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Improving the Quality of Palliative Care for Patients in the ICU

Improving the Quality of Palliative Care for Patients in the ICU. J. Randall Curtis, MD, MPH Pulmonary and Critical Care Medicine University of Washington. Outline. Epidemiology of death in the ICU Communication with patients and families Practice of withdrawing life support

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Improving the Quality of Palliative Care for Patients in the ICU

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  1. Improving the Quality of Palliative Care for Patients in the ICU J. Randall Curtis, MD, MPH Pulmonary and Critical Care Medicine University of Washington

  2. Outline • Epidemiology of death in the ICU • Communication with patients and families • Practice of withdrawing life support • System-level interventions

  3. Changing Nature of Death in the ICU p<0.001 Prendergast & Luce, AJRCCM, 1997

  4. Variability in Clinician Approach to Withdrawing Life Support Cook, JAMA, 1995

  5. Physician Biases Around Withdrawing Life Support • Physicians prefer to withdraw: • Natural rather than iatrogenic cases • Most recently instituted therapies • Therapies that will result in delayed death • Physician factors affect decisions • Younger, academic, specialist, and less religious were more willing to withdraw Christakis and Asch, Lancet, 1993

  6. Pain in Seriously Ill Hospitalized Patients: SUPPORT • Of 3624 patients able to be interviewed • 50% reported pain • 15% reported severe pain • 15% were dissatisfied with pain control • Patients with MOF or sepsis report similar pain to other patients • Intensivists had lowest satisfaction for pain control Desbiens, Crit Care Med, 1996

  7. Curtis, J Pain Sx Manage, 2002; 24:17

  8. Quality of Dying and Death and ICU Treatments QODD scorep value ICU in last month 0.4 Yes (n=25) 64.6 No (n=179) 67.7 # of invasive treatments 0.02 0 (n=135) 68.2 1 (n=16) 66.8 >2 (n=33) 60.8 Curtis, J Pain Sympt Management, 2002; 24:17

  9. Summary: Epidemiology of Death in the ICU • Majority of deaths in the ICU involve withholding or withdrawing life support • Some evidence suggests we don’t do this as well as we should • ICU death need not necessarily be a “bad death”

  10. Outline • Epidemiology of death in the ICU • Communication with patients and families • How are we doing? • How can we improve? • Practice of withdrawing life support • System-level interventions

  11. What Do We Know About End-of-life Communication in the ICU? • <5% of patients can participate in ICU decisions about withholding treatments • Communication is primarily with family • Families rate communication as more important than clinical skill • Families under immense burdens • Emotional, financial, personal health Prendergast, AJRCCM, 1997; Covinsky, JAMA; 1994

  12. Survey of 920 Family Members of Patients in 43 French ICUs • Psychological symptoms common • Anxiety: 70%; Depression: 35% • Caregiver factors associated with family anxiety or depression • Absence of regular meetings with MD, RN • Absence of a family meeting room • Perceived contradictions in info provided • Absence of a waiting room Prochard, Crit Care Med 2001; 29:1893

  13. Before-after Study of Communication Intervention in Medical ICU • Intervention: family conference held within 72 hours if attending predicts • ICU stay >5 days or mortality >25% • Conference conducted by attending • Review medical facts and options • Discuss patient’s perspective on EOL • Agree on care plan • Agree on criteria of success or failure Lilly, Am J Med 2000; 109:469

  14. Results of Communication Intervention in Medical ICU Before After (n=134)(n=396)p value* ICU LOS (d) 4 3 0.004 Worst APACHE quartile Survivors 5 4.5 0.8 Died 5 3 0.02 Overall mortality odds ratio* After:before 0.61 (0.38-0.98) *adjusted for APACHE III Lilly, Am J Med 2000; 109:469

  15. Study of Effectiveness of Clinician-Family Communication • 102 consecutive patients in ICU >2 days; 76 patients visited by family • Interviewed family after meeting with physician to assess comprehension • Failure to understand basics of • dx (20%), px (43%), tx (43%) Azoulay, Crit Care Med 2000; 28:3044

  16. Study of ICU Family Conferences • Daily screen of all ICUs in 4 hospitals • If conference planned, contact attending: • Is discussion of withholding or withdrawing life support likely? • Willing to have conference recorded? • Consent all conference participants • Qualitative and quantitative analyses Curtis, J Crit Care, 2002; 17:147

  17. Family Conferences and Participants • 51 family conferences • 51 unique families • 36 unique physicians leading conference • (26 MDs did 1 conference; 7 MDs did 2; • 3 MD did 3 or 4) • 214 family members Curtis, J Crit Care, 2002; 17:147

  18. Content of the Discussions • Openings and introductions • Two-way information exchange • Discussion of the future • Prognosis: survival & quality of life • Decisions to be made • Discussions of dying and death • Closings Curtis, J Crit Care, 2002; 17:147

  19. Support Acknowledging the difficulty and emotions Discuss patient’s life and values Support for families decisions Accessibility Style Directness with caring Active listening Addressing conflicts Communication Style and Emotional Support Curtis, J Crit Care, 2002; 17:147

  20. Support: Personalize the Patient MD: Tell us a little bit about (patient name). None of us really know her. What is she like? What does she value about life? What kinds of things does she like to do? Curtis, J Crit Care, 2002; 17:147

  21. Support: Easing Burden MD: You can get that sick very quickly just from pancreatitis. Bringing her to the hospital any sooner wouldn’t have made a difference… it’s not like we would have been able to give her a medication that would have prevented all this from happening. So you don’t need to worry that if you’d only brought her in a sooner things would be different. Curtis, J Crit Care, 2002; 17:147

  22. Support: Support for Family Decision-Making MD: With medical science we could prop him up and try to get him through this, but it seems clear that his wishes would be to not have that done. I think it’s a reasonable decision you’ve all made and a brave one also in that you have to put aside your own personal feelings of wanting to have him around. Letting go is difficult, but I think you’re doing him a great service by honoring his wishes at this time. Curtis, J Crit Care, 2002; 17:147

  23. Duration of Family Conferences and Proportion of Family Speech MeanSD Duration of conference 32 min 17-45 min Proportion family speech 29% 14-44% McDonaugh, in progress

  24. Proportion Family Speech Correlates with Family Satisfaction % Family Speech Duration How well did…r (p value)r (p value) MD communicate 0.37 (0.01) -0.07 (NS) Conf. meet needs 0.31 (0.04) 0.08 (NS) How much conflict -0.31 (0.04) 0.28 (0.07) McDonaugh, submitted

  25. Summary: Discussing Dying and Death in the ICU • Communication with critical care clinicians important to families • Important to ascertain goals and values directly from patients/families • Develop a “protocol” for family discussions • Include agenda and emotional support techniques • Listen to families • Critical care clinicians could use help

  26. Outline • Epidemiology of death in the ICU • Communication with patients and families • Practice of withdrawing life support • System-level interventions

  27. Withdrawal of Life Support Is a Medical Procedure • Education of patient and family • Proper setting and monitoring • Adequate sedation and analgesia • Active role for physician • Prepare for complications • Documentation • Quality improvement

  28. Setting and Monitoring • Quiet and privacy • Remove all monitoring and disable alarms • Physical exam sufficient to assess pain and diagnose death • Liberalize visitation • Stop laboratory and radiographic tests

  29. Sedation: Drugs and Doses • Drugs used to treat pain and agitation usually sufficient • Narcotic, benzodiazepine, neuroleptic • Doses • Explicit dosing guidelines difficult • No dose is too high if lower doses fail • Difficult to kill patients with narcotics • Document reasons for increasing

  30. Once the Decision Is Made to Withdraw, Just Turn It Off • Only justification for weaning life support is when its abrupt removal will cause discomfort • All life support except ventilator can just be turned off • Stuttering withdrawal can and should be avoided

  31. Terminal Discontinuation of the Ventilator Full Ventilatory Support Remove supplemental O2 and PEEP Reduce set rate or PS gradually • Titrate sedation to ensure comfort • Takes 5 minutes • Titrate sedation to ensure comfort • Takes 5 minutes • Titrate sedation to ensure comfort • Takes 5-20 min

  32. Should Patients Be Extubated After Withdrawing Mechanical Ventilation? • Little evidence to guide decisions • Clinicians frequently have strong opinions • Case-based judgment based on • Family preferences • Level of support, amount of secretions, level of consciousness

  33. Outline • Epidemiology of death in the ICU • Communication with patients and families • Practice of withdrawing life support • System-level interventions

  34. Before-after Study of Proactive Palliative Care Consult in a Medical ICU • Intervention: automatic palliative care consult for patients with • Anoxic encephalopathy after cardiac arrest • MODS: >3 organs for >3 days • Goals of the consult: • Communicate prognosis to family • Identify patient preferences • Discuss treatment options with family • Implement palliative care strategies Campbell, Chest 2003; 123:266

  35. Results of Palliative Care Consult Intervention in Medical ICU Before After (n=22)(n=21)p value ICU LOS (days) Anoxic enceph 7.1 3.7 0.01 MODS 10.7 10.4 0.74 ICU LOS from diagnosis (days) Anoxic enceph 7.1 3.7 0.01 MODS 5.8 2.1 0.05 Campbell, Chest 2003; 123:266

  36. Before-After Study of a Withdrawal of Life Support Order Form • Intervention: Implementation of a standardized order form for withdrawing life support • Developed by a multi-disciplinary team • Presented at institutional multi-disciplinary forum for feedback from staff • In-service education conducted in each ICU Treece, Am J Resp Crit Care Med, 2003; 167:A582

  37. Components of the Withdrawal of Life Support Form • Preparation • DNAR order; document discussion with family; discontinue prior orders • Analgesia and sedation • Infusion with broad range; no maximum dose; document reason for increase • Ventilator withdrawal protocol • Principles of withdrawing life support

  38. Clinician Satisfaction Ratings Generally High MD (n=61) RN (n=73) %YES%YES Orders Helpful? 98 84 Sections helpful Preparation 70 36 Sedate/Analgesia 93 70 Ventilation 79 44 Principles 98 6 Treece, Am J Resp Crit Care Med, 2003; 167:A582

  39. Narcotic Dosing and Time to Death After Ventilator Withdrawal Pre Post p value (n=42)(n=57) Mean dose (mg) 1 hr prior vent w/d 4.0 7.0 0.07 1 hr post vent w/d 7.5 9.5 0.31 Time to death (hrs) After vent w/d 6.2 5.3 0.60 Treece, Am J Resp Crit Care Med, 2003; 167:A582

  40. Benzodiazepine Dosing and Time to Death After Ventilator Withdrawal Pre Post p value (n=42)(n=57) Mean dose (mg) 1 hr prior vent w/d 0.1 4.3 0.001 1 hr post vent w/d 0.2 5.5 0.001 Time to death (hrs) After vent w/d 6.2 5.3 0.60 Treece, Am J Resp Crit Care Med, 2003; 167:A582

  41. Resources: Recent Reviews Prendergast, Puntillo. Withdrawal of life support. JAMA 2002; 288:2732. Truog et al. Recommendations for end-of-life care in the intensive care unit. Crit Care Med 2001; 29:2332-46. Way et al. Withdrawing life support and resolution of conflict with families. Brit Med J 2003; 325:1342.

  42. Available from Oxford University Press • www.oup.com

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