Palliative Care Principles and Anesthesiology Clinical Practice: Current Perspectives

Abstract

Background Palliative care is a person-centered approach aiming to relieve patient’s health-related suffering and it is often needed when caring for critically ill patients to manage symptoms and identify goals of care. Aim To describe the integration of palliative care principles in anesthesiology clinical practice, within and outside the ICU and to analyze the additional challenges that COVID-19 pandemic is posing in this context. Methods For the purpose of this review, PubMed database was searched for studies concerning palliative care and end of life care, in contexts involving anesthesiologists and intensivists, published in the last 5 years. Results Anesthesiologists and intensivists integrate palliative care within their daily practice providing symptoms management as well as family counseling. High-quality communicational skills are fundamental for anesthesiologists and intensivists especially when interfacing with surrogate decision makers in the ICU or with patients in the preoperative setting while discussing goals of care. Coronavirus disease 2019 (COVID-19) pandemic has challenged many aspects of palliative care delivery: reduced family presence within the ICU, communication with families through phone calls or video calls, patient–physician relationship mediated by bulky personal protective equipment and healthcare workers physical and psychological distress due to the increased workload and limitations in resources are some of the most evident. Conclusion Anesthesiologists and intensivists are increasingly facing challenging clinical situations where principles and practice of palliative care have to be applied. In this sense, increasing knowledge on palliative care and providing specific training would allow to deliver high-quality symptom management, family counseling and end of life guidance in critical care settings. COVID-19 pandemic sets additional difficulties to palliative care delivery.

Effect of high flow nasal oxygen on inspiratory effort of patients with acute hypoxic respiratory failure and do not intubate order

“…In this scenario, providing timely palliative interventions with adequate symptoms relief represents a major issue 13 . However, it has been reported that more than half of all patients with a DNI order who receive non-invasive respiratory support for AHRF survive to hospital discharge-often with no worse quality of life compared to those with no ceiling to treatment escalation 15 .…”

“…Moreover, Bräunlich et al speci cally investigated the effect of HFNO on inspiratory effort as assessed by esophageal manometry in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) 12 showing a signi cant reduction in respiratory rate, inspiratory effort, and work of breathing. In this scenario, HFNO therapy can play a valuable role in managing the respiratory needs of patients who receive a "Do Not Intubate" (DNI) order, aligning with the goals of care outlined in the ceiling to treatment escalation 13 . Goals of care that preclude intubation and mechanical ventilation (MV) are more frequently decided by patients suffering from AHRF; thus, the individualization of the therapeutic approaches employed to support respiratory function is of pivotal importance to respect patient's preferences and improve quality of life 14 .…”

Palliative Care in the Intensive Care Unit: Not Just End-of-life Care

“…Since the ICU setting is burdened by high mortality and high suffering, providing palliative care to critically ill patients and their families is a major goal of ICU care [13]. Palliative care aims to maintain and improve the quality of life of all patients and their families at any stage of life-threatening illness [14].…”

“…Decision-making, alignment of treatment with the patient's goals, emotional support for families, and the basics of symptom management are core elements of palliative care and should be routine aspects of critical care [15]. Studies have shown that integration of palliative care in the ICU improves quality of life, shortens hospital and ICU length of stay, lowers the care-giver burden, and reduces the use of emergency resources [13,[16][17][18][19].…”

Palliative Care and End-of-Life Issues in Patients with Brain Cancer Admitted to ICU

“…Additionally, comorbid and frail patients may experience an even worse course [ 2 ], with difficult hospital stay, sometimes requiring postsurgical intensive care unit (ICU) admission. Peculiar management is expected for patients with anticipated poor prognosis, as aggressive therapeutical approaches would not determine a full restoration of organ function, and life expectancy may not be affected by curative care [ 3 ]. In this light, ICU admission may be considered inappropriate.…”