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1. Palliative Care in the ICU Lori Popejoy, PhD(c), RN, BC, GCNS
Research Coordinator
Boone Hospital Center
3. Technology and Treatment Callahan (1993) identified a a vanishing line between life and death
Technological imperative
Orchestration of death
70% of all ICU deaths occur after a decision to forego or withdraw life sustaining technology or treatment (Predergast, 1998)
4. Technology and Treatment The decision to withhold treatment is more common than the decision to withdraw (Tolle et al, 2000)
The decision to withdraw life support has been described as a de facto standard of care in U.S. hospitals (Luce, 1997)
Data indicates that (Fins, et al.1999):
77% of patients in the ICU had DNR orders
46% had comfort plans in place yet many continued to receive antibiotic treatment (41%) and blood draws (30%)
5. Pain Management 50% of patients in the SUPPORT trail described directly or indirectly through proxy reports that they experienced moderate to severe pain in the last 3 days of life (Lynn et al., 1997)
Patients in palliative care had pain identified 3x more often than patients on the MICU (Paice et al, 2004)
6. Pain Management 20% of patients in the MICU did not receive treatment for pain or dyspnea (Paice et al., 2004)
Surgical ICU nurses gave 37% of allowed doses of narcotics for pain (Whipple, 1995)
Restraints were used more often in the ICU
(Paice et al., 2004)
7. Symptom Management 55-75% of ICU patients with cancer experienced pain, anxiety, sleep disorders, or unsatisfied hunger or thirst (Nelson et al., 2001)
ICU patients were found to have symptom distress related to (Paice et al., 2004)
Pulmonary congestion (92%)
Confusion (86%)
Fever (78%)
Dyspnea (78%)
8. Symptom Management 60% of patients with respiratory failure reported anxiety and dyspnea (Somogyi-Zalud et al., 2000)
Sleep disturbances and delirium were also common (McCusker, 2001)
9. Suffering Suffering is more than physical suffering
Morse (2001) identified suffering as profound sorrow associated with the irrevocable changes that illness and death have on the future hopes and dreams of individuals and their family members
Suffering of the patient and/or family is frequently not addressed
10. Power of the ICU Patients and family members believe that the ICU can offer remarkable control over recovery and death (Campbell, 2002)
Technological imperative leaves the impression that there is always something more that can be done (Campbell)
11. Power of the ICU Initially family members may feel optimistic about the patients recovery, but ultimately they may have to identify that a good death is the best that can be hoped for
Decisions unfold over time (Karlawish, 1996)
Good death
A death free from avoidable distress and suffering for the patient, family members, and caregivers, which is in general accord with the patients and family members wishes and is consistent with clinical culture and ethical standards (Tolle et al., 2000)
12. Patient and Family Decision-Making Use of advanced directives
Chose of one family member as proxy may be an artificial mechanism for decision-making
Patients are expected to make decisions about issues for which they have no real world experience
Patients may prefer not to make the decision ahead of time but rely on family decision makers
Families do not always speak in a unified voice
(Arnold, & Kellum, 2003; Jacobs, 1998; Pulchalski et al, 2000; Reubenfeld, & Curtis, 2003)
13. Communication Families hear differing viewpoint primarily from physician specialists (Asch et al, 1997; Counsel, & Guin, 2002)
Leads to confusion
Anger
Hostility
Frustration
This was strongly supported by the ICU focus groups as main source of nurse frustration
14. Communication Health care team members do not always agree on the diagnosis or best treatment for a patient
HCT members have personal issues about death and dying that limit their ability to effectively communicate with patients and families
Physicians did not report problems communicating with nurses, but nurses do report problem communicating with physicians (Baggs & Schmitt, 2000)
15. Communication ICU focus group revealed that nurses did not believe they were empowered to talk to family members about the possibility of death
Nurses also reported that they will always answer questions with honesty even if it means that they will potentially be in trouble
16. Communication Patients may be willing to live in a physical state that many of us would deem unacceptable (Olivero, & Fraulo, 1998)
Tolerance for treatment burden is highly individualized (Rushton et al., 2002)
17. Be Careful What You Ask Physicians and nurses are not able to predict a patients desire for resuscitation (Puopolo, 1997)
It is not helpful to ask vague questions such as do you want everything done
Everything is simply not understood by most people
It is important to understand what makes the patients life worthwhile
What do they wish to be able to continue doing in their life
What goals they have for the future
18. Difference between knowing and understanding It takes time for information to move from being known and to being understood
Family conferences are strongly encouraged (Curtis, 2001)
Frequent
Uninterrupted
Greater than 10 minutes in length
HCT members should listen more than they talk
By the time the first conference as taken place the family already has preconceived information about the patients condition and the HCT (Kaufman, 1998)
19. Barriers to using Palliative Care Principles in the ICU Difficulty identifying who is going to die
Palliative care is often used only when intensive interventions have failed
Reluctance to openly discuss the potential for death early in the patients stay
ICU environment may not be conducive to family involvement
20. Models of Palliative Care Transitional model
Partially integrated model
Incorporates ideals of liberalized visiting and aggressive pain and symptom control
Mixed Model
Patients receive aggressive treatment
Simultaneously receive preparation for the possibility of death
(Field, & Cassel, 1997)
21. Models of Palliative Care Mixed model
Recognition of the limits of technology
Recognizing the potential for death (Miller et al, 2001)
Move energy toward
Treatment
Open communication
Shared decision-making
Aggressive management of symptoms
Emotional support for suffering
22. Possibilities for Change Grant for the development and evaluation of a palliative care program in the ICUs
Team that includes palliative care specialist, the palliative care medical director, oncology and integrative therapies director, oncology social worker, ICU director, ICU manager, research coordinator
Other staff participants as the project unfolds
Units involved include the MICU, SICU, NSICU
23. Possibilities for Change Mixed model has been selected
Using criteria developed by Miller, Boyle, and Forbes (2001) and the Quality Indicators for EOL Care a plan has been developed for evaluation of the current system that includes:
Evaluating the culture of the ICUs
Focus groups with ICU nurses (done not analyzed)
Delineate which model of EOL care is used in each unit
24. Possibilities for Change Identify problems inherent in predicting death
Evaluate communication flow
Focus groups
Physician input
Evaluate EOL protocols and standards of practice
Can we use what is developed for the transitional model used throughout the hospital
Review the role of
Chaplaincy
Social work
Scope of nursing practice
25. Possibilities for Change Evaluate the role of integrative therapy
Evaluate communication with patients and family members
Evaluate protocols for withdrawal of life support
Evaluate bereavement protocols
Including staff debriefing and grief
Need for this was supported in the focus groups
26. What do we hope to accomplish? The broad goal at this time is to make palliative care in the ICU more acceptable to medical staff members and nurses, so that patients can receive optimum care. Our hope is that the mixed model will more closely align to the goals of ICU treatment. The transitional model has not proven to be effective in the ICU environment.