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Lehigh Valley Hospital and Health Network Allentown, Pennsylvania

L. V. o. EHI. H. A. L. L. E. Y. HOSPITAL AND HEALTH NETWORK. Practical Applications of Palliative Care in Critical Care Medicine. Daniel E. Ray MD, MS, FCCP. Lehigh Valley Hospital and Health Network Allentown, Pennsylvania. Disclosure. Supported, in part, by :

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Lehigh Valley Hospital and Health Network Allentown, Pennsylvania

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  1. L V o EHI H A L L E Y HOSPITAL AND HEALTH NETWORK Practical Applications of Palliative Care in Critical Care Medicine Daniel E. Ray MD, MS, FCCP Lehigh Valley Hospital and Health Network Allentown, Pennsylvania

  2. Disclosure • Supported, in part, by : • The Robert Wood Johnson Foundation (#047999) • Dorothy Rider Pool Healthcare Trust • Dexter F. and Dorothy H. Baker Foundation • No other conflicts of interest

  3. Objectives • Describe palliative care principles that are pertinent to the ICU setting • List practical interventions to immediately integrate palliative care in the ICU • Review methods to facilitate cultural change around palliative care in the ICU

  4. Palliative Care • Philosophy of care • Organized, highly structured system for delivering care • Provided during routine course of health care • Provided by palliative care specialists in complex cases

  5. Palliative Care • Enhancing quality of life for patient and family • Helping with decision-making • Providing opportunities for growth • Optimizing function http://www.nationalconsensusproject.org/

  6. Quality Indicators for Palliative Care in the ICU • Patient and family-centered decision making. • Communication. • Continuity of care. • Emotional and practical support. • Symptom management. • Spiritual support. • Support for ICU clinicians. Clarke EB, et al. Crit Care Med 2003, 31:2255-62.

  7. Barriers to ICU Palliative Care • Unrealistic patient/family expectations • Inadequate prognostication by physicians • Insufficient training of physicians in palliative medicine Nelson JE. Crit Care Med 2006; 34:S324-S331

  8. Barriers to ICU Palliative Care • ICU culture • ‘rescue from life-threatening illness’ • ‘death denying’

  9. “…it would be naïve and self-defeating to take direct aim at strong belief systems in devising strategies to improve care. We cannot ignore the fear - even if irrational - that palliative care will shorten life nor the powerful biological drive to survive…” Nelson JE. Crit Care Med 2006; 34:S324-S331

  10. Palliative care is delivered as part of routine comprehensive care in the ICU

  11. Patient and Family-centered Decision Making • Recognize the patient and the family as the unit of care • Elicit patient’s values and preferences for ICU care • Reduce patient anonymity

  12. Patient and Family-centered Decision Making • Protocolize timing of family meetings • Initial family contact within 24-48 hours of ICU admission • Daily contact for update • Scheduled family meeting for any significant status change

  13. Patient and Family-centered Decision Making • Set up family expectations

  14. Patient and Family-centered Decision Making • Reduce patient anonymity • ‘Get to Know Me’ poster www.massgeneral.org/palliativecare/palliative-micuproject.htm

  15. Communication • With patients and families • Within the team

  16. Communication - Family 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

  17. Communication - Team 100 2.5 90 80 2 70 60 1.5 50 Avg LOS (days) Daily Goals in the ICU 40 1 30 0.5 20 10 0 0 Oct Feb May Dec Nov Aug April Sept 2-Jun 2-Jan Jul 03 March Jun 03 Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Percent of residents and nurses per week understanding goals Impact of daily goals sheet on ICU LOS Pronovost P et. al. J Crit Care 2003; 18:71-75

  18. Communication - Team • Poor interdisciplinary communication associated with: • Increased mortality • Increased length of stay • Higher readmission rates • Improved communication is associated with: • Enhanced professional relationships and learning • Decreased job stress • Higher patient satisfaction

  19. Continuity of Care • Maximize continuity of care across clinicians • Orient new clinicians regarding patient and family status • Prepare patient/family for change in clinicians

  20. Continuity of Care • Situational, Background, Assessment,and Recommendation (SBAR) • Used by US Navy to insure critical information is communicated • Situation and background are objective • Assessment and recommendation allow delivery of subjective information • Creates redundancy Hoffman LA. Crit Care Alert 2006; 7:49-50

  21. Continuity of Care • Implementation of SBAR • 98% of nurses using SBAR • Reduction of adverse rate from 89.9 to 39.6 per 1000 patient days Landro L. The Wall Street Journal. June 26, 2006:D1-2

  22. Emotional and Practical Support for Patient/family • Waiting Room Program • Family assistance • Clinician support • Privacy/sleeping quarters • Open visiting hours Critical Care Family Assistance Program, Chest Foundation; http://www.chestnet.org/

  23. Emotional and Practical Support for Patient/family • Society of Critical Care Medicine: www.icu-usa.com • Web-based program for ICU waiting rooms • Customized for processes in each ICU • Provides educational material for families related to common procedures and diagnosis in ICU • Satisfaction survey

  24. Emotional and Practical Support for Patient/family • No One Dies Alone (NODA) http://www.peacehealth.org/Oregon/NoOneDiesAlone.htm • Volunteer program to be present during a patient’s death • Bereavement Services

  25. Symptom Management • Development of protocols and guidelines • “Make it easy to do the right thing, at the right time, in the right way” • Delirium/agitation protocol • Comfort Measures only protocol • Ventilator withdrawal protocol • Bowel regimen guideline • Neuromuscular blockade protocol • Family meeting within 48hrs

  26. Text

  27. Effect of Sedation Protocol on Outcome • Randomized control trial • Intervention: daily sedative interruption • Outcome: • Decrease in duration of mechanical ventilation (55.9 hrs vs. 117 hrs) • Length of stay (5.7d vs. 7.5d) • Need for tracheostomy (6.2% vs. 13.2%) • Reduction in symptoms of PTSD Brook et al. CCM 1999; 27:2609-2614 Kress et al. AJRCCM 2003; 168:1457-1461

  28. Spiritual Support • Provide strong pastoral care (spiritual care) presence in the ICU • Attendance in inter-disciplinary rounds • Formal consultation with spiritual assessment and plan of care • Look for ‘moral distress’ • Venue for discussion (M&M, grief rounds, death rounds, end-of-life rounds)

  29. Spiritual Support • ‘Death Rounds’ • Monthly discussion of the issues and emotions surrounding the care of dying patients • 76% or residents felt worthwhile • 76% felt it should incorporated into all ICU rotations • Schwartz Rounds www.theschwartzcenter.org Hough CL et al. Journ Crit Care 2005; 20:20-5

  30. Organizational Support for Clinicians • Needs assessment of clinical providers • Unit specific and department wide • Nurse education • 6-hour in-service • Overview/definition of palliative care • Pain management/adjunctive therapy • Spirituality • Ethical principles • Communication: how to deliver bad news • Annual competency training

  31. Organizational Support for Clinicians • Physician education • Monthly lecture in communication skills • Delivering bad news and holding family meetings • Spirituality • Inter-disciplinary ICU morbidity & mortality • Medical Staff Progress Notes (Fast Facts; http://www.eperc.mcw.edu ) • Regional Symposium • Symptom management • Spirituality • Ethical Principles

  32. Organizational Support for Clinicians • Local champions and academic detailing • Institutional feedback (Treece PD et al. Crit Care Med 2006; 34:S380-7) • ICU peer review for end-of-life care (Mosenthol AC et al. Crit Care Med 2006; 34:S399-403)

  33. Pearls and Pitfalls • Culture change takes time • Value patient and family as unit of care • Link with existing resources • Be prepared for misfires • Be persistent

  34. Web Resource Links • Lehigh Valley Hospital: http://www.lvh.org/pcinicu • No One Dies Alone Program: http://www.peacehealth.org/Oregon/NoOneDiesAlone.htm • Schwartz Rounds: www.theschwartzcenter.org • University of Washington http://depts.washington.edu/eolcare/ • Get To Know Me Poster www.massgeneral.org/palliativecare/palliative-micuproject.htm • Center to Advance Palliative Care www.capc.org

  35. Questions

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