The Growth of Palliative Practice and End of Life Care in an Academic Teaching Intensive Care Unit

Abstract

Objective Dying in the intensive care unit (ICU) has changed over the last twenty years due to increased utilization of palliative care. We sought to examine how palliative medicine (PM) integration into critical care medicine has changed outcomes in end of life including the utilization of do not resuscitate (no cardiopulmonary resuscitation but continue treatment) and comfort care orders (No resuscitation, only comfort medication). Design: Retrospective observational review of critical care patients who died during admission between two decades, 2008 to 09 and 2018 to 19. Setting: Single urban tertiary care academic medical center in Washington, D.C. Patients: Adult patients who were treated in any ICU during the admission which they died. Interventions and Measurements We sought to measure PM involvement across the two decades and its association with end of life care including do not resuscitate (DNR) and comfort care (CC) orders. Main Results: 571 cases were analyzed. Mean age was 65 ± 15, 46% were female. In univariate analysis significantly more patients received PM in 2018 to 19 (40% vs. 27%, p = .002). DNR status increased significantly over time (74% to 84%, p = .002) and was significantly more common in patients who were receiving PM (96% vs. 72%, p < 0.001). CC also increased over time (56% to 70%, p = <0.001), and was more common in PM patients (87% vs. 53%, p < 0.001). Death in the ICU decreased significantly over time (94% to 86%, p = .002) and was significantly lower in PM patients (76% vs. 96%, p < 0.001). The adjusted odds of getting CC for those receiving versus those not receiving PM were 14.51 (5.49-38.36, p < 0.001) in 2008 to 09 versus 3.89 (2.27-6.68, p < 0.001) in 2018 to 19. Conclusion: PM involvement increased significantly across a decade in our ICU and was significantly associated with incidence of DNR and CC orders as well as the decreased incidence of dying in the ICU. The increase in DNR and CC orders independent of PM over the past decade reflect intensivists delivering PM services.

Core components of end-of-life care in nursing education programs: a scoping review

“…In almost all reviewed studies, one of the main components of end-of-life care education programs in nursing is familiarity with the principles of end-of-life care [ 6 , 14 , 21 , 23 , 24 , 33 , 34 ]. These studies state that things like definition and historical overview of end-of-life care should be considered at the beginning of educational programs [ 6 , 14 , 23 , 24 ].…”

“…In almost all reviewed studies, one of the main components of end-of-life care education programs in nursing is familiarity with the principles of end-of-life care [ 6 , 14 , 21 , 23 , 24 , 33 , 34 ]. These studies state that things like definition and historical overview of end-of-life care should be considered at the beginning of educational programs [ 6 , 14 , 23 , 24 ]. Jeong et al in the same context, state that according to many nurses, their position in providing end-of-life care needs to be clarified, and they have challenges in differentiating this type of care from palliative care [ 11 ].…”

“…Also, nurses had concerns about improving communication behaviors, decision-making, and facilitating continuous care. Malik et al [ 14 ] 2017 United States of America Education End-of-Life Care for Certified Nursing Assistants in Long-Term Care 20 nurses One group pre and post-test The topics of educational content included: an overview of palliative nursing care, pain management, care at the time of death, assistance in personal development and self-care, and communication with the patient and family. Lippe et al [ 29 ] 2017 United States of America Evaluating End-of-Life Care Education Within Nursing Programs 33 nursing faculty members Descriptive - cross-sectional The educational content is the same as the curriculum headings of the end-of-life nursing education consortium (ELNEC)) including an introduction to palliative nursing care, pain management, symptom management, ethical issues in palliative nursing care, cultural considerations in end-of-life care, communication, loss, grief, and bereavement, and final hours.…”

“…This is even though many nurses do not receive such training in full while studying and working [ 5 , 13 ]. Failure to provide palliative and end-of-life education for nurses is not new, and many reputable nursing organizations call it a historical flaw in the nursing education program [ 14 ].…”

Palliative Medicine and End of Life Care Between Races in an Academic Intensive Care Unit

“…This study, however, was limited to patients undergoing mechanical ventilation for heart failure. 22 With the increasing integration of palliative care medicine into ICU care, 23 it is imperative to understand inequities that may be present at the end of life, to ensure access to this essential resource to people of all races.…”