw themselves as guides for the families and believed in the necessity to prepare families for both best-case and worst-case scenarios. (2) The “wait-and-see” physicians preferred open-ended treatment (no limitations). Neurologically injured patients need time to uncover their true recovery potential, they argued. They often avoided talking to the family about dying or other worst-case scenarios during this phase. Conclusions Depending on the individual physician in charge, ethical issues may rest unresolved or not addressed in the later trauma hospital phase. Nevertheless, team collaboration serves to mitigate inter-physician variability. There are problems and pitfalls to be aware of related to both proactive and wait-and-see approaches. The timing of best-interest discussions and treatment-limiting decisions remain challenging after severe traumatic brain injury. Routines for timely and open discussions with families about the range of ethically reasonable options need to be strengthened.

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Section: Discussionmentioning

confidence: 99%

Inter-physician variability in strategies linked to treatment limitations after severe traumatic brain injury; proactivity or wait-and-see

2021

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“…In UK on the other hand, they have recognized how di cult late withdrawals are and crafted detailed guidelines to support staff, families and secure the right of patients to avoid prolongation of treatment no longer in their best interest (19). In USA neuro-palliative care is a growing eld developed as a response to unmet patient and family needs (47).…”

Section: Establish Guidelines For Late Withdrawalsmentioning

confidence: 99%

Inter-physician variability in strategies linked to treatment limitations after severe traumatic brain injury; proactivity or wait-and-see

Robertsen¹,

Helseth²,

Førde

2021

Preprint

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Background Prognostic uncertainty is a challenge for physicians in the neuro intensive care field. Questions about whether continued life-sustaining treatment is in a patient’s best interests arise in different phases after a severe traumatic brain injury. In-depth information about how physicians deal with ethical issues in different contexts is lacking. The purpose of this study was to seek insight into clinicians’ strategies concerning unresolved prognostic uncertainty and their ethical reasoning on the issue of limitation of life-sustaining treatment in patients with minimal or no signs of neurological improvement after severe traumatic brain injury in the later trauma hospital phase. Methods Interviews with 18 physicians working in a neurointensive care unit in a large Norwegian trauma hospital, followed by a qualitative thematic analysis focused on physicians’ strategies related to treatment-limiting decision-making. Results A divide between proactive and wait-and-see strategies emerged. Notwithstanding the hospital’s strong team culture, inter-physician variability with regard to ethical reasoning and preferred strategies was exposed. All the physicians emphasized the importance of team – family interactions. Nevertheless, their strategies differed: (1) The proactive physicians were open to consider limitations of life-sustaining treatment when the prognosis was grim. They initiated ethical discussions, took leadership in clarification and deliberation processes regarding goals and options, saw themselves as guides for the families and believed in the necessity to prepare families for both best-case and worst-case scenarios. (2) The “wait-and-see” physicians preferred open-ended treatment (no limitations). Neurologically injured patients need time to uncover their true recovery potential, they argued. They often avoided talking to the family about dying or other worst-case scenarios during this phase. Conclusions Depending on the individual physician in charge, ethical issues may rest unresolved or not addressed in the later trauma hospital phase. Nevertheless, team collaboration serves to mitigate inter-physician variability. There are problems and pitfalls to be aware of related to both proactive and wait-and-see approaches. The timing of best-interest discussions and treatment-limiting decisions remain challenging after severe traumatic brain injury. Routines for timely and open discussions with families about the range of ethically reasonable options need to be strengthened.Trial registration: Not applicable

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“…palliative and hospice care) has become central to EOL health care, 3 including inpatient and ICU settings. 4 Palliative care facilitates patient goals of care, treatment decisions based on patient values, and patient and family social support 5 to prevent suffering for patients with life threatening illnesses. 6 Initiatives to support consultative models of palliative care services 7 in inpatient settings are increasingly recommended.…”

mentioning

confidence: 99%

“…15 Within NeuroICU settings, patients often present with life-limiting or terminal conditions (i.e., catastrophic presentation) and require swift prognostication. 5 At the same time, few neurology and neurosurgery patients engage in consideration of goals of care (e.g., advance care planning) in advance of rapid health decline. 16 Despite benefits of palliative care in addressing these issues, palliative care consultation has been reported to be requested in less than a quarter of patients, 5 and palliative care services for critically ill neurology and neurosurgery patients is understudied.…”

mentioning

confidence: 99%

“…5 At the same time, few neurology and neurosurgery patients engage in consideration of goals of care (e.g., advance care planning) in advance of rapid health decline. 16 Despite benefits of palliative care in addressing these issues, palliative care consultation has been reported to be requested in less than a quarter of patients, 5 and palliative care services for critically ill neurology and neurosurgery patients is understudied. 17 One main barrier to palliative care and hospice service utilization in NeuroICU settings may be delay in referral to such services.…”

mentioning

confidence: 99%

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Palliative Care Services in the NeuroICU: Opportunities and Persisting Barriers

Morris

Mroz

Popescu

et al. 2021

Am J Hosp Palliat Care

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Background: End-of-life (EOL) supportive care, including palliative and hospice services, is an area of increasing importance in critical care. Neurointensivists face unique challenges in providing timely supportive care to terminally ill patients expected to expire in the NeuroICU. Objective: This study explored the extent of effective utilization of, and recorded barriers to, palliative and hospice services in a dedicated 30-bed NeuroICU at a large academic medical center. Design: A retrospective chart review of patients who expired in the NeuroICU was conducted. The timeline from patient admission to arrival of palliative care services was traced. Qualitative review of chart notes was used to identify barriers to provision of palliative services. Setting: A total of 330 patients expired in the NeuroICU during the study period, including 176 from the neurology and 154 from the neurosurgical service. Results: Across services, 146 expired patients were never referred to palliative care or hospice services. Of those referred, over one-third were referred more than 4 days past admission to the NeuroICU. On average, patients were referred with less than 1 day before expiration. Common barriers to referral for supportive services were documented (e.g., patient expected to expire, family declined service). Conclusions: Despite benefits of palliative care and an in-hospital hospice opportunity, we identified lack of referral, and particularly delays in referral to services as significant barriers. Our study highlights these as missed opportunities for patients and families to receive maximum benefits from these services. Future research should solidify triggers for EOL services in this setting.

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Palliative Care in the Neuro-ICU: Perceptions, Practice Patterns, and Preferences of Neurointensivists

Cited by 27 publications

References 7 publications

Inter-physician variability in strategies linked to treatment limitations after severe traumatic brain injury; proactivity or wait-and-see

Inter-physician variability in strategies linked to treatment limitations after severe traumatic brain injury; proactivity or wait-and-see

Inter-physician variability in strategies linked to treatment limitations after severe traumatic brain injury; proactivity or wait-and-see

Palliative Care Services in the NeuroICU: Opportunities and Persisting Barriers

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